Hysterectomy

The uterus is the muscular organ in the pelvis where a pregnancy grows, and the cervix is its lower end, which opens into the vagina. A total hysterectomy removes the uterus and cervix; a subtotal, or supracervical, hysterectomy removes the body of the uterus and leaves the cervix. Removing the fallopian tubes at the same time, called salpingectomy, is now common because it may lower the future risk of ovarian cancer. Removing the ovaries, called oophorectomy, is a separate decision based on your age, your cancer risk and the condition being treated. A radical hysterectomy, used for some cancers, also removes tissue around the cervix and the upper vagina, and often lymph nodes. The approach can be laparoscopic, through small cuts with a camera; robot-assisted, through similar cuts; vaginal, with no abdominal cut; or abdominal, through a horizontal or vertical incision in the lower abdomen.

A hysterectomy is usually recommended when a problem of the uterus seriously affects quality of life or health and other treatments have not worked, are unsuitable or are not wanted. Common reasons are fibroids causing heavy bleeding, pain or pressure; heavy menstrual bleeding that has not responded to medicines, a hormonal coil or endometrial ablation; adenomyosis, where the lining grows into the muscle of the uterus; endometriosis with severe pain, usually together with removal of the endometriosis deposits; and uterine prolapse, when the womb drops into the vagina. It is also a main treatment for endometrial cancer, some cervical cancers and ovarian cancer, and may be advised for precancerous changes or for women with an inherited high risk of cancer. Because it ends fertility, women who may want children are usually offered alternatives first, such as myomectomy for fibroids. Your gynaecologist discusses the options that suit your condition and plans.

Hysterectomy is done under general anaesthesia, and a vaginal hysterectomy can also be done under spinal anaesthesia. In laparoscopic surgery, the surgeon makes three or four small cuts in the abdomen, fills it with carbon dioxide gas and uses a camera and fine instruments to separate the uterus from its blood supply and supporting ligaments, taking care to protect the bladder and the ureters, the tubes that drain the kidneys. The uterus is usually removed through the vagina, and the top of the vagina, called the vaginal vault, is stitched closed. Robot-assisted surgery follows the same steps with instruments controlled from a console. In a vaginal hysterectomy the uterus is removed entirely through the vagina, which suits prolapse and smaller wombs. Abdominal surgery is kept for very large uteruses, some cancers or situations where keyhole access is unsafe. The operation usually takes about 1 to 3 hours, and a urinary catheter is usually removed within a day.

Candidates are women for whom a hysterectomy is the right treatment for their condition and who are fit for surgery. Before deciding, it is important to be sure that you do not want a future pregnancy and to understand the alternatives. Preparation includes a pelvic ultrasound or MRI to map fibroids or other disease, a cervical screening test if one is due, and sometimes a biopsy of the lining of the uterus to rule out cancer. Blood tests check for anaemia, which is common with heavy bleeding and may be treated with iron before surgery. Hormone injections are sometimes used for a few months to shrink large fibroids before keyhole surgery. You agree in advance whether the cervix, tubes and ovaries will be kept or removed. Blood thinners and some hormone medicines are adjusted on medical advice. International patients can usually send scans and reports in advance for a remote review of the plan.

After keyhole, robotic or vaginal surgery you are usually walking the same day and go home after 1 to 3 nights; after abdominal surgery the stay is about 3 to 5 nights. Light vaginal bleeding or discharge is normal for a few weeks, and tiredness can last longer than the pain. Most women return to desk work after about 2 to 4 weeks, or about 6 weeks after abdominal surgery. Heavy lifting, intense exercise, swimming and sexual intercourse usually wait about 6 to 8 weeks, to let the vaginal vault heal. For travel, plan to stay near the hospital for about 2 to 4 weeks, depending on the approach and your recovery, so that the wounds can be checked and the pathology report discussed. On the flight, walk regularly, drink fluids and wear compression stockings if advised, because the risk of blood clots is raised for several weeks after pelvic surgery. Arrange a gynaecology follow-up near home.

Hysterectomy is a common operation and serious complications are uncommon, but it is major surgery. General risks include bleeding, sometimes needing a transfusion, infection of the wound, bladder or vaginal vault, and blood clots in the legs or lungs. Injury to the bladder, ureters or bowel can occur and is usually repaired during the same operation. Rarely, the vaginal vault opens after keyhole surgery, which is one reason to avoid intercourse until it heals. A switch from keyhole to open surgery is sometimes needed. Some women notice changes in bladder function or, in the long term, prolapse of the vaginal vault. If both ovaries are removed before menopause, menopause begins immediately, with hot flushes and a higher long-term risk of bone thinning and heart disease, so hormone therapy is often discussed. If the ovaries are kept, they usually continue to work. For most women, hysterectomy ends heavy bleeding permanently, and pain or pressure from fibroids or adenomyosis improves clearly.