Hysterectomy is the removal of the uterus.

 

What are the types of hysterectomy?

Total hysterectomy refers to removal of uterine body and uterine cervix.

Subtotal hysterectomy refers to removal of uterine body and preserving the cervix.

Radical hysterectomy refers to removal of uterine body, uterine cervix, upper vagina, paracervical tissue and selective lymph nodes as in cancer cervix.

 

What are the routes of hysterectomy?

Abdominal: The uterus is removed through an abdominal incision. 

Vaginal: The uterus is removed through the vagina. 

Laparoscopic Assisted Vaginal Hysterectomy: The vaginal removal of uterus is assisted with laparoscope.

Laparoscopic Hysterectomy: The procedure is mainly done through laparoscope.

 

What are the reasons for hysterectomy?

  • Uterine leiomyomata / Fibroids
  • Pelvic Endometriosis / uterine Endometriosis (Adenomyosis)
  • Menstrual disturbance 
  • Premalignant uterine or cervical diseases 
  • Malignant uterine and Ovarian tumours
  • Uterine prolapse
  • Complication of child birth

 

Alternatives to hysterectomy 

Depend on reasons for hysterectomy. 

In heavy or irregular periods medications, hormones, Mirena and endometrial ablations may be useful to avoid hysterectomy. 

In fibroids myomectomy with or without Zoladex to reduce fibroid size can alleviate heavy or irregular periods and pressure symptoms. 

Excision and coagulation of endometriosis can control endometriosis and its symptoms and may be alternative to hysterectomy. 

Local treatment i.e.LETZ, laser and cone biopsy are well established treatment for premalignant condition of uterine cervix. 

In selected cases of ovarian tumours removal of the affected ovary may be adequate without removal of the uterus. 

Laparoscopic or minimal access surgery to support the prolapsed uterus can be used to elevate the uterus without removing the prolapsed uterus. 

Alternative techniques are now available to reduce the need to perform hysterectomy at Caesarean Section. Those include injection of prostaglandins, inflatable balloons, special sutures and internal iliac artery ligation.

 

The best decision?

Is the one based on knowledge and fact rather than on myth and misinformation.

 

How can I know what is fact and what is myth?

You need to research before you can reach the truth. 

 

Can I avoid hysterectomy?

There are many situations in which less extensive surgery may be available or preferable.  Hysterectomy has both advantages and disadvantages.  There are times when a hysterectomy may be the best procedure for this particular situation.  Each patient situation is unique. 

 

Am I having additional procedure performed at hysterectomy?

Sometimes an ovary is removed at hysterectomy i.e. oophorectomy. Occasionally both ovaries are removed i.e bilateral oophorectomy. 

Salpingectomy refers to removal of a tube. Bilateral salpingectomy means removing both tubes. 

Removal of an ovary and tube is termed salpingo-oophorectomy.

 

Is hysterectomy safe? 

Hysterectomy is a major operation. There is a small risk of complications and rarely death. The risks need to be compared to the risks of alternative treatments or no treatment at all. 

Improvements in medical care have shortened recovery time. Better and newer pain control allowed patient to go home earlier. 

Most healthy women are able to go home the next day after a vaginal hysterectomy, and two days post uncomplicated abdominal hysterectomy.

 

Is the vaginal route safer?

There is less pain and recovery is faster if the uterus is removed through the vagina without the need to make an abdominal incision.

Sometimes large ovarian cysts, extensive endometriosis, large fibroids, or unexplained pelvic pain make the vaginal route difficult or impossible.  

In such disease processes the gynecologist uses laparoscope through the belly button to look at the pelvic organs.  Other instruments such as graspers, scissors, electrosurgical cautery, ligasure, advanced P K Tissue management system, needle holder, suture materials, endosuture, endopouch, endoloop are inserted through other small abdominal incisions to perform steps in hysterectomy, and to allow it to be completed through the vagina; Laparoscopic Assisted Vaginal Hysterectomy (LAVH) or completed through laparoscope; laparoscopic hysterectomy (LH).

While LAVH and LH are often less invasive than an abdominal hysterectomy it is more invasive than a vaginal hysterectomy.  

If the hysterectomy can be done vaginally, then no abdominal incisions are needed.  

There are no studies to show that LAVH is better than vaginal hysterectomy if the latter can be done safely.   

Sometimes the deciding on the route of procedure is best after looking through laparoscope.

 

Does abdominal hysterectomy still have a place?

An experienced laparoscopic surgeon may do almost any hysterectomy through the laparoscope. However; this may need a long time with subsequent significant increased complication risks. 

While new instruments such as debulking equipement, are aiding in the removal of large fibroids, through the laparoscope, it is often safer to use an incision rather than the laparoscope.

After hysterectomy much of healings happen around top of vaginal and pelvic floor. If incision is avoided recovery is marginally faster; but not as noticeable as after laparoscopic removal of ovarian cyst where most healing happen in abdominal incision not at the level of ovarian attachment. 

 

Will orgasm be the same after hysterectomy?

Pre-hysterectomy counselling should cover sexual activity and orgasm.

The most predictive factor in postoperative sexuality and orgasm was preoperative sexual activity and orgasm.

Most women would have no change in the way they feel orgasm post hysterectomy as they did not have problem with orgasm prior to surgery.

Some women report improved orgasm after hysterectomy as they do not experience the pain or bleed occurred prior to hysterectomy.

A small number of women would have less interest in sex as they did prior to surgery. 

Sometimes orgasm may be different from what experienced prior to surgery.  

Some women who had sexual dysfunctions prior to hysterectomy still have sexual dysfunctions after hysterectomy. 

 

Is it better to keep my cervix?. i.e to have Supracervical (Subtotal) hysterectomy 

Some 50-60 years ago, most surgeons couldn't safely remove the uterus and they would leave the cervix.  This is called a subtotal hysterectomy.  

With improved surgical technique and in an attempt to prevent cervical cancer developing in residual cervix (stump) more surgeons removed the whole of the uterus. 

Recently there has been revival in the practice of leaving the cervix.

Claimed advantages of subtotal hysterectomy include:

Orgasm is better.

The risk of vaginal vault prolapse is less. Cervical support system is interrupted at hysterectomy. However much damage of cervical support occurs at time of childbirth and damaged tissues can be repaired at hysterectomy

If the cervix is normal do not remove it. However; Cervical cancer and in particular adenocarcinoma can be difficult to detect or treat.

In the above three claims there are no good studies to support them.

 

After hysterectomy am I going to have depression?.

It is not easy to assess this issue as comprehensive proper study is essential to answer this question.

Some studies have shown that hysterectomy for benign disorders does not cause depression and may improve psychiatric symptoms in many women. 

One would expect hysterectomy which; stops pain and bleeding occurring every month, to alleviate or improve depression.     

As any surgery depression can follow hysterectomy. However; depression before surgery is the best predictor of depression afterwards.            

Obviously infertile women who wanted babies, and needed hysterectomy because of a problems such as endometriosis or fibroids, may not be able to face they would never carry a baby. 

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