Dr.Kawita Bapat

What Is Hysterectomy ?

Hysterectomy-the removal of the uterus-is one of the most common types of surgery performed in women. A hysterectomy is one way of treating problems affecting the uterus. Because it is major surgery, your doctor may suggest trying other treatments before hysterectomy. For severe conditions-and those that have not responded to other treatment-a hysterectomy may be the best choice. The choice depends to some extent on the effect of the condition, and the surgery, on your life. You should be fully informed of all options before you decide.

This explains the types of hysterectomy and why it might be needed. It discusses other options you may have for treatment. The physical effects and risks of treatment are covered, too. If you choose to have a hysterectomy, this pamphlet can help prepare you for what's involved.

About the Uterus

The uterus is a muscular organ in the pelvis. The opening of the uterus is the cervix. In pregnancy, the uterus holds and nourishes the fetus. In labor, it contracts to deliver the baby. When a woman is not pregnant, the lining of the uterus (the endometrium) is shed each month in her menstrual period.

Sometimes, there are problems with the uterus. A woman may have pain or heavy bleeding. Growths or cancer can also occur. These problems require treatment.

Conditions Affecting the Uterus

Hysterectomy may be performed to treat conditions that can affect the uterus. Some are benign (not cancer), and others are cancer. Some have symptoms that cause discomfort, while others can threaten your life.

Your condition may be treated with medicine or various types of surgery, including hysterectomy. The choice of treatment depends on the nature and extent of your condition as well as personal factors. These factors include your plans to have children in the future, the amount of discomfort you are having, and other options available. Other forms of treatment often are tried first. If they don't work, hysterectomy may be considered. Following are some of the conditions for which hysterectomy may be performed

Uterine Fibroids

Uterine fibroids (myomas) are the most common type of growth found in a woman's pelvis. They are benign and can be a variety of sizes. Most are small and don't cause symptoms or need to be treated.

If fibroids grow, they may cause pain. They may press against the bladder and other pelvic organs. Fibroids that press against the lining of the uterus may cause irregular or heavy bleeding.

Fibroids tend to shrink after a woman goes through menopause. If you are near menopause, you may want to see how it affects your fibroids before you try any treatments.

Some medications can shrink fibroids. However, they work only as long as they are taken. Once they are stopped, the fibroids may grow again. They can help women near menopause who have symptoms. The medicine used to shrink fibroids can cause bone loss if it is used for too long. Therefore, it is usually used for just a few months.

Medicine may also be used briefly to shrink fi-, broids before surgery, such as myomectomy. In myomectomy, only the fibroids are removed. The uterus is leftin place. Sometimes, a myomectomy is not possible. Then the whole uterus must be removed to relieve symptoms.

Abnormal Uterine Bleeding

Irregular, heavy, or severe bleeding from the uterus may be caused by fibroids or by hormonal changes. It may also be caused by infection of the uterus and by cancer.

Treatment is directed to the cause of the bleeding. Hormone therapy may help control the bleeding. If you have lost a lot of blood, you may not have enough iron. Iron may be given to build your stores, but it will not stop the bleeding. Hysterectomy may be an option if other treatments don't work and the bleeding is a problem for you.

Cancer

Diseases of the cervix can develop over time into cancer. They can progress rapidly or develop slowly over years, depending on the person and the extent of the disease. Precancerous changes of the cervix detected by a Pap test can be diagnosed early and treated with good success without a hysterectomy.

Cervical disease becomes serious-invasive cancer-when it moves into deeper tissue layers or spreads to other organs. Cancer can also affect the lining of the uterus and the ovaries. In some women with these cancers, radiation and other treatment may control the disease. In other women, hysterectomy may be the only way to stop the cancer from spreading to other organs.

Pelvic Support Problems

The pelvic organs (bladder, uterus, rectum, and intestines) are supported by muscles, ligaments, and fascia (tough sheets of tissue). The ligaments and fascia may be weak and unable to support these organs, often due to obesity, chronic cough, or stretching in childbirth. This can allow the pelvic organs to sag or even stick out through the opening of the vagina. There may be a "bearing-down" sensation of pressure in the pelvic region and problems in controlling urine.

There are things you can do to ease these problems. Avoid doing things that strain the pelvic muscles:

Stop smoking
Lose weight
Avoid constipation by getting plenty of fluids and fiber in your diet

You can strengthen your pelvic muscles by doing Kegel exercises. Your doctor or nurse can show you how. You can also be fitted with a pessary, a device placed in the vagina that holds the organs in place. If you are past menopause, taking hormones may help keep the tissues more flexible and less apt to stretch.

Sometimes surgery can be done to put the organs back in place. If other treatment fails, a hysterectomy may be needed to correct pelvic support problems.

Endometriosis

Cells like those lining the uterus may also grow on the ovaries, fallopian tubes, and other pelvic structures. This is called endoinetriosis. Patches of endometriosis may bleed at the menstrual period or at other times. The blood may build up in cysts. Endometriosis may cause scarring, adhesions, pain, or infertility. Adhesions bind the affected surfaces of the organs to each other. The condition mostly affects women who are of childbearing age. It usually is not a problem after menopause because a woman no longer has menstrual periods.

Endometriosis can often be treated with hormones. If they do not work, the patches of endometrial tissue can be removed through a laparoscope. If this fails, a hysterectomy may be done.

Pelvic Pain

There are many possible causes of pelvic pain. It may take time to diagnose the problem. One source may be irritation of the pelvic organs, which may cause adhesions or scarring. This may be a result of endometriosis, infection, or injury. Pelvic adhesions usually affect the surface of the uterus, the tubes and ovaries, and the intestines. Pelvic pain can also result from problems in other parts of the body. It can be caused by conditions that affect the back or the bowels.

The treatment for pain depends on the cause. Different types of medicine can work well against many causes. Surgery done through the laparoscope may be an option, too. For some conditions, other treatments such as heat or relaxation exercises may help. A hysterectomy should be done only if other treatments have been tried but failed to relieve the pain.

About Hysterectomy

There are three types of hysterectomy:

Partial (or subtotal), in which the upper part of the uterus is removed but the cervix is left in place
Complete (or total), in which the entire uterus, including the cervix, is removed
Radical, in which the entire uterus, lymph nodes, and support structures around the uterus are removed.

Tests are needed before the surgery. Your blood and urine will be tested. You may be given one or more enemas. Your abdominal and pelvic areas may be shaved. Antibiotics usually are given to prevent infection. A needle may be placed in your arm or wrist. It is attached to a tube that will supply your body with fluids, medication, or blood. This is called an IV line. Monitors will be attached to your body before anesthesia is given. You may be given a general anesthesia, which makes you unconscious, or a regional one, which blocks out feeling in the lower part of your body.

Risks

As with any surgery, problems may occur. These could include thrombophlebitis (blood clots in the veins or lungs), severe infection, bleeding after surgery, bowel blockage, injury to the urinary tract, problems related to anesthesia, or even death. Even though the risks of hysterectomy are among the lowest of any major surgery, you and your doctor must weigh the benefits and risks.

After Surgery

The length of stay in the hospital after surgery varies by type of surgery. You can expect to have some pain for the first few days. Normal activities, including sex, usually can be resumed in about 6 weeks. Meanwhile, don't douche or put anything in the vagina.

As you recover, activities such as driving, sports, and light physical work may be increased gradually. You and your doctor can plan your return to normal activities, including your return to work, at a rate best suited to your own recovery. If you can do an activity without pain and fatigue, it should be okay. If activity causes pain, discuss it with your doctor.

The surgery can have other effects that are both physical and emotional. Some last briefly, and others are long term. You should be aware of these effects before having a hysterectomy.

Physical

After hysterectomy, a woman's periods will stop. She can no longer get pregnant. If the ovaries are left in place, though, they still produce hormones. A woman who still has her ovaries will not have the symptoms that often occur with menopause, such as hot flashes. The ovaries still produce eggs, too, but because the eggs are not fertilized, they dissolve in the abdomen.

If the ovaries also are removed with the uterus before menopause, there are hormone-related effects. It is as though the body goes through menopause all at once, rather than over a few years as is normal. Symptoms can usually be treated with the hormone estrogen.

Emotional

Many women have a brief emotional reaction to the loss of the uterus. This response depends on a number of factors: how well they were prepared for the surgery, its timing, the reason for having it, and whether the problem is cured. Women who are affected by the early loss of their ability to have children may feel depressed. If problems persist, discuss them with your doctor.

Hysterectomy and Sex

Some women may notice a change in their sexual response after a hysterectomy. Because the uterus has been removed, uterine contractions that may have been felt during orgasm will no longer occur. Some women have a heightened response, however. In part, this is because they no longer have to worry about getting pregnant and may be relieved of discomfort.

If the ovaries have not been removed, the outer genitals and the vagina are not affected. In this case, a woman's sexual activity is usually not impaired. If the ovaries are removed with the uterus, vaginal dryness may be a problem during sex. Use of estrogen can help relieve dryness.

If the procedure required making the vagina shorter, deep thrusting during sex may be painful. Being on top during, sex or bringing your legs closer together may help.

Finally...

Hysterectomy is just one way to treat uterine problems.

It is major surgery.

Before you decide whether it is right for you, get as much information as you can:

About your condition
About other treatment options
How hysterectomy may affect you

Some conditions can be treated without this procedure. For others, it is the best choice. Discuss all your options with your doctor.

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Estimated Percentage of Hysterectomies by Diagnosis, 1988-1990
Diagnosis	Percentage
Uterine leiomyoma (fibroid)	33.5
Endometriosis	18.2
Prolapse	16.2
Cancer	11.2
Endometrial hyperplasia (heavy growth of uterine lining)	6.0
Menstrual/menopausal symptoms	4.5
Cervical dysplasia (precancerous changes)	1.4
Pain	0.6
Other	8.5
Adapted from Wilcox LS, Koonin LM, Pokras R, Strauss LT, Zhisen X, Peterson HB. Hysterectomy in the United States, 1988-1990. Reprinted with permission from the American College of Obstetricians and Gynecologists (Obstetrics and Gynecology, 1994, 83, 549)