A Division of Atlanta Women’s Health Group
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Hysterectomy

There are a number of reasons why a woman may need to have a hysterectomy. These reasons fall into two broad categories — hysterectomies that are absolutely necessary to save the life of the mother such as hysterectomies for cancer, overwhelming infection, and uncontrollable bleeding and hysterectomies to improve the quality of life of a woman. This latter type of surgery may be done for disabling pelvic pain or flooding which results in lost time from work, the presence of benign tumors which cause discomfort from pressure on the bladder or rectum, or for pelvic weakness which results in urinary incontinence, falling out of pelvic structures, or problems with control of one’s bowels

Unfortunately, sometimes the term “hysterectomy” is used incorrectly to mean removal of the ovaries as well as the uterus. Terms such as “complete hysterectomy” or “total hysterectomy” are confusing. While most physicians mean the complete removal of the uterus including the cervix but not the ovaries, many consumers interpret this to mean the removal of the uterus, tubes, and ovaries. The correct term for removal of the ovaries is “oophorectomy” or “ovariectomy” — with “bilateral” oophorectomy meaning that both of the ovaries were removed. When the ovaries are removed, “surgical menopause” results, creating an abrupt decline in ovarian hormones such as estrogen; women who undergo surgical menopause can expect to have severe hot flashes immediately after surgery. If only one ovary has been removed, the remaining ovary may continue to produce a normal level of hormones, preventing immediate menopause. Occasionally, after a hysterectomy without removal of the uterus, a patient may experience menopausal — like symptoms for a month or two because of disruption of the blood supply to the pelvic. This normally corrects spontaneously after a while.

Following hysterectomy, a woman who wishes to take estrogen for menopause-related changes does not need to take another hormone — progesterone or a progestin — to guard against an increased risk of uterine cancer that could result from estrogen alone. Therefore, menopause treatment following removal of the uterus is greatly simplified.

There are several forms of hysterectomy

Radical hysterectomy — the operation for uterine or ovarian cancer. The uterus and the pelvic tissue and lymph glands to removed to attempt complete removal of the cancer. The ovaries may or may not be removed. Obviously, when this is needed it must be done.

Abdominal hysterectomy (TAH) — this is the old fashion way of removing diseased tissue in the pelvis by cutting the abdomen open either by an up and down (vertical) or a sideways (transverse or Pfannensteil) incision. There still is a place for it in modern gynecology — for very large masses, suspected cancer or severe infection. Fortunately, for many women, this has been replaced by laparoscopic hysterectomy (see below). The main advantage of abdominal hysterectomy is that everything can be clearly seen and that any gynecological surgeon at almost any facility can perform this procedure with skill and safety. The main disadvantage is a painful abdominal incision, a longer hospital stay (typically 2-4 days), a large scar, and a longer convalescence (approx 6-8 weeks).

Vaginal hysterectomy (TVH) — For many years this has been the preferable method of hysterectomy for the right candidate. It offers the advantage of surgical speed, low cost, a shorter hospital day (2-3 days) and an easier convalescence (4-6 weeks). Unfortunately many younger gynecological surgeons do not feel comfortable with this approach because of their lack of training.

Laparoscopic hysterectomy — There are several forms of this operation. On one case, it is done totally laparoscopically (TLH) with the removal of the uterus through the abdomen or vagina and in the other case, part of the dissection is done laparoscopically (LAVH) and then, the surgery is completed vaginally to make it easier and safer to remove the uterus through the vagina. Using these techniques, perhaps 75-80% of abdominal hysterectomies can be converted to a vaginal approach. Typical hospital stays are 24-48 hours and convalescence can be as little as 2-4 weeks. All surgery has risks–the general risks include bleeding, transfusions, infection, and loss of function of limbs, paralysis allergic reactions to drugs, blood clots, and even death. These complications can occur even if the surgeon never touches your body.

Laparoscopic robotic hysterectomy — This is the latest version of the laparoscopic hysterectomy. In this version, the operator sits at a console and does the entire case robotically. It offer the advantage of seeing the pelvic floor three dimensionally and gaining access to more difficult areas of the body. It is very expensive and very trendy. It should be reserved for converting highly complex procedures such as hysterectomies for large uterine fibroids, complex pelvic adhesions, or cancer from the traditional abdominal route (TAH) to laparoscopic surgery. It is inappropriate to use this for simple hysterectomies as a marketing gimmick.

Specific complications of hysterectomy may include menopause, loss of the ability to bear children, more extensive surgery than originally planned, injuries to bowel, bladder, the urinary tract, and pelvic blood vessels, hernias, wound infections etc. etc. Before you consider surgery, be sure that you understand the problem that you have, the alternatives to surgery, the benefits to surgery, and what might happen if you choose not to do it. IF YOU HAVE ANY QUESTIONS OR ARE NOT SURE, GET A SECOND OPINION. If your surgeon does not offer you enough time to answer all of your questions to your satisfaction, find another surgeon you can relate to.

Finally, if your problem is excessive bleeding or cramps, be aware that there are alternative minimally invasive operations that can stop bleeding without a hysterectomy, without a hospital stay, and without a period of convalescence.