New York State Department Of Health 10/91
THIS BOOKLET DISCUSSES:
A hysterectomy is an operation to remove the uterus (womb). Most hysterectomies are not emergency operations, so you have time to think about your options. This booklet is designed to help you understand the options and their meaning for you.
FUNCTIONS OF THE UTERUS & OVARIES
The uterus cradles and nourishes a fetus from conception to birth, and aids in the delivery of the baby. It also produces the monthly menstrual flow, or period.
The ovaries have two major functions. One is the production of eggs or ova, which permit childbearing. The second is the production of hormones or chemicals which regulate menstruation and other aspects of health and well-being, including sexual well-being.
If the egg that is released during a woman's normal monthly cycle is not fertilized, the lining of the uterus is shed by bleeding (menstruation).
After a hysterectomy, a woman can no longer have children and menstruation stops. The ovaries generally continue to produce hormones, although in some cases they may have reduced activity.
Some hysterectomies also include removal of the ovaries, so the supply of essential female hormones is greatly reduced. This can have various effects, as discussed later.
WHETHER OR NOT TO HAVE A HYSTERECTOMY
Hysterectomy is one treatment for a number of diseases and conditions. If you have cancer of the uterus or ovaries or hemorrhage (uncontrollable bleeding) of the uterus, this operation may save your life.
In most other cases, a hysterectomy is an elective procedure. The operation is done to improve the quality of life to relieve pain, heavy bleeding or other chronic conditions and discomfort. But there may be other ways of treating or dealing with these problems. So together with your doctor you should weigh all the alternatives and effects of the different choices to help you decide what is right for you.
REASONS FOR A HYSTERECTOMY OR ALTERNATIVES
Reasons why hysterectomies may be recommended fall into three categories:
The following describe the more common reasons for recommending hysterectomies.
CANCER OF THE UTERUS OR OVARY
Cancerous organs and, in some cases, adjoining organs and structures, are removed in order to stop the spread of this life-threatening disease.
These are common noncancerous (benign) tumors of the uterus and they are the most frequent reason for recommending a hysterectomy. They grow from the muscular wall of the uterus and are made up of muscle and fibrous tissue. Many women over 35 have fibroids, but usually have no symptoms.
In some women, however, fibroids (myomas) may cause heavy bleeding, pelvic discomfort and pain and occasionally pressure on other organs. These symptoms may require treatment, but not always a hysterectomy. For example, there are some promising new experimental drugs that may temporarily shrink the tumors.
However, these drugs may have serious side effects and are generally very costly. There is also a type of abdominal surgery (myomectomy) that removes the myoma without removing the uterus (see page 11 for additional information). These treatments may be sufficient or they may offer temporary relief and enable a woman to postpone having a hysterectomy, especially if she still wishes to bear children.
Some women choose to do nothing since fibroids will often shrink in size as a woman goes through menopause.
Another common reason for recommending a hysterectomy is endometriosis. This is a noncancerous condition in which cells similar to the uterine lining grow like islands outside of the uterus. This growth occurs most commonly in the ovaries, fallopian tubes, bladder, bowel and other pelvic structures, including the uterine wall. These cells may cause pain and discomfort by bleeding at the time of menstruation. Endometriosis may also cause scarring, adhesions and infertility.
Symptoms can vary greatly and some women choose to do nothing, or find that drug therapy, pain relief medication or more localized surgery are effective. When these are not effective, hysterectomy may be the treatment of choice.
As a woman ages, the vaginal supports begin to lose their muscle tone and sag downward (prolapse). With prolapse, the bladder and/or rectum may be pulled downward with the uterus. This happens to most women to some degree. For the vast majority, the sagging is minor and produces no symptoms.
If the prolapse worsens, some women experience a heavy or dragging feeling in the pelvic area, problems controlling bladder and/or bowel function, and occasionally, protrusion of one of the organs through the vaginal opening.
Some women get relief from a number of these symptoms by doing special (kegel) exercises to strengthen the pelvic muscles, by taking hormone therapy or by using a plastic or metal ring (pessary) which may help to hold the uterus in place. None of these treats the underlying problem.
A hysterectomy with repair of supporting structures is usually recommended in more serious cases. A woman has to decide for herself if the discomfort is great enough to have a hysterectomy.
CANCER OF THE CERVIX
Precancerous changes in the cervix are often found on routine Pap smears. These lesions or abnormalities must be treated, but rarely with a hysterectomy. When detected early and treated effectively, most of these conditions do not progress to invasive, life-threatening cancer. they can be treated conservatively. Most can be treated on an outpatient basis.
It is only in the case of invasive cancer of the cervix that hysterectomy may be the treatment of choice.
PRECANCER OF THE UTERUS
A precancerous change can occur when the lining (endometrium) of the uterus overgrows. Hyperplasia of the endometrium means an "overgrowth" of the lining of the uterus. It causes irregular and/or excessive bleeding. It can usually be treated with hormone therapy. In more severe cases or cases that do not respond to hormone treatment, hyperplasia of the endometrium may lead to cancer of the uterus. In these cases, hysterectomy would be the treatment of choice.
Irritation of the lining of the abdomen may cause adhesions (scarring) which bind affected organs to each other. The adhesions can result from endometriosis, infection or injury. The symptoms may include severe pain, bowel and bladder problems and infertility.
Pain relief medication or less drastic surgery, such as laser therapy, can be effective in some cases. In very serious cases, hysterectomy may be recommended. However, a hysterectomy itself can cause adhesions.
UNUSUALLY HEAVY BLEEDING
It is normal for the amount and length of menstrual flow to vary from woman to woman. There may also be differences in menstrual flow from one cycle to the next. If bleeding that is unusually heavy or frequent for you occurs, this may be due to a variety of causes. The most common causes are fibroids and hormonal changes.
Because there can be many reasons for unusually heavy bleeding, getting an accurate diagnosis is vital before deciding on a course of treatment. Depending on the diagnosis, drug therapy or minor surgery may be indicated. Rarely, there can be hemorrhage of the uterus in which case a hysterectomy can be life saving.
This is a common symptom. As with heavy bleeding, there can be a number of causes for pelvic (lower belly) pain. These include endometriosis, fibroids, ovarian cysts, infection or scar tissue. Pain in the pelvic area may not be related to the uterus.
Therefore, a careful diagnosis is essential before considering whether to have a hysterectomy.
BENEFITS & RISKS
A hysterectomy may be life-saving in the case of cancer. It can relieve the symptoms of bleeding or discomfort related to fibroids, severe endometriosis or uterine prolapse. On the other hand, you may prefer to seek alternatives to surgery for these symptoms or other problems related to the uterus and pelvic organs.
Symptoms like pelvic pain or unusual bleeding may not necessarily be related to the uterus. An accurate diagnosis will help you to determine the potential benefits and risks of a hysterectomy.
The risks of hysterectomy include the risks of any major operation, although its surgical risks are among the lowest of any major operation.
Hysterectomy patients may have a fever during recovery, and some may have a mild bladder infection or wound infection. If an infection occurs, it can usually be treated with antibiotics. Less often, women may require a blood transfusion before surgery because of anemia or during surgery for blood loss. Complications related to anesthesia may occur.
As with any major abdominal or pelvic operation, serious complications such as blood clots, severe infection, adhesions, postoperative (after surgery) hemorrhage, bowel obstruction or injury to the urinary tract can happen. Rarely, even death can occur.
In addition to the direct surgical risks, there may be longer-term physical and psychological effects, potentially including depression and loss of sexual pleasure. If the ovaries are removed along with the uterus prior to menopause (change of life), there is an increased risk of osteoporosis and heart disease as well. These will be discussed later along with possible treatments.
In making a decision, you should also consider that a hysterectomy is not reversible. After a hysterectomy, you will no longer be able to bear children and you will no longer menstruate. You need to evaluate the impact these changes would have on you.
Talk about your concerns with your doctor or a counselor and your partner. You may want to bring your partner to your doctors office to discuss concerns before having the operation.
REMOVAL OF TUBES AND OVARIES
Should your ovaries be removed along with your uterus if you have a hysterectomy?
If you have a diagnosis of uterine cancer, the ovaries should be removed because the hormones they secrete may encourage the growth of the cancer. They also may have to be removed in severe endometriosis because they produce the hormones that are responsible for endometriosis.
The fallopian tubes are generally removed when the ovaries are removed because they are adjoining structures and their sole purpose is to serve as a passageway between the ovaries and the uterus.
In cases other than uterine cancer or endometriosis, there is controversy among doctors about the advantages and disadvantages of removing ovaries and tubes as part of a hysterectomy.
Some doctors believe that healthy ovaries should be removed as part of a hysterectomy in women who are over a certain age, when normal ovarian hormonal activity may be diminishing. It is done as a preventive measure to reduce the risks of developing ovarian cancer. This is because ovarian cancer is very difficult to detect at an early stage and is often resistant to the best medical treatments.
Other doctors disagree because this cancer is not common and because removal of the ovaries does not always guarantee women will not develop ovarian cancer. (Rarely, the cells that cause ovarian cancer can be present in the body even after the ovaries are removed.) In addition, ovaries produce several hormones which are beneficial to women. They protect against serious diseases such as heart disease and osteoporosis and contribute to sexual pleasure.
As a woman ages, the ovaries gradually reduce their production of hormones. When menstruation ends, at the menopause, the ovaries markedly diminish production of estrogen, and this results in decreased protection against heart disease and osteoporosis. For a period of time after menopause, the ovaries continue to produce androgen, a hormone which is primarily critical for maintaining women's sexual desire. Normally, androgen may produce additional facial hair as well. Removing the ovaries causes menopause to occur more abruptly. The symptoms of menopause include hot flashes, night sweats, insomnia, fatigue, depression and vaginal dryness.
After ovaries are removed-or when menopause occurs-hormone replacement therapy often helps. Hormone replacement therapy cannot exactly duplicate the hormonal activity of the ovaries, but will reduce the risks of heart disease and osteoporosis, and reduce menopausal symptoms like hot flashes and vaginal dryness. It may also contribute to sexual pleasure. However, there are some women who cannot be placed on hormone replacement therapy. For example, some women with liver disease or a history of hormone-dependent tumors, such as breast cancer, may not be able to take these hormones.
Every person reacts differently, and reactions are a combination of emotional and physical responses. We still have much to learn about the effects of hysterectomy on sexual function.
Some women say they enjoy sex more after a hysterectomy, particularly if they had a lot of bleeding and pain beforehand. Some women feel more relaxed not worrying about getting pregnant.
Some women who have hysterectomies experience diminished sexual enjoyment. There may be a number of reasons for this which are only partially understood.
For some women, uterine contractions and pressure against the cervix add to sexual pleasure. Others may feel less pleasure or reduced desire due to loss of certain hormones, especially after removal of ovaries. In addition, loss of hormones can cause vaginal dryness and make sex uncomfortable. Hormone replacement therapy may relieve some of these symptoms. A vaginal gel or lubricant can reduce vaginal dryness. For some women, reduction in sexual pleasure is temporary while they and their partners adjust. Because sexual feelings are so individual, it may be difficult to predict exactly how a hysterectomy will affect your feelings.
Some women report having a strong emotional reaction, or feeling down, after a hysterectomy. Most feel better after a few weeks, but some women do feel depressed for a long time. Other women experience a feeling of relief after a hysterectomy.
No longer being able to bear children can cause emotional problems for some women. Some women feel changed or feel they have suffered a loss. Talking things over with your physician, your partner, a friend or a counselor often helps. It may help to talk with a friend or another woman who has had a hysterectomy before and after your operation.
Alternatives to hysterectomy have their own benefits and risks. A myomectomy for fibroids, for example, is more localized therapy and does not involve removal of the uterus. However, like hysterectomy, it does involve general anesthesia and is a major operation. A myomectomy is a technically more difficult operation than a hysterectomy, and there may be increased risk of bleeding and infection. With this procedure, tumors may remain or recur which may lead to further surgery in the future, sometimes a hysterectomy.
Laparoscopy is a common procedure which enables the physician to visualize and treat a number of gynecologic conditions such as endometriosis through one or more minute incisions in the abdomen. It usually requires one day surgery and general anesthesia. Laser therapy or microsurgical techniques can be utilized with laporoscopy.
Each drug therapy has its own side effects and you should review these with your physician. Some therapies are more experimental and their benefits and risks may not be as well understood. You need to carefully review with your doctor what is known about any therapy you choose.
More localized therapy, like a myomectomy in the case of fibroids or laser or drug treatment in the case of endometriosis, may be valuable as an initial procedure for you, with the option of a hysterectomy later. Or you may choose to simply bear with your symptoms for awhile and see what happens over time since the bleeding and discomfort related to endometriosis or fibroids may diminish as a woman enters menopause.
In considering a hysterectomy, you may wish to get a second opinion. A second opinion means that a second doctor will review your medical history, examine you and advise you as to whether he or she agrees with your primary doctors treatment recommendation. It is an opportunity for you to discuss your condition with another expert. Many health insurance plans require and pay for a second opinion before any major surgery. If you don't know another doctor to ask for a second opinion, your insurance company or the county medical society (listed in the white pages of the phone book) can give you the names of appropriate doctors in your area. It is preferable to request a physician who is board certified in obstetrics and gynecology.
Finally, because every woman is unique and because a hysterectomy was recommended to you because of your individual needs, it is important that you discuss your personal risks and benefits with your doctor before deciding whether to have a hysterectomy. As with other surgery, different doctors make different judgements about when to recommend this operation.
DIFFERENT TYPES OF HYSTERECTOMIES
All hysterectomies are major operations involving removal of at least the uterus. Some types of hysterectomies involve removing other organs as well. It is important to talk with your doctor about the kind of hysterectomy recommended for you.
This operation involves removing both the body of the uterus and the cervix, which is the lower part of the uterus. The cervix is usually removed to prevent subsequent cervical cancer. It can sometimes be done through the vagina (vaginal hysterectomy); at other times, a surgical incision in the lower belly (abdominal hysterectomy) is preferable. For example, if you have large fibroid tumors, it is difficult to safely remove the uterus through the vagina.
Vaginal hysterectomy, when it can safely be performed, generally involves fewer complications, a shorter recovery period and no visible scar.
In a total hysterectomy and bilateral (both sides) salpingo-oophorectomy, the ovaries and fallopian tubes are removed, along with the uterus and cervix. "Complete hysterectomy," which is sometimes used to refer to this procedure, is not a medical term.
In this operation, only the upper part of the uterus is removed, but the cervix is not. Tubes and ovaries may or may not be removed. This procedure is always done through the abdomen.
This procedure is reserved for serious disease such as cancer. The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen. Since cancer is unpredictable, other organs or parts of other systems are sometimes removed as well.
HOSPITALIZATION & RECOVERY
Presurgical routines vary from hospital to hospital.
After the operation, the hospital stay is usually less than a week, depending on the type of hysterectomy and whether there are any complications.
Since hysterectomy is a major operation, discomfort and pain from the surgical incision are most pronounced during the first few days after surgery, but medication is available to minimize these symptoms.
By the second or third day, most patients are up walking. Normal activity can usually be resumed in four to eight weeks. Each patient is an individual, so the pace of recovery will vary.
Sexual activity can usually be resumed in six to eight weeks.
During recovery, you may need to rest frequently at first. Plan ahead and ask friends, neighbors or relatives to help you when you get home. It will probably take a while to feel peppy.
Many women find that special exercises can help them recover faster and feel better.
You can discuss both presurgical procedures and your recovery, including useful exercises, with your doctor.
ASK YOUR DOCTOR
menopause be treated? What are the risks and benefits of such treatment?
of stay? anesthesia? infection? transfusion? urinary catheter?
For more information, call:
New York State Department of Health Hotline 800-522-5006
American College of Obstetricians and Gynecologists
(free patient education materials)
Center for Medical Consumers
This booklet was developed with the assistance of consumer groups and professional medical organizations. ********************************* New York State Department of Health Date posted 8/8/94