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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: Endometriosis 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: 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: 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. Hysterectomy — Points to consider Your doctor may recommend a hysterectomy if none of the treatments for the various conditions mentioned in the previous section have worked. Whether or not to have a hysterectomy, and if so, how soon, all depends on the severity of your symptoms. If cancer has been diagnosed, you really have very little choice. Having the operation as quickly as possible increases your chances of recovery. Hysterectomy as a solution for the other conditions is not so clear cut. Often a woman is able to handle pain and bleeding if given drug treatment and iron tablets, and then she will have more time to consider the implications of hysterectomy. Sometimes lesser surgical operations will forestall severe symptoms so that, if a woman wants to have children, this may still be possible. In the case of prolapse, this is rarely dealt with by hysterectomy unless there are other symptoms such as very heavy periods. If a hysterectomy has been suggested for you, (other than for cancer), the following questions can help you make up your mind about the operation:
Earlier menopause Many women are not told that they can expect to have an earlier menopause after a hysterectomy, even if their ovaries are not removed. One third of women enter menopause within two years of surgery, regardless of age. On average, menopause occurs four to six years earlier than would have occurred naturally. Diagnosis  Often a doctor will have a fairly good idea of the type of your problem after examining you and listening to your symptoms. The doctor should make detailed notes of your medical history and your concerns. Your blood will probably be tested for hormone levels. You should also be given a pelvic ultrasound scan. The newer transvaginal scans, where the probe is placed inside the vagina, have made diagnosis of pelvic disease much easier. If the scan shows any abnormalities or is unclear, your doctor may want to investigate further using hysteroscopy, a procedure in which a viewing device is inserted into the uterus. A sample of the lining of the womb (endometrium) may be taken. Endometrial sampling is done either as an outpatient procedure, or by D&C—dilatation and curettage—usually when you are under a general anaesthesia. In a D&C, your cervix will be opened (dilatation) and the lining of your uterus (the endometrium) will be systematically scraped (curettage) with a long, thin instrument. The strips of the lining will then be examined under a microscope. Since having a hysterectomy is such an irrevocable step, you may wish to have a second opinion from another doctor. You are entitled to this under the NHS, and it is said that a good doctor is one who will offer to arrange a second opinion just before the patient asks for it! Hysterectomy — The operation You have had all the relevant tests, weighed up your options and decided that having a hysterectomy is the best solution for you. Now you must come to an agreement with your doctor as to how the operation is to be performed - either vaginally or abdominally - and how much of your reproductive organs are to be removed. Through the vagina or the abdomen? When the hysterectomy is performed through the vagina there is no visible external scar. Vaginal hysterectomy has fewer complications and involves a shorter hospital stay and more rapid recovery. In this country about one quarter of all hysterectomies are performed vaginally. The greater frequency of abdominal hysterectomy is mainly due to doctors' preference for this procedure, but in some cases, such as where the uterus is very large because of fibroids, a vaginal hysterectomy is impossible.  Most surgeons have their own personal preferences based on their experience and skills, so if a surgeon rarely performs vaginal hysterectomies, it will probably not be in your best interests to ask for one. If there are no medical reasons why you shouldn't have this type of operation, you may want to seek a consultant who prefers the vaginal method. If you are having an abdominal hysterectomy, you can request that your surgeon makes a cut at the bikini line if possible. This is a horizontal cut just above your pubic hair, as shown in Diagram 1. It heals well and leaves an almost invisible scar . If your uterus is very large, you have large fibroids or your ovary has a large swelling on it, this incision may not be possible and a vertical cut may be made instead, as in Diagram 2. Laparoscopic hysterectomy A laparoscope is a viewing instrument like a telescope which is inserted into the abdomen to enable the doctor to see the pelvic organs. This avoids the need for a large abdominal incision. A small (1/4 inch) incision is made just below the belly button for the laparascope to be put through. Two additional small incisions are made on either side of the abdomen for insertion of instruments used to carry out the operation, see Diagram 3. The uterus is usually removed through the vagina although sometimes the small incisions for the laparascope are used if the uterus is not too large. The advantage of laparascopic hysterectomy is that it is a less invasive operation than abdominal hysterectomy, so recovery times are shorter. However, there is a potential for complications because the surgeon's view is limited and inadvertent damage to other organs may occur. Types of hysterectomy  These vary according to your condition and how much can safely be left in place. You and your doctor should aim to leave in as much as is possible considering the implications for your subsequent health.
The operation Preparation for both vaginal and abdominal hysterectomy is similar. If you are having an abdominal hysterectomy, you will have a strip at the top of your pubic hair shaved the night before your operation. On the day, you may be given a suppository to empty your bowels, and you will not be allowed to eat or drink anything except perhaps a cup of tea early in the morning if you are to be operated on late in the day. Before going to the theatre, you will be given pre-medication drugs to dry up your saliva and make you relax. Once you are in the small room just outside the operating theatre, you will be given the anaesthetic. This is done either by an injection that puts you to sleep and then having a "drip" containing the anaesthetic attached to you, usually in the back of your hand, via a thin plastic tube, or by having the drip put in while you are awake. In some special circumstances, a general anaesthetic is not given, and an epidural or spinal anaesthetic is used instead. This is an injection of anaesthetic around or in the spinal cord which numbs all the nerves below it. Once you are asleep, a catheter (a narrow tube) will be inserted into your bladder to empty it. The inside of your vagina may be painted with Bonney's blue, an antiseptic dye that makes lining up the vaginal walls easier. The abdominal approach: after the skin of your abdomen has been cleaned with antiseptic, the incision will be made and the uterus removed by clamping and cutting large blood vessels and then tying them off. The top of the vagina is then closed and each layer of tissue of your abdomen is individually stitched shut until the wound is completely closed, either with dissolving stitches or metal clips. The latter must be removed six to eight days later. After about six to eight weeks the scar is usually barely noticeable. The vaginal approach: this procedure is very similar except that the necessary cuts are made internally, through the vagina. Each operation takes about an hour, depending on which type of surgery you are having. Hysterectomy — After the operation Recovering When you wake up you will almost certainly feel groggy after the anaesthetic. You will also feel some pain. Don't worry - this is quite normal. Your pulse and blood pressure will be monitored to make sure that they are steady, and you will be given painkillers when you ask for them, or you will be given a hand-held morphine pump so that you can control your own pain relief. If you have difficulty in emptying your bladder, another catheter may be used to help. If you've had a vaginal hysterectomy, a urinary catheter will most likely be left in place for a day or so, depending on the doctor's policy. You may also have a drip in your vein to provide fluids for the first 24 hours or so. Some women may have a bit of plastic tubing leading out of the abdominal incision and attached to a small container which will drain small amounts of blood and fluid that can accumulate after surgery. You should get out of bed and sit in a chair as soon as possible the day after the operation. This is to help improve your circulation and avoid the risk of blood clots. Moving about will also help get rid of wind, which can be very troublesome and painful. For the most part, women who've had vaginal hysterectomies will become mobile earlier. During the first couple of days, you will gradually begin to eat and drink and soon you will be doing both normally as well as walking around. Within seven to ten days, you'll be able to go home. The effects of a general anaesthetic will take some time to wear off (up to six weeks) and people are advised not to drive during this time. The anaesthetic can also make you feel very tired and many women have difficulty concentrating in the early weeks after the operation. You won't be able to do anything very active, especially lifting, until about six weeks after the operation as your abdominal muscles and tissues will not have healed completely until then. During the first six weeks you need to rest as much as possible. Go to bed when you feel tired. Make a point of asking family and friends to help you around the house. You may be entitled to a home-help from your local social services, especially if you have a large family. Contact the social services department of your council before you have the operation to find out what they can do for you. But if this is impossible the hospital should also have a social work department and you can ask to see their social worker to see if she or he can arrange for you to have help when you go home. You can do gentle exercises once the stitches are out. If there is a physiotherapist in hospital you can ask her for other exercises, or look in the books listed in the Resources section of this leaflet, particularly the booklet by Haslett and Jennings. This contains detailed descriptions of exercises you can do from the first day after your operation. Walking is very good exercise. Begin with ten minutes a day, gradually increasing the distance when you feel ready and aiming for about 45 minutes by six weeks after the operation. There may be vaginal discharge for up to four weeks after the operation, gradually turning from red to a pale brown colour. Six weeks after the operation, you will go back to the hospital for a check-up to see that your abdomen and vagina have healed well. In the not-so-distant past, when anaesthesia was less sophisticated and blood for transfusion was not available, the operation had a more serious effect on a woman's health and it took longer for her to recover. The time it takes to heal after any major surgery varies from woman to woman and depends to a large extent on their health before the operation and why the hysterectomy was done. Listen to your body and don't do more than you feel able to. Most women feel completely well within six months, but some take longer to recover fully. Returning to work It is a good idea to discuss your return to work with your manager before the operation. It may be helpful to get a letter from your doctor explaining how long your recovery is expected to take and outlining the support you will need. Today many women are ready to return to work from eight to twelve weeks after the operation, but this depends on the type of work and the amount of travelling involved.  Exercise Lie with your head on a pillow and your knees bent up. Pull your tummy in. With your knees kept together, slowly move your knees to the left and then to the right, just a little bit to each side. Doing this exercise gently and rhythmically with a 'tic-toc' movement, may also relieve flatulence Most employers allow up to three months sick leave after hysterectomy. It may be appropriate to negotiate a phased return to work or flexible hours. You should not do any heavy lifting until at least twelve weeks after the operation. If your job involves sitting for long periods, make sure that your back is supported and that you get up and walk around every couple of hours. Hormone Replacement Therapy (HRT) If you have had your ovaries removed, you will have an artificial menopause if you have not already reached that time of your life. The resulting hot flushes, night sweats, and other menopausal symptoms may be more severe than if you had had a natural menopause. You may want to consider taking Hormone Replacement Therapy (HRT). This means replacing the missing female hormone oestrogen with tablets, implants, or skin patches. You should be monitored fairly closely to see how you get on and different dosages or forms of HRT can be tried if problems occur. HRT can also eliminate the vaginal dryness that may occur, making sexual intercourse uncomfortable. Sex after hysterectomy Sexual intercourse very soon after surgery may cause bleeding from the suture line at the top of the vagina, but after the six week check-up, and after the bleeding or discharge has stopped, sex can normally be resumed. Take your time and do what feels comfortable for you. If you had previously experienced pain because of the condition that led to the hysterectomy, then your sex life after the operation will be enhanced. If you are in a relationship with a man, you will no longer run the risk of an unwanted pregnancy. If vaginal dryness is a problem try a vaginal lubricant. You can buy lubricants from the chemist—look on the shelf near the condoms. It is not clear what impact hysterectomy has on sexual function. Although the majority of women in two studies said that their sex lives were better or unchanged after hysterectomy, a few said they had less interest in sex. Women with reduced sexual enjoyment were more likely to have had pre-existing sexual or relationship problems. Depression after hysterectomy If you have understood what the operation will entail and have come to your own decision to have it, you are less likely to be depressed about it afterwards. Although the uterus does have an emotional significance for most women, it is important to put its loss and your general well-being into perspective. Nevertheless, if you are depressed, take your feelings seriously and try to arrange with friends and family or a professional counsellor for emotional support. Talking to other women who have had a hysterectomy can be very reassuring (see Resources section for details of support networks). Hysterectomy — Resources and links Organisations Endometriosis Society Hysterectomy Association The Daisy Network Books Hysterectomy and the Alternatives by Jan Clark (Vermilion, 2000) Family Doctor Guide to Hysterectomy & The Alternatives by Dr Christine West (Dorling Kindersley, 2000). Hysterectomy, Vaginal Repair, and Surgery for Stress Incontinence by Sally Haslett, Molly Jennings, Hilary Walsgrove and Wendy Weatheritt (Beaconsfield Publishers, 5th Edition, 2003). Hysterectomy New Options and Advances by Lorraine Dennerstein, Carl Wood and Ann Westmore (Oxford University Press, Second Edition, 1999). Originally written by Nancy Duid and Wendy Savage MB FRCOG. This edition revised by Women's Health, July 1999
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