A hysterectomy is a surgery for the removal of a woman’s uterus, also called the womb. This also stops a woman’s menstrual cycle and ability to become pregnant. This surgery is more common in the U.S. than anywhere else in the world. According to the Centers for Disease Control and Prevention, 600,000 women undergo the procedure each year and about 20 million American women have already had it done — making this surgery the second most frequently performed procedure for women in the U.S.
Researchers studied the medical records of more than 3,400 women and found in roughly 1 in 5 women the surgery was unnecessary.
In some cases, this surgery is life-saving and necessary to improve a woman’s quality of life. For instance, women who have uterine cancer or painful uterine fibroids may need to remove the uterus to improve survival or painful symptoms. Others who have complications from implants such as the Essure Permanent Birth Control may be forced to remove their uterus and fallopian tubes because of extensive damage caused by the metal coils.
However, sometimes women have unnecessary hysterectomies which put them at increased risk for a number of other health problems from hormone imbalance to pelvic organ prolapse, a condition that leads to pelvic organs sagging into the vagina. Some surgical techniques — such as procedures performed with a surgical tool called a power morcellator — may even put women at risk for spreading undiagnosed uterine cancer in the abdominal cavity.
A study published in the American Journal of Obstetrics and Gynecology in March 2015 called the number of hysterectomies performed in the U.S. into question. Researchers studied the medical records of more than 3,400 women and found in roughly 1 in 5 women the surgery was unnecessary. For instance, a number of women had their uterus removed for abnormal uterine bleeding when there were alternative therapies that doctors could have tried before surgery.
Before a woman undergoes a hysterectomy, there are a number of factors to consider, including the type of procedure about to be performed, the surgical technique a doctor may recommend and the possible complications.
Regardless of the type of surgery used, a hysterectomy is considered a major surgical procedure with the possibility of several complications, some of which are serious. More experienced surgeons typically have less trouble with complications. Some are more common, like infections and bleeding. Women are less aware of other complications, like the threat of uterine cancer, pelvic organ prolapse or incontinence. The overall rate of complications is low at about 1 percent, but some of these complications can be fatal.
- Infection. These are some of the most common complications. Infections usually occur in the incision or the top of the vagina, also called the vaginal cuff. While infections usually respond to antibiotics, sometimes more surgery might be needed to treat the infection. Patients typically have a 30 percent chance of infection while at the hospital.
- Pain. About 85 percent of women suffer moderate-to-severe pain after surgery that necessitates pain medication to control. Some women may have to take highly addictive drugs like morphine or fentanyl for relief.
- Blood Loss. The average blood lost during a hysterectomy is roughly the same amount as three menstrual cycles. During an abdominal hysterectomy, it is double that. Women should be aware that a blood transfusion may be necessary. Women who already have heavy periods are at additional risk.
- Organ Damage. The organs surrounding the uterus may be damaged during surgery. For example, the bowel, bladder and urinary tract may be injured. If the bowel is injured, it can be especially troublesome because infection sets in quickly after a bowel injury. Surgeons try to catch injuries during surgery so they can repair any damage while performing surgery.
- Early Onset Menopause. Even if a woman retains her ovaries, menopause came about 4 to 5 years earlier in women who had their uterus removed. Without the uterus, blood flow to the ovaries might be disrupted, prevented them from properly producing hormones. The symptoms of menopause vary, but these include: hot flashes, loss of libido, vaginal dryness, depression, irritability and night sweats.
- Psychological Problems. A number of mental changes may occur and are different from woman to woman. Some studies found women may experience depression, anxiety and decreased sex drive after the operation. Some women may need to take medications to control the symptoms.
- Increased Risk of Heart Attack and Stroke. If a woman has the procedure done in her forties or younger, she is at increased risk of heart attack and stroke.
- Urinary or Fecal Incontinence. Frequent urination, incontinence and bowel dysfunctions can also occur, leaving a woman constipated or with fecal incontinence.
- Pelvic Organ Prolapse. Without the uterus, pelvic organs may sag into the vagina, a condition known as pelvic organ prolapse or POP. This may require more surgery to repair. Some women may have transvaginal mesh implanted to hold up sagging organs. But these implants carry complications of their own, such as organ perforation and painful sex.
- Risk of Spreading Uterine Cancer. Certain surgical techniques may increase the risk or spreading uterine cancer. Cancerous cells can hide in fibroids and other tissues. Without testing fibroids before surgery, it is impossible to tell if cancerous cells are present. A number of women undergo surgery with a tool called a power morcellator, a drill-like device that chops up fibroids and uterus tissues into smaller pieces for easy removal. Some women went in for a routine operation only to be told they now have stage 3 or 4 uterine cancer.
- Increased Risk of Cancer. Some studies also connect hysterectomies to several cancers, including thyroid cancer, bladder cancer and renal cancer.
These are just some of the complications that can occur. Depending on any other health issues a woman may have, she may be at risk for additional complications.
When Do Doctors Recommend Hysterectomies?
The U.S. Food and Drug Administration’s Office on Women’s Health suggests that a doctor may recommend a hysterectomy in a handful of cases. Keep in mind that there may be alternatives to this surgery even with these conditions. Women should always discuss all options with their doctors.
Uterine fibroids are benign, non-cancerous masses of tissue that grow on the walls of the uterus. For some women, fibroids do not pose much of a problem without treatment. However, some women may suffer pain, discomfort or heavy bleeding. If there are too many fibroids to remove individually, a doctor may recommend removing the uterus. Fibroids are the most common reason women get hysterectomies.
After several vaginal births, a woman may suffer uterine prolapse — a condition where the uterus slips out of its usual place in the pelvic cavity and sags into the vagina. Obesity and menopause may also cause this problem. If the uterus sinks into the vagina, this can cause bowel and urinary problems as well as pelvic pain and discomfort.
Endometriosis and Adenomyosis
Endometriosis occurs when the lining of the uterus grows outside of the uterus. This can cause heavy periods and pain. Adenomyosis occurs when the lining of the uterus grows inside the wall of the uterus where it doesn’t belong, making the wall overly thick. This causes severe pain and heavy bleeding.
If cancer is present in the ovaries, uterus, cervix or lining of the uterus, a hysterectomy may be the best option for treatment.
Different Types of Hysterectomies
There are three different types of hysterectomies, depending on the amount of the uterus removed: total, partial or radical.
- Total hysterectomies are the most common type of hysterectomy and remove the entire uterus including the cervix. Doctors may or may not remove the fallopian tubes and ovaries.
- Partial hysterectomies remove just the upper part of the uterus and leave the cervix in place. As with a total hysterectomy, the ovaries may or may not be removed.
- Radical hysterectomies are most often used to treat cervical or other cancers. This procedure removes all of the uterus, the cervix and tissue surrounding the cervix, including part of the vagina. The ovaries and fallopian tubes may or may not be removed.
How is a Hysterectomy Performed?
Depending on the woman’s health history and reason for surgery, a surgeon will decide on the best type of technique. Each of these may have risks and benefits.
In this technique, doctors make a cut about 15 cm in length in the lower abdomen to reach the uterus. One of the drawbacks to this technique is a more lengthy recovery and more blood loss, but it is the most popular technique performed in the U.S. Surgeons must cut through several layers of fat, muscle and the lining of the abdominal cavity.
Most abdominal hysterectomies are also called total abdominal hysterectomies because doctors choose to remove the cervix and the uterus. Some doctors argue that the cervix should be left in place because it may cause problems later on. Though, studies show women who keep the cervix may still have a 20 percent chance of spotting.
Because of the extensive tissue cutting involved, it takes about 6 to 8 weeks to recover.
Doctors access the cervix and uterus through a small cut in the vagina. After gently cutting the uterus away from surrounding tissues, the surgeon can pull the tissue out through the vagina. The top of the vagina is sutured with sutures that dissolve on their own in 4 to 6 weeks. There is less pain and no scar on the stomach. Women also recover more quickly from this type of hysterectomy. It generally costs less to perform, though the downside is the organs are less visible and doctors may have a more difficult time seeing them during surgery.
If a woman has endometriosis or uterine growths, this method might not be the best way to approach a hysterectomy.
With advances in surgical technique, many doctors are in favor of a laparoscopic approach. Studies show this approach leads to less bleeding, less pain and less risk of infection. Many doctors recommend this type of surgery to women who cannot have vaginal hysterectomies. Doctors insert a laparoscope with a small camera at the end along with several tools through small incisions in the abdomen. Doctors use a monitor to see the inside of the pelvis and make the necessary cuts. Many surgeons use thermal energy to seal blood vessels and cut tissues.
Surgeons can then pull the uterus out of the vagina or through a small incision in the abdominal wall. Women usually recover in about 3 weeks and patients are usually able to go home the same day of surgery.
Some surgeons use a tool called a power morcellator. These instruments resemble drills that have long tubes with cutting blades at the end. Surgeons use these devices to chop up pieces of fibroids or chunks of the uterus and suck them out of the pelvic cavity through a small tube. But, the FDA recently warned that power morcellators may spread undiagnosed uterine cancer that may be hiding in fibroids or other tissues.
If you are considering having a hysterectomy, it is very important that you ask your doctor if he or she will be using a power morcellator.
There are a number of other treatments that may be able to treat certain conditions without removing the uterus. Make sure you have an in depth conversation with your doctor about your options.
- Uterine prolapse. Instead of removing the uterus, a woman may be able to do Kegel exercises and other pelvic floor therapies that strengthen the pelvic muscles to better hold up organs.
- Endometriosis Removal of the endometrial tissue while leaving the uterus intact or oral contraceptives.
- Cervical dysplasia. If precancerous or abnormal cells are in surface tissues or are very light, doctors may be able to do a loop electrosurgical excision procedure (LEEP). LEEP removes these problematic cells.
- Abnormal bleeding. Several things may cause abnormal bleeding, including hormone levels, infection, fibroids or cancer. Some treatments include dilation and curettage (D&C), where the lining and contents of the uterus are removed, medications, hormones and IUDs may be used to treat these conditions without surgery.
- Fibroids Doctors may be able to cut off the blood supply to a fibroid and stop it from growing without removing the entire uterus. Fibroids may also be removed in a procedure called a myomectomy. If women choose a myomectomy, they should ask if their doctor is using a power morcellator. The FDA warned that these surgical tools can spread undiagnosed uterine cancer.
As always, patients have the right to a second or even third opinion. Before undergoing a major surgery like a hysterectomy, make sure to weigh all the risks and benefits and discuss them with your doctor.