Hysterectomy is a surgical removal of the uterus. It does not necessarily mean removal of the ovaries.
Hysterectomy is one of the most common operations performed in Australia and New Zealand. Every year in Australia, around 30,000 women have a hysterectomy. In fact, it is the second commonest major surgical operation after Caesarean section for women under the age of 60. A large-scaled survey found that over 1 in 5 women have had a hysterectomy in Australia. This procedure is commonly performed as a definitive cure of many gynaecological conditions and undesirable symptoms, leading to better health, wellbeing and improved quality of life.
A hysterectomy may be advised for various reasons, such as:
- Uterine fibroids– when there are large or multiple fibroids that cause pressures, pain and discomfort, or produce heavy periods;
- Heavy or irregular menstrual bleeding– especially when the problem does not improve with first-line therapies;
- Endometriosis– in particular when endometriosis involves the uterus, leading to a condition called “adenomyosis”. The uterus becomes enlarged, resulting in heavy, painful periods;
- Prolapse of the uterus – when the uterus prolapses into the vagina or beyond the vaginal open because of pelvic floor dysfunction or “weakness”;
- precancer change of the uterine line cells (atypical endometrial hyperplasia); and
- persistent abnormal Pap smear results; or some precancer changes of the cells on the cervix.
These conditions can cause disabling level of pain, discomfort, severe disturbance to normal activities, or emotional distress.For women with these unpleasant symptoms, hysterectomy can offer a welcomed cure.
Heavy periodscan be treated with medical therapies (IUCDs – Mirena etc, hormonal pills, injections, implant, non-hormonal medications) or Endometrial Ablation/ Resection of lining of uterus. All these methods have a failure rate. The only definitive treatment is the removal of the uterus, i.e. Hysterectomy.
Fibroids can be removed with a surgical procedure called myomectomy. Myomectomy is generally recommended for women who are planning for pregnancies in the future. However, as the uterus is preserved after myomectomy, there are chances that fibroids may re-grow, or the symptoms may return before the woman reaches menopause. Hysterectomy offers a definitive treatment of problematic fibroids for women who no longer desire to get pregnant.
Dr Johnson would be happy to outline the available options and help to find out the best choice for you.
There are different ways to perform a hysterectomy. The choice of approach depends on diagnosis, pathology, prior pelvic surgeries, size of the uterus, and the preference and skill of the surgeon.
- Abdominal (Open) hysterectomy – It is the most invasive type of hysterectomy because it involves a large incision in the abdominal wall, i.e. laparotomy. The incision may be either horizontal - the “bikini incision” – or vertical from just low the umbilicus (“bellybutton) down to the level of pubic bone. The operation is followed by a hospital stay of 2-4 days. Complete recovery takes around 6 weeks.
- Vaginal hysterectomy – The entire hysterectomy is performed through the vagina. An incision is made in the upper vagina, and the uterus is pull down and removed from down below. The vagina is then sutured from below and there is no scar in the abdomen. This procedure is most appropriate for women who have delivered children vaginally and have significant prolapse, because the ligaments supporting the uterus have been stretched and the uterus is attached more loosely. Also, there should be no other significant pelvic pathology as the surgeon would not be able to fully assess the pelvis from the small incision in the vagina.
- Laparoscopic hysterectomy – The uterus is removed entirely using the keyhole technique and the incision at the vagina is closed from above. There is no vaginal surgery with this technique. The surgeon makes tiny incisions (usually 0.5 – 1 cm) on the abdomen. The laparoscope, a miniature camera attached to a slender telescope and a powerful light source, is inserted through a small incision in the navel (“bellybutton”). This camera projects a clear image from inside the body onto a video screen. It enables the surgeon to have a close-up view of the female reproductive organs on a video screen and make a thorough assessment of the pelvis. As the image is magnified, the surgeon can identify the anatomy more clearly and perform a meticulous surgery. With the laparoscopic instruments, the uterus is detached and removed through a small incision at the top of the vagina.
The laparoscopic approach allows an operation that would have been done with open abdominal surgery.
Because the procedure is minimally invasive, laparoscopic surgery is a less traumatic way of removing the uterus. Compared to open abdominal procedures, it is associated with a dramatic decrease in pain, less scarring and faster recovery. Patient can often get up and move around on the first day after the hysterectomy. The hospital stay is typically 1 – 2 days only, and the patient can usually return to her normal activities after about two to three weeks. This is much quicker than having an open abdominal hysterectomy, where complete recovery would take up to 6 weeks.
Another advantage is reduced risk of infection, because tissues are not exposed as they are in open surgery.
In summary, a laparoscopic hysterectomy gives you the benefits of:
- less pain
- less scarring
- faster recovery
- shorter hospital stay
- earlier return to work and normal activity
In comparison to vaginal hysterectomy, the cutting-edge camera technology allows laparoscopic surgeons to have an accurate view of all pelvic organs, and therefore have better control of bleeding and carry out a very precise surgery during laparoscopic hysterectomy. This is particularly important for women who have had previous abdominal surgery, Caesarean sections, pelvic infection or some gynaecological procedures.
You will have the opportunities to discuss any questions with our doctor before the surgery. You will have to sign a consent form, have some routine blood test and be told about what to eat in the days before surgery. You will also receive medication to help cleanse the bowel.
The average stay in hospital after a laparoscopic hysterectomy is 1-3 days. Most patients can get out of the bed and move around the day following the surgery and are eating and drinking normally within this period.
The average time to resume normal activities is 2 weeks, and return to work within approximately 4 weeks, compared to 6 weeks after an open abdominal surgery.
Your vagina is preserved so you can maintain your usual sex life after a hysterectomy. In fact, many women experience better sex lives after having their uterus removed. This is because the uncomfortable symptoms have been cured, there is no more inconvenience of menstrual bleeding, and the couple does not need to practice birth control or worry about unplanned pregnancy. Indeed, many of our patients described that they have become a new happy woman after the hysterectomy!
We do advise a rest period of 6 weeks before resuming sexual intercourse after a hysterectomy. Our doctor will discuss this with you.
Uterus does not produce hormone. Its only functions are to carry pregnancies and to produce menstrual bleeding. Ovaries are the reproductive organs that produce female hormones.
If the ovaries are preserved during a hysterectomy, your female hormone cycles will continue until you reach the natural menopause. This avoids undesirable menopausal symptoms and reduces the need of hormonal replacement therapy (HRT). The hormones secreted from the preserved ovaries will continue to protect your bones and other bodily functions.
The current standard practice in Australia is to preserve the normal ovaries during a hysterectomy for women under 65 years old. Exceptions are when the ovaries are diseased, there is a strong family history of ovarian cancer, or when the woman’s symptoms are related to her female hormonal cycle.
In other words, a hysterectomy DOES NOT cause menopause unless the ovaries are removed at the same time. It does not speed up the ageing process.
Before the surgery, our doctor will go through the details of these options and help you to make an informed decision.
A hysterectomy is a major surgical procedure and like any surgical procedure is associated with some risk.It has been estimated that the risk of any complication occurring following a hysterectomy is about 30%.The majority of these are minor complications such as wound infections, bladder infections,minor injuries to muscles or nerves from being positioned on the operating tale and a prolonged time for bladder function to return following removal of the catheter.These complications will usually be identified and treated and often will not require you to stay in hospital.The exception to this is if your bladder does not work as it should.The main reason for the bladder not working after a hysterectomy is that it is normally located on the front of the uterusand in moving it away from the uterus to prevent any damage whilst removing the uterus and cervix,the nerves to the bladder can be bruised or injured.It may take a period of time for these nerves to recover their normal function.For this reason,a specific post-operative protocol is in placeto scan the bladder by ultrasound to ensure that it has normal function.This will help to prevent short term problems such as urinary tract infections and may prevent long-term bladder problems.
Nearly all women who have hysterectomy will have a small blood clot at the top of the vagina where the uterus has been removed.This is calleda haematoma,which is like a bruise.Occasionally, this haematoma can become infected or may be very large and require drainage.Symptoms of an infected haematoma include offensive vaginal discharge,pain and/or fever.An ultrasound may help to diagnose a haematoma.Treatment can include antibiotics,either by mouth or through a vein.Occasionally the haematoma may need to be drained under an anaesthetic through the vagina.Rarely a laparoscopy or laparotomy would need to be performed.
The most serious complications following hysterectomy are considered to be injuries to the bladder (the organ that holds urine),the ureter(the tube that leads from the kidney to the bladder),the bowel and the major blood vessels.In addition, medical complications such as clots that develop in the legs or lungs, or excessive stress that is placed on the heart and lungs from the surgery can occur resulting in heart attack or stroke.The likelihood of these complications occurring will depend on the reason for your hysterectomy,your past surgical and medical history and your age.It is important to recognise that your long-term safety is the most important aspect of your treatment and the necessary steps to ensure your safety is the first priority.
Specific problems can include bladder injuries,which are usually recognised at the time of surgery.If you are having a vaginal or laparoscopic hysterectomy,these can usually be dealt withby that route,without having to make a large incision in your abdomen.Occasionally a large incision in the abdomen would have to be madeto repair the bladder.If you required a bladder repair following an injury,you would have a catheter in your bladder which may stay in for up to one week.You may be able to go home with the catheter in after instruction on caring for it at home if this is your preference.
Injuries to the ureter(the tube that leads from your kidney to your bladder)may only require a stent-a small hollow tube placed through the ureter from the kidney to the bladder for about 6 weeks.These can be inserted through the bladder without an incision in the abdomen and can be removed through the bladder in a simple procedure,again without an incision in the abdomen.Sometimes the ureter must be ‘reimplanted’ in the bladder.This means that a large incision is made in the abdomen(vertical midline incision see picture),the ureter is cut and placed into the top of the bladder to drain normally.A stent would be placed as above and would need removing,usually at about 6 weeks.This procedure would normally be performed as an outpatient.The bladder and the ureterwillusually function completely normally after this procedure.You will require a special X-ray test at between 6 weeks and 3 months to make sure that the bladder and the ureter are working normally.
Injuries to the large blood vessels are the most urgent complication and require immediate attention. If you are having a laparoscopic or vaginal hysterectomy it is likely that a very large incision(midline vertical incision)would be made in the abdomen for immediate repair.Almost certainly there would be a blood transfusion.Your stay in hospitalis likely to be longer than anticipated.Injury to a blood vessel is a very serious and life-threatening complication.
Injuries to the bowel may occur during a hysterectomy and can be very serious.The injury to the bowel may be very small and may not be detected at the time of the initial surgery.The injury may occur during any type of hysterectomy.If they are detected,then they can often be repaired by the route that the procedure is being undertaken.If you are having a vaginal or laparoscopic hysterectomy,then you may require a laparotomy to repair the injury.You will be given antibiotics and you may require a colostomy.A colostomy is where a loop of bowel is brought to the skin and stitched in place with a bag is placed over this.The bowel contents will empty into the bag.This will usually be in place for three months after the surgery to allow the bowel time to heal.When the bowel is healed,the loop of bowel is closed and placed back in the abdomen.Very occasionally the colostomy may be permanent.If a bowel injury occurs during surgery and is missed,then there may be development of a serious infection in the abdomen.This will require surgery witha large incision in the abdomen and a colostomy(see above).You are likely to have a prolonge dhospital stay whilst the infection is treated and may require admission to an intensive care ward.This is a very serious and life-threatening complication.The risk of bowel injury that is missed is rare with any type of hysterectomy being less than 1/1000 cases. That is for every 1000 hysterectomies performed,there will be approximately one missed bowel injury.
In the post-operative phase following hysterectomy,common complications may include infection in the bladder,the wounds, the top of the vagina or the cervix,medical complications such as clots developing in the legs or lungs,ongoing bleeding from blood vessels cut during the surgery.Whilst inhospital your observations will be taken and signs of temperature,increasing pain or problems with your urine will be monitored.You may require more tests and treatments if one of these complications occurs.
After you have gone home,if you have an increasing amount of pain,increasing vaginal bleeding,high fevers or sweats or vaginal discharge that is offensive then you should contact Dr Johnson and ask for further advice.
A hysterectomy is a major surgical procedure and your recovery will depend on a number of factors:
- The type of hysterectomy that you have
- Your age
- Any associated medical problems that you have
- Individual response to surgery and post-operative pain
- The occurrence of any complications
Recovery rates will vary for each individual and are between 2-4 weeks.Generally,you should allow 2-4 weeks recovery following a vaginal or laparoscopic hysterectomy and 6 weeks following an abdominal hysterectomy.You should not do heavy lifting for 6 weeks and no heavy exercise for the first 2 weeks.You are encouraged to walk regularly each day and rest when you feel tired.You can drive a car when you are comfortable stopping in an emergency (usually about 10 days).You are also advised to consult your car insurance company regarding any restrictions on driving following surgery.You can resume intercourse after you have been seen for follow-up or at 8weeks.
- reduce to nil over the fortnight as your internal wound heals. You should wear panty liners
- You may need to take some simple analgesia for pain/discomfort, especially on waking and settling at night.
- You may feel fatigued.
- You may require up to four to six weeks off work.
- For the majority of women hysterectomy surgery does not have a negative effect on sexual function.
- For the first two to three weeks lift nothing greater than five kilograms. Increase gently as tolerated over six weeks. You should have returned to strenuous activity by two to three months, depending on the type of surgery, although full recovery may take longer.
- Only when you know you can drive comfortably and, in an emergency breaking situation, act without restriction, should you drive a car. This is usually 7-10 days after laparoscopy, and 3-4 weeks after open abdominal surgery.
- Avoid inserting anything into the vagina for 8 weeks to allow time for healing to take place (e.g. use sanitary pads and not tampons).
Common Issues:
- Constipation: You should avoid straining hard to pass stool. If you do not open your bowels for more than two-three days you may need to take or increase the use of regular bowel medication such as movicol, coloxyl, or lactulose. Your chemist can advise.
- Shoulder pain may occur secondary to laparoscopic surgery irritating the diaphragm (with pain referred to the shoulder or chest). This should settle by 1-2 days. It is usually eased by simple analgesia (panadol, anti-inflammatory tablets) and mild heat to the area.
- Pain: wound tenderness and discomfort is usual and may last up to 2-3 weeks. You should be able to walk reasonably comfortably with analgesia
- Wound infections are uncommon. The usual sign of an infection is that the skin around the wound becomes very red and hot or there may be discharge from the wound. Small infections may settle after the discharge is cleaned away and an antiseptic like Betadine is applied twice daily. If you are concerned about the wound please contact us or GP; it is possible antibiotics may be required.
The following signs and symptoms are not part of a normal recovery:a fever > 38.5°C or are feeling unwell offensive vaginal discharge or heavy bleeding wound becomes hot, painful or has offensive fluid draining from it nausea and vomiting which does not settle unable to empty your bladder or bowel severe pain. Tenderness or swelling in a leg/calf
