Hysterectomy: When Is It Necessary?
An hour after the birth of Jan Cole's second child, the midwife was just about to make her exit. One final check of her uterus, however, revealed a problem. The postpartum bleeding hadn't stopped. To Jan's shock and dismay, she was immediately rushed into the operating room. After five hours of surgery, she emerged without her uterus.
Jan is just one of the approximately 570,000 women in the United States who undergo ]]>hysterectomies]]> each year. Although this figure is down from a peak of 724,000 in 1985, hysterectomy is still the second most commonly performed major surgery in the United States. This statistic becomes all the more astounding when you realize that half the population (men) never have this operation at all.
Historically, women had their reproductive organs removed for every conceivable complaint ranging from headaches to liver trouble. Nineteenth century physicians firmly believed that removing the ovaries could modify a woman's personality, making her a "generally more agreeable creature." Even textbooks written as recently as the mid-1970s proclaimed the uterus worthless once childbearing was completed.
Fortunately, the modern medical community has become a little more enlightened. The extent of the uterus' role in a woman's body is still not completely understood. However, there is mounting evidence in favor of saving it whenever possible. The American Heart Association cites research indicating that the hormone, prostaglandin, secreted from the uterus may offer protection from heart disease. In addition, a study in Obstetrics and Gynecology looked at the loss of bone density in women who had a hysterectomy before menopause compared with those who didn't. The women whose uteruses were removed showed a significant loss of bone.
There is good reason to believe that many of the hysterectomies performed in the USA are not necessary.
- The CDC was one of the first to study appropriateness for this procedure in 1981 and their report questioned 15% of the hysterectomies.
- A 1993 study by RAND corporation of 7 different health plans concluded that 16% of hysterectomies were clinically inappropriate, and another 24% were of questionable value.
- In the past several years, advances in the fields of minimally invasive surgery, myomectomy, uterine artery embolization, medical management, and pain management have led opponents of hysterectomy to suggest that as many as 75% of hysterectomies performed this year will have been unnecessary.
Problems Leading To Hysterectomy
The reasons for hysterectomy can seem as individual as each woman's personal story. They do, however, fall into a few broad categories. Hysterectomies are most often performed for:
- Severe pelvic pain and/or abnormal bleeding
- A diagnosis of ]]>cancer]]>
- To save a woman's life, most commonly when the uterus ruptures during labor
The most common ailment initiating a hysterectomy is the overgrowth of ]]>fibroid]]> tumors in the uterus. If the tumors are small and aren't causing any distress, you and your doctor can comfortably adopt a watchful waiting strategy. Large or rapidly expanding fibroids are often a source of significant pain and anemia due to excessive bleeding.
If you want to bear children or feel strongly about not giving up your uterus, you can opt for a surgery called ]]>myomectomy]]> . This operation excises fibroid tumors but leaves the uterus intact. The drawbacks are that it is a slightly riskier procedure and offers no guarantee that the fibroids won't come back. In fact, 15-20% of women see the tumors return within the next five years.
In addition, depending on where in the uterus the fibroids are removed from, the surgical scars may increase the risk that the uterus will break or rupture during a future pregnancy or labor. If the incision must be made deep into the uterine muscle, your surgeon may recommend that future deliveries would need to be done by cesarean section.
There is another procedure now available called uterine artery embolization, which is sometimes considered as an alternative to hysterectomy. The uterine artery is embolized (obstructed), which results in decreased blood flow to the uterus and shrinkage of the fibroids.
Another diagnosis that sometimes leads to hysterectomy is endometriosis , a condition in which clumps of tissue from the uterine lining grow outside their natural site. The result is severe pain and unmanageable menstrual flow. Thanks to hormone therapies and more conservative surgical options, hysterectomy is now less commonly indicated in women with endometriosis. Doctors may recommend removal of the uterus to solve abnormal pelvic bleeding of undefined origin or pain that doesn't respond to treatments such as hormone regimens or dilation and curettage.
Thirty-three percent of hysterectomies in postmenopausal women are due to a prolapsed uterus. Years of childbearing and the hormonal changes that accompany menopause can weaken the pelvic floor muscles. Deprived of support, the uterus sinks so that it rests against the bladder and bowels. A hysterectomy can remedy the resulting ]]>incontinence]]> , constipation, and pelvic pressure. Alternatively, a device worn in the vagina called a pessary may give the sagging uterus the boost it needs to help a woman avoid or postpone a hysterectomy.
Cancer of the ]]>cervix]]> , ]]>uterus]]> , or ]]>ovaries]]> prompts about 17% of hysterectomies. Cervical cancer, if caught in its early stages by a routine Pap smear, can be successfully treated by less drastic measures. In the rest of the cases, a hysterectomy often means the difference between life and death.
Occasionally, doctors must perform an emergency hysterectomy to save a patient's life. This rare situation occurs when bleeding cannot be stopped after childbirth or very rarely in the case of an infection in the reproductive organs.
Types of Hysterectomies
The term hysterectomy refers only to the removal of the uterus. In cases of cancer, serious infection, or endometriosis, the ovaries may be removed at the same time. This procedure is called an ]]>oophorectomy]]> . When the fallopian tubes, which connect the ovaries to the uterus are also removed, the procedure is then referred to as a ]]>salphingo-oophorectomy]]> .
There are three surgical approaches to hysterectomy.
Transabdominal and Transvaginal Hysterectomy
Currently, three out of four hysterectomies are performed abdominally. They are referred to as a transabdominal hysterectomy, a statistic that has not changed over the last 20 years. Research shows, however, that the risk of post-surgical complications from this procedure is 1.7 times that of the vaginal approach, which is called a transvaginal hysterectomy.
Laparoscopically Assisted Vaginal Hystertomy
Since recovery with vaginal hysterectomies is faster than those performed through the abdomen, a third surgical approach, which combines ]]>laparoscopy]]> and a vaginal hysterectomy, is sometimes used. It is referred to as a laparoscopically assisted vaginal hystertomy or LVH. With this method, a small scope, called a laparoscope, is inserted into the abdomen through the belly button for viewing purposes and surgery is performed through small incisions in the abdomen. Surgeons are able to perform part of the hysterectomy in this manner, allowing it to be completed through the vagina.
Your gynecologist will recommend which procedure he or she believes is the best choice for you based on your gynecologic history, findings on pelvic examination, and the indication for which the hysterectomy is being done. In general:
- Abdominal hysterectomy may be necessary if the uterus is significantly enlarged by fibroids or if there is significant scarring between the uterus and other pelvic organs due to past endometriosis or infections.
- The choice between a simple vaginal hysterectomy or a laparoscopically assisted one is most commonly based on whether a patient is considered to be at high risk of having scar tissue (such as those with endometriosis). Scar tissue would make a vaginal hysterectomy difficult to safely complete.
- If you are considering a hysterectomy, you should ask your doctor to describe the pros and cons of each procedure for your individual circumstances.
In most instances, the entire uterus including the cervix is removed. A variation, known as a subtotal or partial hysterectomy, leaves the cervix in place. Some women fear that removing the cervix will interfere with sexual pleasure. There is no definitive scientific evidence to support this belief.
What To Expect As You Recover
Physical changes following a hysterectomy will be most dramatic if you've not gone through menopause. Menstrual periods will cease and childbearing will no longer be possible. If the ovaries are removed at the same time, your body suddenly will be deprived of estrogen as well. In this event, doctors almost always recommend ]]>hormone replacement therapy (HRT)]]> to prevent the premature onset of menopause. In addition to staving off hot flashes and vaginal dryness, estrogen helps maintain bone mass and might affect a woman's risk of heart disease.
Women may have many different emotions in the wake of a hysterectomy. You may experience everything from a sense of well-being to feelings of ]]>anger]]> , ]]>grief]]> , and loss. Women who were planning future pregnancies are the hardest hit emotionally. Even if their families are complete, many women mourn the loss of their reproductive capacity. On the other end of the spectrum, women battling cancer can feel intense relief following the operation. A few studies done in the 1960s and 1970s indicated that women are more prone to clinical depression after a hysterectomy. However, more recent research refutes that claim.
The question of how a hysterectomy affects your sexuality is a complicated one. A number of women have reported sexual function changes, which include loss of libido, decreased sexual arousal, and difficulty achieving ]]>orgasm]]> . But a 1999 study in the Journal of the American Medical Association reported just the opposite, citing increases in overall sexual function after hysterectomy. However, since the patients were only followed for 4-6 months prior to a hysterectomy, the authors could not conclude that sexual function returned to levels equivalent to those prior to the symptoms that lead to the surgery.
More research is needed on this issue. In particular a better-defined relationship between sexual function and the anatomy of a woman. It may be that by sparing the nerves and blood vessels vital to normal sexual function, as done in men for prostate operations, will preserve sexual function. In addition though, your feelings about yourself, your partner's view, your sexual organs, and your hormone levels are all factors in determining your libido and your sexual response. Although it may take some adjustment, the majority of women who enjoyed a satisfying sex life before a hysterectomy are able to resume it after the operation.
No woman wants a hysterectomy she doesn't need. It's important, therefore, to be as informed as possible before going into the operation. Most hysterectomies are not performed on an emergency basis, affording time to consider all the options and to seek a second opinion if necessary. You can minimize your risk of emotional problems following the operation by discussing your feelings and concerns openly with your doctor. Scheduling the surgery with adequate time to get used to the idea (at least several weeks) can also help you feel comfortable with your decision.
The American College of Obstetricians and Gynecologists
National Women's Health Information Center
The Canadian Women's Health Network
The Society of Obstetricians and Gynaecologists of Canada
Bernstein S. McGlynn E. Siu A. et al. The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium. JAMA . 1993;269:2398-2402.
Watson, NR, Studd JW, Garnett T, et al. Bone loss after hysterectomy with ovarian conservation. Obstet Gynecol . 1995 Jul;86(1):72-7.
Last reviewed May 2008 by ]]>Jeff Andrews, MD, FRCSC, FACOG]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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