There was a time when if a woman bled too much, had any pelvic mass, an abnormal Pap, hurt or felt pressure “down there”, she was told that the best way to ensure her gynecologic health was to “take it out”. . . to get a hysterectomy. When I trained at the University of Chicago decades ago, hysterectomies were the most common surgical procedure scheduled in our gynecologic operating rooms. Hysterectomy is second only to Caesarian deliveries as the most frequently performed major operation in the United States. Over twenty million U.S. women have had a hysterectomy and 600,000 are performed annually. Four months ago I joined that number. I, too, had a hysterectomy.What are the reasons most hysterectomies are performed?
The most common symptoms leading to hysterectomies are heavy or irregular uterine bleeding, pelvic pain and pelvic pressure. Most hysterectomies are performed in women between the ages of forty and forty-five. But in the last two years we have actually seen a decrease in overall hysterectomy rates in these relatively young women and an increase (by up to 45%) in women older than age 75 (I fall in between). The clinical conditions leading to a hysterectomy vary from annoying to life-threatening, but most hysterectomies are still performed for benign conditions:
- Fibroids — These account for up to 30 percent of hysterectomies. Fibroids are benign growths that appear in up to one-third of women in their forties. (There may be a genetic and/or ethnic tendency to develop these). In most cases they are silent and won’t require intervention. But if they become very large (like a four-month pregnancy or greater), cause significant pain, pressure and/or abnormal or heavy bleeding, they require therapy. Hysterectomy is the final solution, but there are often alternatives for symptoms of bleeding. These include: birth control pills, anti-hormones (GnRH, which can stop periods and shrink the fibroids)and an intrauterine system that slowly releases progestin (Mirena). There are also new non-invasive procedures such as MRI directed ultrasound to destroy the core of the fibroids and shrink them and minimally invasive techniques in which uterine vessels are embolized in order to block blood flow to the fibroid. Finally, ablation of the lining of the uterus can be performed through an instrument inserted through the cervix. This allows the uterine lining to be destroyed by either cautery, heat, laser or freezing.
- Depending on their size, and placement, fibroids can also be surgically removed (myomectomy). This can be performed through a laparoscope (using small incisions in the abdomen), or, if the fibroids “poke through” the endometrium, through a hysteroscope which is inserted through the cervix. If the fibroids are large and a woman wants to maintain her ability to have a pregnancy, myomectomy can be done through an open incision in the abdomen (laparotomy). So why consider a hysterectomy? Fibroids can grow back and do recur (and cause clinical problems) about twenty percent of the time and may then require a repeat procedure or... if “enough is enough” a hysterectomy.
Now lets get back to the other reasons for hysterectomy:
- Endometriosis — This can cause both abnormal bleeding and chronic pelvic pain and accounts for about 10% of hysterectomies. Endometriosis is caused by the abnormal migration or growth of endometrial cells (which normally line the uterine cavity) onto surfaces of pelvic organs or onto the lining (peritoneum) of the pelvis and abdomen. These cells bleed; precipitate pain, scar tissue formation and development of blood filled cysts when stimulated by hormones produced by the ovaries during the reproductive years. This condition may then cause severe menstrual pain and diminish fertility. Hormonal, anti-hormonal, as well as laparoscopic surgeries to excise the abnormal implants or bloody cysts will be the first line of therapy. Hysterectomy is the last resort.
Pre-cancerous and cancerous conditions accounts for about 23% of hysterectomies.
- Ovarian cancer — This does mandate a hysterectomy together with removal of the fallopian tubes, ovaries and appropriate lymph nodes.
- Endometrial cancer (Cancer of the lining of the uterus) — This too is an indication for hysterectomy. This condition often “announces itself” with abnormal peri or post-menopausal bleeding.
- Genital prolapse — Which accounts for 10 to 15% of all hysterectomies. This is a condition in which the pelvic ligaments supporting the uterus, bladder and rectum are severely stretched or injured (often due to previous pregnancies and deliveries) so that these organs protrude down or out of the vagina. Prolapse causes a sensation of pulling or pressure and can also create problems with urination and/or bowel movements. A pessary can be inserted to hold up the organs, but many women don’t like the way it feels or the fact that it had to be periodically removed and cleansed. The definitive treatment for a prolapsed uterus is hysterectomy. Additional types of surgery may be needed for bladder or rectal prolapse.
Women often have a combination of symptoms. In my case, I had recurrent, growing fibroids (I had a myomectomy years ago) and over the past year they caused bleeding and cramping. In addition I had developed prolapse, probably from my two previous deliveries. (My daughters however, were definitely worth it!)
There are several types of hysterectomies. What are they?
The terminology regarding hysterectomy is somewhat confusing. A total hysterectomy means the removal of the uterus together with the cervix, not the ovaries. (If both of the ovaries are removed, it is called a bilateral oopherectomyif both the ovaries and Fallopian tubes are removed it’s termed a bilateral salpingo-oophorectomy. A sub-total hysterectomy is the removal of the uterus without the cervix. A sub-total hysterectomy often takes less time to perform than a total hysterectomy and is less likely to cause bleeding or injury to the near by ureters and bladder. In the past it was also thought that leaving the cervix would be beneficial for sexual response, but studies have shown that neither sub-total nor total hysterectomy diminished sexual response. Leaving the cervix may however, help prevent future prolapse problems.
What about the vaginal versus abdominal approach? Which surgery is most frequently performed and what are the indications?
We have some idea of procedure rates from an article published in a The New England Journal of Medicine article in 2002: Sixty five percent of hysterectomies in the U.S. were total abdominal hysterectomies performed through an open incision (laparotomy). Surgery through an open abdominal incision is usually indicated for:
Invasive cervical cancer (this will require a radical hysterectomy).
Endometrial cancer that has invaded the uterine wall or the cervix or has spread to other areas in the pelvis.
Large uterine fibroids
Severe scarring with or without endometriosis
Twenty three percent of hysterectomies were total vaginal hysterectomies. The vaginal route is considered preferable to abdominal surgery because it’s a “ no scar” procedure. The post-operative hospitalization, pain, risk of bleeding, need for transfusion and recovery time are at least half that of abdominal hysterectomy. Pelvic or uterine prolapsed, Non-invasive cervical cancer and Fibroids that are not too large and can be removed (with the uterus) vaginally are all indications for this procedure.
There are three variations on the above procedures:
- Laparoscopic assisted vaginal hysterectomyThe removal of the uterus is performed through a vaginal route but a laparoscope is inserted in the abdomen to better visualize the organs and, if necessary, facilitate in the removal of the ovaries, lymph nodes and/or scar tissue. A woman is a candidate for this procedure (also termed LAVH) if: She has had previous pelvic surgeries and has suspected scar tissue or she has early cervical or endometrial cancer where the ovaries and lymph nodes need to be removed.
Which are the easiest surgeries for the patient?
Vaginal hysterectomy allows most patients to be nearly pain-free after a week and return to work after three weeks. Next, in terms of recovery, laparoscopic assisted vaginal or laparoscopic abdominal hysterectomy allow for a 3 to 4 week recovery (as compared to 6 weeks for an open abdominal incision). But patients need to know that fatigue can last longer then incision healing time. (In my case, even though I went back to work in less than 3 weeks, I didn’t feel that my usual energy had returned until I was 6 weeks post op). I must point out that the laparoscopic procedures may take longer in the operating room, (which means a longer time under anesthesia), often cost more (a lot of expensive disposable instruments are used) and require special surgical expertise.
How does a patient decide whether she needs a hysterectomy, and if so, how, and by whom?
She should ask her physician about medical alternatives, and if available and feasible, try them first. If they don’t work or are inappropriate, she should consult with a gynecologist (or if she has cancer, a gynecologic oncologist) about the various surgical approaches. And she should also ask about the surgeon’s personal preference and expertise. The good news is that studies have shown that for most women a hysterectomy improves the quality of their lives and may be life saving. In my case, it did.Dr. Judith Reichman, the TODAY show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of .
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.