Hysterectomy: what you need to know
The definition of a hysterectomy: It is the surgical removal of the uterus plus or minus the structure that make up the female genital system.
The indications can be divided in benign and malignant, emergency and elective.
Benign: When cancer is not a cause or a concern.
Most commonly performed for a multifibroid uterus, endometriosis with or without adenomyosis, abnormal uterine bleeding/ dysfunctional uterine bleeding, sepsis (infection) from the uterus, or the structures attached to it. It can also be the result of an infection caused by complications of pregnancy or an abortion .
Malignant: When cancer is diagnosed or suspected.
These include cancer of the uterus, cervix (early stages), ovarian, tubal and as a precaution in women at high risk of developing cancer in families where certain genetic aberrations have been proven. These include BRCA and LYNCH gene abnormalities.
Emergency hysterectomies are most commonly done when there are complications during other operations like caesarean sections, evacuations of products of conception, when bleeding cannot be controlled and it is a life saving procedure. The procedure includes a surgical incision of the abdominal wall or by a vaginal approach and entails the careful removal of the uterus and, or the structure related to it. The vaginal approach allows for a faster recovery and less post operative pain.Return to normal activity is quicker and it does not have the extra risk of an abdominal wound in terms of healing and potential wound complications. The one down side of a vaginal hysterectomy is that there is an increased risk of vagina, bladder or bowel prolapse later.
The abdominal hysterectomy should be performed in cases where a difficult operation is anticipated and there are other factors to consider such as a large uterus, ovarian pathology, or where cancer is suspected. Abdominal hysterectomies are also sub-divided into simple and radical where a radical includes removal of some part of the vagina and removal of lymphnodes and occasionally other parts like the appendix or omentum.
Complications depend on patient factors, surgeon factors, and type of operation factors.
Patient factors include weight, mobility, risk of blood clots, post operative wound care and pain threshold.
Surgeon factors depend on the type of suture material used, operative time, technique, etc.
Type of operation
Vaginal vs abdominal procedures and the reason for the operation, ie cancer or something not potentially malignant like abnormal bleeding.
As emergency vs an elective planned operation. These complications range, from bleeding, pain, wound sepsis, haematomas, bladder and bowel injuries, long term risks of adhesions, bowel obstruction, bladder or bowel prolapse, hernia formation, etc.
Depending on if the ovaries were removed or not there may be menopausal symptoms including hot flushes, mood swings, sleeping problems, night sweats, sexual problems (decrease in libido, dry vagina, pain during intercourse), weight gain, etc. The advantages of retaining the ovaries include prolong in life expectancy, androgen production that may contribute to libido and sexual function. Ovaries may also cause painful intercourse, or residual ovarian syndrome.
The cervix (mouth of the womb) may be removed in most cases, but if not then it can cause spotting (minimal bleeding), and in some women be important in sexual pleasure/ climax.
However, there is evidence to suggest that sexual pleasure improves after a hysterectomy and this may be related to the reason for the hysterectomy.
Follow-up after a hysterectomy will be influenced by the indication and type of hysterectomy performed. Some women may still be expected to do vault smears (like pap smears), and frequent gynaecological examinations.
The decision to have a hysterectomy requires information of the indication, alternative treatment if available, age, the need to remove the ovaries or not, the risks of complications, and the long term follow-up plus prognosis. Due to the fact that a hysterectomy is a major operation complete understanding and counselling is required and should not be taken lightly.