Hysterectomy

What you should know

Hysterectomy is the second most common surgery among women in the United States. Every year, approximately 600,000 women undergo a hysterectomy and by age 60 years, about one of every three women has undergone the surgical procedure. So what is a hysterectomy? Why do so many women have one?

Know Your Anatomy
Your uterus, also called "womb," is the hollow, muscular organ where a fetus grows during pregnancy. Unless you are pregnant or your uterus is enlarged for other reasons, you cannot normally feel it yourself. The top of the uterus is rounded and wider than the bottom part (kind of shaped like an upside-down pear). The lower part is called the cervix - or mouth - of the uterus. Your health care provider can view the cervix at the top of the vagina when he or she performs a pelvic examination and takes a Papanicolaou (Pap) smear. In addition to the uterus, women also have two fallopian tubes, which extend out from each side of the uterus; these tubes carry eggs from the ovaries (the organs that produce eggs during a woman's reproductive years).

What Happens During a Hysterectomy?
A hysterectomy is an operation to remove the uterus. Depending on the reason for the hysterectomy, one (unilateral) or both (bilateral) fallopian tubes (salpingectomy) and/or one or both ovaries (oophorectomy) may also be removed at this time as well.

Sometimes only the top part of the uterus is removed, leaving the cervix in place. This is called a partial, or supracervical ("above the cervix") hysterectomy. Removal of the uterus alone, including the cervix, is called a complete or total hysterectomy.

Removal of the uterus, both tubes, and both ovaries is termed a total hysterectomy with bilateral salpingo-oophorectomy.

The traditional hysterectomy, with or without removal of tubes and ovaries, is done through a surgical cut above the pubic bone. If only the uterus is being removed, the surgery can sometimes be done through the vagina, without making a visible cut on the skin. A third technique is through a laparoscope, a lighted tube that is inserted through a small cut just below the belly button. The type of procedure chosen depends on the reason for the hysterectomy, the surgeon's preference and experience, and the patient's preference.

After a hysterectomy, menstrual periods stop and you can no longer become pregnant. If both ovaries are removed, menopause will occur in those who have not yet gone through it. Menopause, however, may or may not occur if only the uterus or the uterus and one ovary are removed. Since the drop in hormone levels is sudden after a hysterectomy, you may experience severe symptoms of vaginal dryness and hot flashes. However, effective treatments are available. You should talk with your health care provider about what to expect after your hysterectomy and discuss what treatment he or she may prescribe.

Reasons for Hysterectomy
Many conditions for which hysterectomy is considered have alternative treatments. Here are the most common conditions:

Fibroids - This is the most common reason for hysterectomy. Although often called "fibroid tumors," these muscle growths in the uterus are not cancerous. Many women develop fibroids without knowing it. Sometimes fibroids grow very large, making the uterus feel hard and irregular. They can also cause severe menstrual cramping as well as heavy bleeding. This in turn may cause anemia as well as pressure on the bladder and rectum, which may result in frequent urination and constipation. Fibroids generally shrink after menopause.

Hormones, including oral contraceptives and injectable birth control can often control heavy bleeding until menopause. There are also medications that shrink fibroids, but they may only be used for a short time and are ineffective in some women (fibroids will usually grow after the medication is stopped). In some cases when a woman wishes to become pregnant, the fibroids can be removed without a hysterectomy. A procedure called uterine artery embolization is a treatment in which medication is injected into the vessels supplying blood to the fibroids, cutting off their blood supply and shrinking them.

Endometriosis - Endometriosis is the second most common reason for hysterectomy. In this noncancerous condition, bits of tissue similar to the uterine lining (endometrium) grow outside or behind the uterus, on or around the ovaries, outside the bowel or bladder, and on the ligaments that support the uterus. When the endometrium inside the uterus builds up, these implants also swell and grow; and when the endometrium inside the uterus sheds and bleeds, so do the misplaced endometrial implants. Pain and infertility can result from these implants and other charges in the abdomen.

Endometriosis can be treated with hormones as well as pain relieving medications, or by removing just the endometrial implants. Endometriosis usually improves after menopause.

Uterine Prolapse - In this condition, the ligaments and tissues holding the uterus in place become weakened (often as a result of childbirth) and the uterus slides down into the vagina. Uterine prolapse causes discomfort and can interfere with sex; it may also interfere with one's ability to control urine. If the uterus slides down so far that the cervix is at or outside the vaginal opening, infections can be a recurrent problem. Depending on how serious and bothersome the prolapse is, hormones or support devices (called pessaries) placed inside the vagina may be helpful, as can surgery to place the uterus back in its proper position.

Cancer - Only one out of every 10 hysterectomies is performed because of cancer. This may include cancer of the uterine lining, uterine muscle, ovaries, fallopian tubes, or cervix. Cancer of the cervix, if caught early by regular Pap smears, can often be treated by removing a small amount of tissue from the cervix.

Other Reasons - Other reasons women might need to have a hysterectomy include severe scarring from repeated pelvic infections, menstrual bleeding so heavy that it causes anemia, and chronic pelvic pain that has not improved with other treatments.

Hysterectomy and Your Sex Life
After having a hysterectomy, many women experience changes in their desire for sex, enjoyment of sex, and orgasm. Several studies have found that women who have hysterectomies because of conditions causing pain and bleeding have a better quality of life in general, more frequent sexual intercourse, and stronger and more frequent orgasms after the surgery.

However, some women find that their desire for, and enjoyment of, sex decreases. If the problem is due to the symptoms of surgical menopause, lubricants to relieve vaginal dryness and hormones to maintain vaginal health and sexual interest can help greatly. Hormone therapy, however, is not right for everyone and your health care provider should evaluate and discuss the advantages and disadvantages of hormone therapy with you.

Lastly, some experts believe that leaving the cervix in place preserves a woman's ability to enjoy sex and have strong orgasms; although this has never been proven by research. Before undergoing a hysterectomy, talk to your health care provider about any sexual concerns you might have.

If Hysterectomy is Suggested
If your health care provider recommends a hysterectomy for reasons other than cancer, there is usually time for you to consider other options before making a decision. For some of the conditions discussed above, alternatives to surgery are available. Women who have tried medical treatments and still have pain and bleeding that interferes with their lives usually experience significant relief and improvement in quality of life after surgery. If you want to preserve your ability to become pregnant or are reluctant to have surgery, ask your health care provider about other available options. You may also want to seek a second opinion (many health insurance companies will pay for this). Be sure you have enough information about your medical condition, alternative treatments, and surgery and recovery to feel comfortable with your decision.

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