Reproductive health

Hysterectomy

Defined as the surgical removal of the uterus, a hysterectomy is one of the most common surgical procedures and can also involve removal of the Fallopian tubes, ovaries, and cervix. Removal of these structures is done to cure or alleviate any number of gynecological complaints. Following a hysterectomy, a woman will no longer have menstrual periods and will no longer be able to become pregnant or to bear children.

There are two main ways in which a hysterectomy is performed. The most common of these—an abdominal hysterectomy—involves the removal of the uterus (and other structures, if necessary) through an incision in the lower abdomen. The second, less common procedure—a vaginal hysterectomy—involves removal of the uterus only through an incision in the top of the vagina. Generally, these procedures last one to two hours and are performed in a hospital with the patient under a general anesthetic.

According to the Hysterectomy Association (United Kingdom), one in five women will have a hysterectomy at some point in her lifetime.¹ In the majority of cases, a hysterectomy is an elective procedure rather than an emergency operation. This means that a woman freely chooses to undergo a hysterectomy in an effort to cure or alleviate the symptoms of any number of gynecological problems (including cramps, endometriosis, and fibroids; see below).

Who is a candidate for a hysterectomy?

While the majority of hysterectomies are performed on women between the ages of 40 and 50, women outside this age group also undergo hysterectomy. If a woman hasn't yet gone through menopause, a woman whose hysterectomy also involves the removal of both of her ovaries (also known as a hysterectomy with bilateral salpingo-oophorectomy; see the types of hysterectomy, below) will experience menopause immediately following surgery, regardless of her age. Removal of the ovaries is not generally necessary unless ovarian cancer or ovarian cysts are suspected. Women whose hysterectomy leaves one or both of their ovaries intact have a 50 percent chance of experiencing menopause within 5 years of their operation.²

As mentioned above, a hysterectomy may become necessary when a woman suffers from the following symptoms:

• heavy or painful or irregular vaginal bleeding
• fibroids (non-cancerous growths of muscle and fibrous tissue) that are either large or that result in pain or bleeding
• uterine cancer
• ovarian cancer
• cancer of the cervix
• cancer of the Fallopian tubes
• endometriosis
• prolapse of the uterus, a condition in which the uterus falls into the vagina
• pelvic inflammatory disease (PID) or adhesions that cause pain not controlled by any other means
• emergencies such as rupture or puncture of the womb (as in other surgery)
• uncontrolled bleeding as the result of childbirth

A doctor may recommend hysterectomy where initial treatments for these conditions has been unsuccessful. Any woman considering hysterectomy must ensure she fully understands the implications of hysterectomy, should she decide to have the operation and of living with her condition, if she chooses not to have surgery. In other words, hysterectomy is a major operation and you should be sure to discuss its risks and implications with your doctor.

What are the risks associated with hysterectomy?

For most women, hysterectomy means the relief of symptoms and the freedom to enjoy life to its fullest. For a number of women, however, the opposite is true. Below are some of the risks associated with hysterectomy. Be sure to discuss these with your doctor or gynecologist.

• stress-induced irritable bowel syndrome
• stress incontinence and/or other urinary symptoms
• damage to the urethra and bowel—because of its proximity to both the bowel and the urethra, this may be more prevalent if the cervix is removed.
• prolapse of the vagina
• back pain
• depression
• Loss of sexual feeling and/or function
• post-operative infection
• hematoma (collection of blood in the wound) and/or thrombosis (blood clot)

While generally effective in the treatment of adhesions, pelvic inflammatory disease (PID), and endometriosis, there is the possibility that such conditions may recur, even after a hysterectomy. This is because each of these conditions is believed to be triggered by the presence of estrogen. Thus, if a woman retains her ovaries following a hysterectomy or if she is advised to take hormone replacement therapy (HRT) following an oophorectomy, her body will continue to produce estrogen, thereby increasing the likelihood of recurrence of these conditions. Again, be sure to discuss these concerns with your doctor or surgeon.

What are the types of hysterectomy?

Your doctor will also likely explain to you the type of procedure he or she will perform. As explained above, there are two main ways in which a hysterectomy may be performed. The most common—an abdominal hysterectomy—involves the removal of the uterus through an incision in the lower abdomen. The second and less common—a vaginal hysterectomy—involves the removal of the uterus through an incision in the top of the vagina. The type of procedure performed depends on the medical condition being treated.

Subtotal hysterectomy

A subtotal hysterectomy or partial hysterectomy involves the removal of the upper two thirds of the uterus while preserving the cervix, Fallopian tubes, and ovaries. Women undergoing this type of hysterectomy will still need to have regular Pap smears to test for the presence of cervical cancer. This procedure is not commonly performed.

Total hysterectomy

The most common type of hysterectomy, a total hysterectomy, also called a total abdominal hysterectomy, removes the entire uterus, as well as the cervix, but preserves the Fallopian tubes and ovaries.

Total hysterectomy with bilateral or unilateral salpingo-oophorectomy

A total hysterectomy with bilateral or unilateral salpingo-oophorectomy removes the uterus, as well as the cervix, Fallopian tubes, and one (unilateral) or both (bilateral) of the ovaries.

Radical hysterectomy

A radical hysterectomy (also called a Wertheims hysterectomy) removes the uterus, cervix, part of the vagina, Fallopian tubes, peritoneum (the broad band of ligament below the uterus), the lymph glands and fatty tissue of the pelvis, and in some cases, also one or both ovaries. This type of hysterectomy is used in the treatment of gynecological cancer.

These procedures are performed in a hospital, under a general anesthetic.

Recovery from hysterectomy

Following surgery, you may very well experience aches and pains throughout your body. It's not uncommon to experience backaches, shoulder and/or abdominal pain, and a stiff neck. Your doctor may prescribe a PCA (Patient Controlled Analgesia) to help you manage your pain. Using the PCA, you will be able to control your own pain medication.

The majority of hysterectomy patients are catheterized during surgery. This means that a small tube is placed in the urethra, allowing urine to pass into a bag at a patient's bedside. When you wake up from surgery and are feeling uncomfortable, you won't have to worry about going to the toilet. Urine will collect in the bag at your bedside and will be emptied regularly by a nurse. The nurse will remove your catheter the day following your surgery. Removal of the catheter is painless.

Because a hysterectomy is a major operation, you will lose fluids both from bleeding during surgery and because of the anesthetic used to put you to sleep. Be sure to drink plenty of water. You may also be attached to a saline drip.

You may experience light vaginal bleeding and drainage around your incision site. This is normal. Your nurse may advise you wear a pad—not only in the gusset of your panties as you would when having your period, but also at the waistband, to absorb any blood or drainage from your abdominal incision.

Although you won't much feel like it, it's important that you take your nurses' advice and try to walk as soon as you're able to following surgery. Walking will help relieve trapped wind or gas and indigestion due to lack of movement. It will also make your first bowel movement following surgery more comfortable. A mild and gentle laxative can also help you open your bowels.

Once you are home, it's important to take things easy. Avoid bending or lifting and be sure to get plenty of rest. Your doctor, nurses, or physiotherapist will recommend exercises to help you regain your mobility. They will also show you how to roll over in bed and how to get in and out of bed comfortably. While these may seem simple, such tasks can be quite uncomfortable for a patient with an abdominal incision. Gently pressing a soft cushion against your stomach as you go from sitting to standing may help you feel more comfortable.

It's important to ensure you get your circulation working properly. Gentle walking—a little further each day—will help. Also, be sure to avoid crossing one leg over the other when lying down. Doing so can interfere with circulation to and from the leg underneath and may lead to blood clots in that leg. Placing a cushion, towel, or pillow under your knees (when on your back) or between your knees (when lying on your side) may help you rest more comfortably.

Depending on the type of work you do, your doctor will advise you to avoid work for 6 to 8 weeks following surgery. If your job involves heavy lifting or a lot of physical exertion, it may take a lot longer to recover enough to return to work.

During the first few weeks following surgery, it's not uncommon to experience backache and abdominal pain. You may have brown discharge for the first while. This will eventually change to a creamy white. If your surgeon has used soluble stitches, these will dissolve and pass out of your body. Otherwise, you will have to visit your surgeon to have them removed. Sutures are usually removed as part of your first follow-up appointment, normally within 7 to 10 days after your surgery.

If you have pain that cannot be relieved by over-the-counter pain medication, pus, bleeding, or smelly discharge, be sure to see your doctor right away. These may be signs of infection or complications from surgery and require medical attention.

Emotional factors

In addition to physical pain, women contemplating hysterectomy—and those who have had a hysterectomy—experience emotional turmoil as well. It's natural to feel apprehensive, anxious, and fearful in the time before a hysterectomy, even if the decision to undergo surgery is your own. These feelings amplify when the decision has been made for you (as with an emergency hysterectomy), and you may feel you have little information, choice, or support.

After surgery, you may wonder about the long-term implications of your surgery and how it will affect your life and your relationships.

Hysterectomy is performed for any number of medical reasons. In rare cases, such as puncture or rupture of the womb during other surgery or excess bleeding during childbirth, hysterectomy is done as a lifesaving measure. Regardless of the reason hysterectomy is done, a woman may experience changes in sexuality due to a number of biological and psychological factors.

Hysterectomy and your relationship

There has been a lot of discussion about the role of the cervix in female orgasm. Routine removal of the cervix in total hysterectomy, even when healthy, has been the subject of debate. For some women, the circumstances necessitating hysterectomy are such that their relationships are hindered. As a result, when a couple tries once again to be intimate following a woman's hysterectomy, intimacy is difficult.

For some women, difficulties with sexual function or sexual feeling following surgery are a continuation of prior problems. Some women, because of pain or discomfort associated with their condition(s), may be so negatively conditioned against sexual activity that they continue to abstain from it/avoid it after surgery.

Other women, however, find themselves freed as a result of surgery and may find a new and heightened sexual responsiveness post-operatively. Given the numerous different reactions possible, it's hardly surprising that there is an increased incidence of depression among women who have undergone hysterectomy as opposed to other types of major surgery. Consequently, the success of a woman?s hysterectomy depends not only on her surgeon's skill, but also on her self-esteem and her sexual partner's acceptance and support.

Most men—and a large number of women—don't fully understand female anatomy or the functional results of hysterectomy. As a result, they may hold onto misconceptions about a woman's sexuality following surgery. Some may equate the loss of the uterus with a loss of libido or femininity and may, as a result, unintentionally avoid sexual interaction. Others may act indifferent outwardly, while on the inside, they may actually feel anxious or guilty about engaging in sexual activity with their post-operative partner.

Yet, when a couple face hysterectomy together, acknowledging and validating each other, communicating feelings and needs, hysterectomy can be a unifying experience.

There is also a crucial link between knowledge and post-operative complications: women who undergo hysterectomy without knowing or understanding the what, the why, and the after effects of hysterectomy suffer more post-operative complications than those who insist on knowing as much as possible.

In short, when a woman is supported by her partner and by medical staff, there is no reason why her sexual function cannot and should not improve following a hysterectomy. When medical staff take the necessary time to answer questions and address any lingering fears and doubts by providing a woman—and her sexual partner—with factual information, few difficulties will arise post-operatively. As with any surgery that can impact sexuality, women facing a hysterectomy should ensure they receive the personal and confidential support and/or counseling necessary to make them feel confident about both their surgery and their life post-operatively.

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1. What is a Hhsterectomy? The Hysterectomy Association. (no date)
2. What is a hysterectomy? The Hysterectomy Association. (no date)