Are You Planning a Hysterectomy?

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If you have heavy abnormal menstrual bleeding, pelvic pain, endometriosis, uterine fibroids, uterine prolapse or cancer of reproductive organs, you may be a candidate for a hysterectomy.

Hysterectomy (removing of the uterus) is the second most common surgery for women, only superseded by cesarean section. Over 600,000 are performed each year in the United States. Approximately 20% are performed prior to the age of 40, 33% by age 65, and 39% by 85 years of age.

There is often some confusion about what a hysterectomy is. By definition, it means just removing the uterus. When the ovaries and tubes are removed, the term salpingo-oophorectomy (salpingo = tubes and oophorectomy = ovaries) is added to the procedure.

Now that we have clarified the definitions, what is involved with the surgery? There are different types of hysterectomies that your doctor will discuss based on the indications, your specific pathology and physical findings. It was just 20 years ago that most hysterectomies were performed by a 12-17cm lower abdominal incision. These abdominal surgeries required at least 2-3 days of recovery in a hospital and most women would take an additional six weeks off to fully recover. Surgeons at the time also could perform a hysterectomy through the vagina with no visible incisions. The recovery is much easier and less painful. While not all indications for hysterectomy can use the vaginal approach, it's still the least invasive surgical options today.

The popularity of laparoscopy offered more options for this surgery. The thought of using a small telescope through a 0.5-1.5 cm incision pushed gynecologists to learn new skills. The term "minimally invasive surgery" encompasses these new techniques. The advantage is not only smaller incisions, but considerably less pain and a quicker recovery period for hysterectomies that once required days in the hospital. These are now outpatient surgeries where the patient goes home the same day.

There is another modification of laparoscopic surgery called a laparoscopic-assisted vaginal hysterectomy. The surgeon uses the laparoscopic approach into the abdomen to help free the uterus from its attachments, and the uterus is then removed through the vagina. Another technique utilizing laparoscopic surgery is to remove the uterus through the small abdominal incisions by cutting it into smaller pieces. This procedure is called a laparoscopic supracervical hysterectomy (LASH). This technique preserves the cervix.

Then came the development of robotic surgery. Initially, this was designed for military application but eventually became available commercially more than 15 years ago. Gynecologists adopted this new technology with great excitement. Robotics has dramatically changed gynecologic surgery. This advanced technology allows the surgeon to perform complex surgeries with a minimally invasive approach. Patients also experience considerably less postoperative pain, improved safety and quicker recovery times.

What are the risks involved with these surgeries? As with most abdominal surgery, bleeding, infection and injury to the surrounding organs would be the most common risks. Other risks can include vaginal prolapse, or portion of the vagina protruding outward and pelvic pain.

Now that we have explored the definitions and types of surgeries, how to do you choose what is the right one for you? One consideration is whether or not to remove the cervix. The benefits of removing the cervix is that for benign disease, PAP tests no longer need to be performed. If you have had abnormal pap smears in the past, your doctor may still want to follow these as vaginal cancers can also develop.

The disadvantage of removing the cervix is that it does increase the risk of surgery. There has been a debate over the decades whether or not the cervix plays a role in the sexual experience. This, unfortunately, is a complex issue with no clear answer. Many experts believe that it does not, but this is a discussion that needs to be addressed with your gynecologist. Women often report that sex is better with less pain and fear of abnormal bleeding. Some women do not complain about increased pain due to scar tissue that has developed or changes and hormones leading to vaginal atrophy and dryness.

Currently, the recommendation is to remove the tubes at the time of hysterectomy. This practice decreases the risk of ovarian cancer up to 25% over a lifetime.

One last consideration: What about the ovaries?

If the indication for hysterectomy is purely because of uterine diseases such as fibroids or abnormal bleeding, then a discussion about the fate of the ovaries is important. In the past, for women near or beyond menopause, the ovaries were often removed. We now know that the ovaries continue to produce hormones including testosterone up until age 60 and sometimes beyond. This is another important issue to discuss with your gynecologist.

If the ovaries are removed, this is an instant pathway to menopause. Some women will need hormone replacement therapy in order to feel normal. Other health risks such as the risk for osteoporosis will need to be addressed, as well. Some women will feel a sense of loss and grief after a hysterectomy. Depression can also occur with the loss of fertility in younger women.

Gynecologists are all well-trained to discuss surgical options. Not all of them perform robotic surgery and if you desire this approach, find someone who does them regularly and has good experience and outcomes. This is also true for vaginal hysterectomies, as the skills required are perfected by experience.

There is a reason that hysterectomies are the second most common surgery and women: They offer a solution to the very common problems listed at the beginning of this article. The surgeries are life changing for those to suffer form pelvic pain, abnormal bleeding, and the discomfort associated with uterine prolapse.

Talk to your gynecologist to help make the best decision for the surgery that is right for you. There are many good resources to help you learn more about your options including: The American College of Obstetrics and Gynecology (ACOG), Medline and Web MD, for example. The better informed you are, the easier it will be to make the right decision for yourself.

Courtesy of Grand Rapids OB/GYN.


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