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Hysterectomy

It's estimated that, by the age of 55, one in five women will have had their womb (uterus) removed. This operation is called a hysterectomy. Many women find there is a lack of information about hysterectomies. Doctors and medical staff don't always have the time or maybe the inclination to go into sufficient detail, while women themselves can find it difficult to talk about this operation because of its emotional as well as physical implications. A lot of technical medical terms are used in talking about a hysterectomy, these pages will explain these terms.

The reproductive organs

The uterus, vagina, ovaries and fallopian tubes make up the organs of your reproductive system.

The uterus (or womb) is a pear-shaped, muscular organ about the size of a clenched fist, located in the middle of your pelvis. It is in the uterus that a pregnancy develops. The lining of the uterus—the endometrium—is shed regularly to produce periods (menstruation).

The uterus has two parts—the corpus which is the major body of the organ and the cervix (the neck of the womb) at the base where it meets the vagina. The vagina is a muscular tube which runs from the cervix to the outside of your body.

The fallopian tubes are attached to the two upper corners of your uterus. Each tube ends very close to an ovary. The reproductive organs are held loosely by several ligaments—the broad ligament, the round ligament and the ovarian ligament.

Why have a hysterectomy?

Hysterectomy should only be considered after alternative treatments have been explored. The following conditions are the most common reasons why women are advised to have the operation.

1. Heavy bleeding

Heavy bleeding is the reason for half of the hysterectomies performed every year in the UK. Many women with heavy bleeding have no detectable pelvic disease, and their heavy bleeding is due to hormonal imbalance, fibroids, or thyroid disease. Sometimes there is no obvious cause.

Your menstrual cycle is controlled by a complicated system of hormones, the type and amount changing throughout the cycle. Occasionally, the levels of these hormones are upset, resulting in irregular and/or heavy bleeding. Why this happens is not very well understood, but it is known that stress can affect hormone levels to such an extent that periods can cease altogether or can become heavier. Hormone irregularities are more common as we get older.

Some of us are uncertain how much bleeding is normal, and we can feel as if we are losing a lot of blood when in fact our loss may be normal. Roughly, heavy bleeding implies losing many blood clots; needing to use both sanitary pads and tampons for more than two days of the cycle; using more than 20 pads each cycle; or if bleeding results in anaemia.

Fibroids

Some women with heavy bleeding have fibroids. These are benign (non-cancerous) muscular growths in the uterus. It is estimated that 20% of women over the age of 30 have at least one fibroid. Fibroids can grow in different places in the uterus. Those which occur totally within the muscle of the uterus and those on the outside generally cause no trouble, and are usually only discovered when a woman is being examined for something else. Fibroids that grow just under the endometrium - the lining of the uterus—can cause problems because they increase the surface area of the endometrium, causing more blood to be lost during menstruation. Sometimes such a fibroid might develop a stalk and grow into the space inside the uterus. These fibroid polyps, as they are called, can cause painful cramps which in some cases can develop into continual pain and irregular bleeding. For more information see the Women's Health online booklet on fibroids.

If you have very heavy periods you may become anaemic. This means your blood does not contain enough red blood cells. This can make you feel dizzy and very tired. If periods are very heavy, everyday life can be extremely disrupted by heavy flooding and irregularity.

Treatment other than hysterectomy

For heavy bleeding without a physical cause, the drugs tranexamic acid and mefanamic acid are currently regarded as the most effective treatment. Hormone treatment in the form of a progestogen, a synthetic female hormone (similar to that found in the mini-contraceptive pill), is sometimes still used.

There are surgical procedures (generally called endometrial ablation) in which the lining of the womb is removed: this relieves the heavy bleeding, but is not appropriate for women who want to have children. Endometrial ablation means the removal of the lining of the womb; there are different names for specific ablation procedures (e.g. TCRE, balloon therapy) depending on the method used to remove the uterine lining.

Another option for women who want contraception is the Mirena coil, a type of IUD which releases progestogen into the uterus and usually causes a reduction in bleeding or stops periods altogether. For more information see the Women's Health online booklet on heavy bleeding.

Iron tablets can be taken to relieve the symptoms of anaemia. Eating iron-rich food can also help—ask your doctor or the practice nurse for advice.

If fibroids are relatively small it is possible to have an operation to remove them alone. This can be done either by passing a surgical instrument through the cervix, a procedure which is relatively new and only appropriate for certain kinds of fibroids, or by performing a myomectomy, which involves an abdominal incision and removal of the individual fibroids. Unfortunately, in 20 per cent of myomectomies a hysterectomy will still need to be done later on. Another option is a procedure called bilateral uterine arterial embolisation, in which the blood supply to the fibroid is blocked off under local anaesthetic. (For more information on treatment see the Women's Health online booklet on fibroids).

2. Pain

Severe period pains can make life miserable. Painful periods can be caused by high levels of female hormones or by an imbalance of prostaglandins —naturally occurring substances in the body which can cause some muscles to contract strongly. Anti-prostaglandin drugs may be prescribed to deal with painful periods, but as they stop ovulation they are not appropriate for everyone. Common causes of severe period pain are pelvic inflammatory disease and endometriosis.

Pelvic Inflammatory Disease (PID)

PID is caused by an infection in the reproductive organs. This often occurs when a sexually transmitted organism such as Chlamydia travels up the reproductive tract, into the tubes and possibly around the ovaries as well. It can also occur following abdominal surgery complicated by infection (such as for appendicitis) or following childbirth if an infection results. It may develop into a chronic condition which can cause pain and scarring and lead to displacement of the pelvic organs.

Treatment other than hysterectomy:
If diagnosed early enough, most cases of PID will respond to antibiotics and no permanent damage will occur. However, if left untreated PID can cause chronic pain and infertility. (For further information, see Women's Health online booklet on Pelvic Inflammatory Disease).

Endometriosis
Sometimes, the cells that line a woman's uterus - her endometrium - appear in the pelvis, on the ovaries, fallopian tubes, vagina or elsewhere. Because hormones affect them in the same way, these cells act like endometrial cells, building up and being shed during the menstrual cycle. The surrounding tissue may become scarred, and often other organs such as the uterus, bladder or the rectum may become stuck down in these scars (adhesions). This can cause extremely painful cramps during periods, chronic pain in the pelvis and pain during sexual intercourse.

Treatment other than hysterectomy:
Alternative therapies such as homeopathy and acupuncture can be very useful. Conventional drug treatment can often keep milder cases under control; either high doses of progestogen or one of a family of drugs called GnRH agonists are used. Sometimes surgery is done to cut away the patches of endometriosis or small areas are burnt by diathermy.

3. Prolapse

Also called a 'dropped womb', this happens when the front and back walls of the vagina, the pelvic floor muscles and the supporting ligaments of the uterus become weakened. The womb then drops down causing a dragging feeling. The bladder and rectum (the back passage) may bulge into the vagina. Prolapse can be caused by pregnancy and childbirth, or continuous heavy lifting. It can also happen after the menopause, when lower levels of female hormones cause a loss of elasticity of the muscles and ligaments. Prolapse can cause backache, uncomfortable intercourse, and incontinence due to pressure on the bladder or bowel.

Treatment other than hysterectomy:
If only the uterus has dropped, a plastic ring pessary can be pushed up the vagina to hold it in place. A repair operation for prolapse involves shortening and tightening the ligaments and repairing the vaginal wall muscles by cutting away some of the loose vaginal skin, bringing together the edges as well as the muscles and stitching it all in place. Sometimes the cervix may also be shortened. The repair is often combined with a hysterectomy. (For further information, see Women's Health online booklet on pelvic organ prolapse).

4. Cancer

The four types of cancer for which a hysterectomy may be done are cervical cancer, cancer of the endometrium (also called cancer of the womb), cancer of the ovary and cancer of the fallopian tube (this is very rare). The chances of a cure are very good if a cancer is diagnosed early enough.

Every year there are approximately 5000 new cases of cancer of the cervix, or neck of the womb, in England and Wales. The cervical smear test is the most effective method of diagnosing cervical cancer. Certain abnormalities can be detected in these cells before they ever develop into cancer and they can be easily treated. A small number of cells from the cervix are scraped off and then examined under a microscope. This should be a painless procedure, especially if the doctor or nurse is gentle. Department of Health guidelines recommend that women aged 25 to 64 have smears every three years. (For further information see Women's Health online booklet on cervical screening).

There are no early detection tests for cancers of the endometrium. The major sign is bleeding after the menopause as this disease occurs mainly in women of that age.

Each year about 5000 women in England and Wales develop ovarian cancer. Ovarian cancer is sometimes detected by internal examination when the doctor may be able to feel a tumour, but it's often very difficult to detect in the early stages. A blood test and ultrasound scan to screen for ovarian cancer are under investigation.

Treatment other than hysterectomy:
The treatment of cervical cancer (as opposed to the treatment of abnormal cervical cells) is usually by hysterectomy and/or radiotherapy. The early stages of endometrial cancer can be treated with high doses of the synthetic hormone, progestogen, and radiotherapy may be undertaken with surgery. Ovarian cancer is almost always treated by surgery, but chemotherapy—treatment with certain drugs which kill cancer cells—may also be used.

5. PMS

A small number of women with very severe PMS choose to have a hysterectomy after they have tried every other option. For more information on PMS you can order the Women's Health online booklet on premenstrual syndrome.

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Originally written by Nancy Duid and Wendy Savage MB FRCOG. This edition revised by Women's Health, July 1999

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