Hysterectomy: Removal of the Uterus

A hysterectomy is a surgery for the removal of a woman’s uterus, also called the womb. This stops a woman’s menstrual cycle and ability to become pregnant. The 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.

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 have their uterus removed to improve survival or relieve 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 metal coils in the device.

However, sometimes women have unnecessary hysterectomies that put them at increased risk for a number of other health problems. Complications include hormone imbalance and pelvic organ prolapse, a condition that leads to pelvic organs sagging into the vagina.

Some surgical techniques may put women at risk for future complications. Procedures performed with a surgical tool called a power morcellator may put women at risk for spreading undiagnosed uterine cancer in the abdominal cavity. If transvaginal mesh is used during a hysterectomy, it could erode or perforate organs, causing severe pain and requiring additional surgery.

A study published in the American Journal of Obstetrics and Gynecology in March 2015 questioned the number of hysterectomies performed in the U.S.

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. Major complications are rare, but serious. More experienced surgeons typically have less trouble with complications. Some complications are common, such as infections and bleeding.

Women are usually less aware of other complications, such as the threat of uterine cancer, pelvic organ prolapse or incontinence. The overall rate of these complications is about 1 percent, but some complications can be fatal.

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.

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

Uterine fibroids are benign, noncancerous 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.

Uterine Prolapse

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, so a hysterectomy may be recommended to address this.

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, making the wall overly thick. This causes severe pain and heavy bleeding. In both cases, a hysterectomy may be recommended or indicated.

Cancer

If cancer is present in the ovaries, uterus, cervix or lining of the uterus, a hysterectomy may be the best option for treatment.

There are three different types of hysterectomies, depending on the amount of the uterus removed.

Some women are not counseled about the differences between total and partial hysterectomies. Doctors may remove the cervix as a precaution without informing the patient.

Depending on the woman’s health history and reason for surgery, a surgeon will decide on the best type of technique. Each of these has risks and benefits.

Abdominal

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 lengthy recovery and a lot of blood loss, but it is the most popular technique performed in the U.S. Surgeons must cut through several layers of fat and 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 its removal may cause problems later on. But studies show that 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.

Vaginal

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 with a vaginal hysterectomy. Women also recover more quickly from this type of hysterectomy. It generally costs less to perform, but the organs are less visible and doctors may have a more difficult time seeing them during surgery.

Laparoscopic

With advances in surgical technique, many doctors are in favor of a laparoscopic approach, possibly utilizing a robot to allow the doctor to manipulate the instruments. Studies show that 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 day of surgery.

Some surgeons use a tool called a power morcellator during a laparoscopic hysterectomy. 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 has 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.

V-NOTES Surgery

Transvaginal natural orifice transluminal endoscopic surgery, or V-NOTES, is a new hysterectomy technique that combines traditional laparoscopic surgery with vaginal surgery. Proponents of this surgery say it leads to better outcomes and recovery for patients.

A January 2022 study in Journal of Minimally Invasive Genecology found “hysterectomy by V-NOTES can be performed as a safe and adequate alternative to VH.” Fewer patients had hospital-readmission in the V-NOTES group.

There are a number of other treatments that may be able to address certain conditions without removing the uterus. Make sure you have an in depth conversation with your doctor about your options.

As always, patients have the right to a second or 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.

According to some studies, hysterectomies are often overused for benign conditions that may not warrant them.

“For 81 percent of hospitals, at least half of all hysterectomies performed between 2015 and 2017 were unnecessary. 1,167 hospitals performed at least 20 unnecessary hysterectomies between 2015 and 2017, and 495 hospitals performed at least 50,” according to the Lown Institute.

Conditions where a hysterectomy might not be necessary include: Benign uterine fibroids, abnormal pelvic bleeding, pelvic pain and a painful bladder condition called interstitial cystitis.

Hysterectomy and Interstitial Cystitis

Interstitial cystitis symptoms such as pelvic pain and urinary urgency may overlap with other conditions and make IC difficult to diagnose. Because of this, women with undiagnosed IC may have unnecessary hysterectomies, according to Drs. Maurice K. Chung and Barry Jarnagin.

Hysterectomy is a major operation with several potential complications. In contrast, a patient may be able to control IC symptoms with a medication called Elmiron.

Elmiron side effects are typically mild and include: Hair loss, gastrointestinal upset and nausea. However, recent studies have linked Elmiron to a type of eye damage called pigmentary maculopathy that could lead to permanent vision loss.

Before having a hysterectomy, patients should ask their doctors to rule out IC.