Hysterectomy

A hysterectomy is the removal of the uterus (womb). In Australia, approximately 30,000 women will have a hysterectomy every year. 

Types of Hysterectomy

There are different types of hysterectomy including:

• Total hysterectomy (also called complete hysterectomy). This procedure removes the uterus and cervix.
• Subtotal hysterectomy (also called partial hysterectomy, or supracervical hysterectomy). This procedure removes the uterus only, and leaves the cervix behind.
• Radical hysterectomy. This procedure involves removal of the uterus, cervix, and removal of a safety margin for severe endometriosis or gynaecological cancer. 

Ovary removal or preservation?

Removal of ovaries: During a hysterectomy the ovaries can be removed or preserved. It does not complicate the hysterectomy or prolong the operation time to remove one or both ovaries and this can be also achieved laparoscopically. It also has no impact on the cost of your operation. 

A young woman will become menopausal if the ovaries are removed (if not already postmenopausal).

Typically, I recommend removal of the ovaries in women who have a high risk of ovarian cancer (BRCA1/2, Lynch, history of breast cancer) and/or in postmenopausal women. 

Preservation of ovaries: Alternatively, the ovaries can be preserved, which maintains the ongoing production of hormones, such as oestrogen and progesterone. Preserving ovaries is useful and recommended in young women who are not at increased risk of ovarian cancer. Surgical menopause at a younger age can increase the risk for osteoporosis, cardiovascular problems or dementia.

Reasons for hysterectomy

A hysterectomy may be recommended for a number of reasons. Benign conditions include those that lead to severe pelvic pain and bleeding. Reasons for hysterectomy include: 

• Uterine fibroids 
• Endometriosis or adenomyosis
• Benign pelvic masses
• Uterine prolapse
• Pelvic inflammation
• Cancer

Alternatives to a hysterectomy

There are alternative options for hysterectomy. These include:

Uterine artery embolisation: I recommend uterine artery embolisation for treatment of arteriovenous malformations (when a group of blood vessels form incorrectly), pelvic congestion syndrome, and tumour-related bleeding when surgery is not possible. This procedure aims to block the blood vessels to the uterus in order to reduce blood flow to the uterus. The blood supply is blocked by a material called an ‘embolic agent’. There are different types of embolic agents including coils, foam, plastic particles and glue. This procedure will require a local and sedation anaesthetic.

Uterine artery embolization is performed by radiologists. Sometimes these procedures are complicated by acute and severe pain that require an immediate hysterectomy. Therefore, the procedure should only be performed by radiologists who have admitting rights to a hospital and who are able to manage that complication. Also, this procedure does not obtain tissue. This means that in the rare cases that a uterus contains a malignancy, this would not be discovered. Patients need to be aware and accepting of this risk. Generally and for some of the reasons mentioned above, the uptake of this procedure has been slow in Australia.

Bakri balloon: A Bakri balloon catheter is invaluable for the management of postpartum haemorrhage (acute bleeding after giving birth) to avoid a postpartum hysterectomy. In cases of severe haemorrhage, it gets inserted into the uterine cavity and then the balloon is inflated. The balloon will stay for one to two days and will then be removed under controlled conditions.

Endometrial ablation: This surgical procedure removes the inner lining of the uterus (endometrium). The main reason for endometrial ablation is to reduce or stop excessive blood loss during the menstrual cycle. Its success rate is around 40% to 60%. This procedure should not be performed for women with known or suspected cancer or precancerous changes, women who wish to retain fertility (this procedure removes your ability to become pregnant), acute pelvic infection and in postmenopausal women.  

Hormonal treatment/IUD: Hormonal treatment is an attractive alternative to hysterectomy to treat heavy menstrual bleeding and is also used for contraception. A progestin-releasing intrauterine device (IUD) is a small coil that is coated with a Progestin hormone that is very slowly released into the uterine cavity. More recently, our group published research which found patients with endometrial cancer or pre-cancer can be successfully treated using an IUD. An IUD is less likely to be effective in conditions that involve the muscle layer of the uterus – called the myometrium (such as large fibroids or adenomyosis). Prior to an insertion of an IUD an endometrial sampling (endometrial biopsy, Pipelle) or a hysteroscopy and a curettage (D&C) needs to be performed to exclude cancer. Possible risks of IUD include perforation of the IUD into the pelvis or lack of effectiveness (30% to 40%).

Pelvic floor exercise and pessaries: In patients with mild pelvic organ prolapse or elderly patients with significant medical co-morbidities a hysterectomy can be avoided by pelvic floor exercise and pessaries. A pessary is a prosthetic device that is inserted into the vagina to support the internal structures after a pelvic organ prolapse.

Comparison of surgical techniques

Abdominal hysterectomy: Hysterectomies can be performed through an abdominal incision (“open”). This incision can be transverse (like a caesarean section) or through a midline incision. The recovery time for an open hysterectomy is 4 to 6 weeks and sometimes longer due to the need for a long incision to heal. An open hysterectomy is preferred for ovarian cancer surgery. An open hysterectomy is outdated for women requiring surgery for benign conditions and should not be performed in those circumstances (except if the uterus is larger than 16 or 18 weeks size). Obese or morbidly obese women should avoid open surgery if not absolutely necessary due to their higher risk of complications.

Vaginal hysterectomy: Many hysterectomies are performed vaginally and this approach has clear advantages over an open surgical approach. These include fewer complications, shorter hospital stay, quicker recovery and shorter healing time. However, some hysterectomies are too risky to be performed vaginally. Previous surgery (caesarean sections) or a narrow vagina (no vaginal birth) often makes this approach impossible. In those circumstances, a total laparoscopic hysterectomy should be considered. Vaginal hysterectomy is the preferred approach for women who have their hysterectomy primarily for pelvic floor repair. The major downside of vaginal hysterectomy is that fallopian tubes that should be removed often remain not removed.

Total laparoscopic hysterectomy is an operation that is completed through keyhole incisions (sometimes referred to as keyhole surgery). It is suitable for almost all patients (excluding ovarian cancer patients), even those with previous surgery, or obese and morbidly obese patients.

Total laparoscopic hysterectomy is well established in Australia and safely practiced by experienced gynaecologists for the past 20 years. It uses a “keyhole” approach: CO2 gas is used to expand the abdominal cavity. Then three or four tiny incisions (5 mm) are made and a high-resolution camera plus thin instruments will be inserted into the abdominal cavity. The camera takes live images and the surgeon can operate by looking at the screen. Our blog Doctor how will you get my uterus out? details how the uterus is removed via laparoscopic surgery.

There are three main advantages of total laparoscopic hysterectomy compared to abdominal hysterectomy:

1. Quicker recovery and less pain: Typically, patients who have a total laparoscopic hysterectomy are active after 1 to 2 weeks (work, home duties), compared to 4 to 6 weeks after an “open” procedure. Patients who have an abdominal and vaginal hysterectomy require more painkillers than patients who had a total laparoscopic hysterectomy.
2. Fewer surgical complications: The risk of surgical complications is approximately 8% and reduced by 30% to 50% compared to an “open” hysterectomy.
3. Cost effective: Total laparoscopic hysterectomy has slightly higher costs of surgery. However these costs are offset by shorter hospital stay (1 to 2 days with total laparoscopic hysterectomy; 5 to 7 days with open hysterectomy).
4. Conversion from laparoscopic to open: Not all laparoscopic hysterectomies are completed laparoscopically. This can be because of sever adhesions (tissues are stuck together) or heavy bleeding. Good surgeons record their conversion rates, which should not be higher than 3% to 5%.

Robotic hysterectomy has become popular in the United States where it is fully funded through health funds. In Australia, the uptake of robotic hysterectomy has been slow. Research from the United States of America suggests that patient outcomes are identical with robotic or laparoscopic hysterectomy.

When is subtotal hysterectomy recommended?

Subtotal hysterectomy leaves the cervix behind. Some gynaecologists advocate for subtotal hysterectomy to preserve pelvic floor and sexual function. However, extensive research on this topic has shown that pelvic floor and sexual function are identical when subtotal and total hysterectomy were compared. The downsides of subtotal hysterectomy include that Cervical Cancer Screening Tests need to be continued, abnormal bleeding may continue, and subsequent surgery to remove the cervix is difficult and risky. In addition, there is a need to make an opening in the abdomen through a cut to remove the uterus (this is not needed with a total hysterectomy). 

My recommendation

For the reasons described above, I routinely recommend total laparoscopic hysterectomy. An abdominal incision (opening of the abdomen) should be avoided under almost any circumstances, except for ovarian cancer surgery. Women who had surgery (e.g. caesarean sections) previously can still have a laparoscopic hysterectomy. If the opening of your abdomen is recommended, I suggest you look for a second opinion.

Risks of hysterectomy

Any surgery carries risks. Risks may include:

• Cardiac, cerebrovascular or anaesthetic complications (less than 1%)
• Deep vein thrombosis (blood clot in calf) or pulmonary embolus (blood clot in lung) (less than 1%)
• Injury to bladder, ureter or bowel, blood vessels and nerves (1%)
• Conversion to open (3% to 5%)
• Infections (2% to 5%)
• Constipation

These above risks are similar across all three surgical techniques.

It is well established the risk of postsurgical complications is 30% less with laparoscopic than with open (abdominal) hysterectomy. The risk of infection is much higher with open surgery than with total laparoscopic hysterectomy. Especially in obese and super-obese women (BMI>40) that risk can be as high as 50%. In contrast, that risk is much lower with total laparoscopic hysterectomy.

However, patients considering a total laparoscopic hysterectomy have a 2% risk that the operation needs to be converted to an open procedure due to unforeseen problems (such as bleeding, adhesions and distorted anatomy).

Patients who have a total laparoscopic hysterectomy often experience “shoulder pain” for up to one day after surgery. This is from the CO2 gas that we use in surgery which can irritate some nerves that run along the spine and radiate upwards into the shoulder blade. 

Patients who require a radical hysterectomy (cancer, endometriosis) have a risk of bladder dysfunction for up to several weeks. 

Removal of ovaries in young women (oophorectomy) will result in menopause and is not recommended for young (premenopausal) patients with benign conditions. 

Recovery from hysterectomy 

Patients will need to stay in hospital for 1-2 days if you have a laparoscopic hysterectomy. For abdominal hysterectomy the hospital stay is 5-7 days. Full recovery from surgery will be 4-6 weeks after surgery for abdominal hysterectomy, 2-3 weeks for vaginal and 1-2 weeks for laparoscopic hysterectomy. All patients will be prescribed pain killers upon leaving the hospital and it is critical that they are continued to be taken beyond discharge from hospital for approximately 10 days.

I recommend avoiding intercourse, vaginal tampons and full baths for the 6 weeks after surgery and other factors that could disrupt wound healing or facilitate an infection. Patients who have constipation tendencies might require laxatives after any surgery because the painkillers may potentially cause constipation. Vaginal discharge following hysterectomy is normal for up to 6 weeks. Further DO'S and DONT'S post hysterectomy are described here.

Please notify me immediately if your condition becomes worse after you have been discharged from hospital.

Exercise after hysterectomy

Whenever possible we will mobilise patients on the day or the day after a hysterectomy with the help of experienced physiotherapy staff. At discharge, I recommend to "take it easy" for 1-2 weeks. Gentle exercise is possible but competitive training should be avoided for a few weeks. 

Follow-up 

After surgery, all patients with uterine cancer (except those with very low risk of recurrence) should be seen regularly for follow-up for 5 years. After five years, the risk of a recurrence becomes very low.  If a patient has a hysterectomy for benign reasons, they are seen once for follow-up.

These examinations will always include pelvic examinations. I will discuss with my patients if any other tests (Cervical cancer screening test, medical imaging, blood tests) are required. Should you experience any bleeding or pain, please do not wait but contact my office straight away.

Reasons hysterectomy is not recommended

Reasons not to have a hysterectomy are birth control or to stop (normal) monthly periods. There are far less invasive procedures available to gynaecologists to achieve birth control which result in the same outcome.

I would not recommend a hysterectomy for menopause symptoms because these are mainly hormonal symptoms, and the uterus does not produce hormones. These symptoms relate to the ovaries and a patient's hormonal function rather than the uterus. Removing the uterus will not address menopausal symptoms.

We also need to be careful with hysterectomy for Cervical Intraepithelial Neoplasia (CIN) without informing women that they will require meticulous follow up including vaginal vault cytology every year after surgery. CIN might recur at the vagina and is challenging to manage.

Unfortunately, some hysterectomies are performed for abnormal uterine bleeding without prior curettage. The chances of finding a uterine malignancy “unexpectedly” are between 10% and 20%. If a hysterectomy is offered for abdominal uterine bleeding it is critical to sample the endometrium for cancer first and only then offer a hysterectomy. 

Should you want to discuss hysterectomy or alternative options with Dr Obermair, please enquire about an appointment.