Abdominal Hysterectomy

ABDOMINAL HYSTERECTOMY OVERVIEW

Abdominal hysterectomy is a surgical procedure in which the uterus is removed through an incision in the lower abdomen (figure 1). One or both ovaries and fallopian tubes may also be removed during the procedure, but their removal is not required for hysterectomy and the decision to remove them is made on an individual basis (figure 2). Women who have their uterus removed, but not their ovaries, will contain to produce female hormones but will not have a monthly menstrual period.

FEMALE ANATOMY

A brief review of female reproductive anatomy may be of help in understanding hysterectomy.

The uterus is a hollow, pear-shaped muscular organ located in the lower abdomen and pelvis. At the upper end of the uterus, the fallopian tubes open on each side. The outer end of each tube lays next to an ovary. The ovaries lay next to and slightly behind the uterus.

At its lower end, the uterus narrows and opens into the vagina. The lower end of the uterus is called the cervix.

REASONS FOR ABDOMINAL HYSTERECTOMY

A hysterectomy may be recommended for a number of conditions. For some of these conditions, there may be an alternative to hysterectomy, described below. (See 'Alternatives to hysterectomy' below.)

Abnormal uterine bleeding — Excessive uterine bleeding, called menorrhagia, can lead to anemia (low blood iron count), fatigue, and contribute to missed days at work or school. Menorrhagia is generally defined as bleeding that lasts longer than seven days or saturates more than one pad per hour for several hours. Abnormal uterine bleeding (or any uterine bleeding after menopause) can also be a sign of uterine cancer. All women with these symptoms should undergo evaluation.

Heavy or irregular bleeding are generally treated first with medication or other surgical alternatives to hysterectomy (see "Patient education: Heavy or prolonged menstrual bleeding (menorrhagia). However, abnormal uterine bleeding that does not improve with conservative treatments may require hysterectomy.

Fibroids — Fibroids (also known as leiomyomas) are noncancerous growths of uterine muscle that occur in up to one-third of all women. Fibroids may become larger during pregnancy, and typically shrink after menopause. They may cause excessive bleeding and pelvic pain or pressure. 

Pelvic organ prolapse — Pelvic organ prolapse occurs due to stretching and weakening of the pelvic muscles and ligaments. This allows the uterus to fall (or prolapse) into the vagina. Prolapse is more common in women who have been pregnant and/or had vaginal childbirth, and in those with certain genetic factors, lifestyle factors (such as repeated heavy lifting over the lifetime), or chronic constipation.

Cervical abnormalities — Hysterectomy is rarely needed for severe cervical precancer that does not resolve after other procedures (such as cone biopsy). 

Endometrial hyperplasia — Endometrial hyperplasia is the term used to describe excessive growth of the endometrium (the tissue that lines the uterus). It can sometimes lead to endometrial cancer. Although endometrial hyperplasia can often be treated with medication, a hysterectomy is sometimes needed or preferred to medical therapy.

Cancer — Cancer of the uterus (endometrium), cervix, or ovaries may require hysterectomy. 

Severe bleeding after childbirth — Hysterectomy may rarely be required in women who have uncontrollable bleeding after childbirth.

Chronic pelvic pain — Chronic pelvic pain can be due to the effects of endometriosis or scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can also be caused by other sources, including the gastrointestinal and urinary systems (see: Chronic pelvic pain in females). It is important for a woman with pelvic pain to ask about the probability that her pain will improve after hysterectomy.

PREOPERATIVE PLANNING AND EVALUATION

Before surgery, you and your clinician should discuss whether your ovaries and/or tubes should also be removed, whether you will need estrogen therapy after surgery, and whether only the portion of your uterus above the cervix will be removed.

Removal of ovaries and fallopian tubes — The ovaries and fallopian tubes may be removed during hysterectomy, a procedure known as an oophorectomy. Removal of these organs is not always required; the decision depends upon several considerations.

Premenopausal women may decide to keep their ovaries to provide a continued, natural source of hormones, including estrogen, progesterone, and testosterone. These hormones are important in reducing the risk of heart disease, maintaining sexual interest, preventing symptoms of menopause such as hot flashes and vaginal dryness, and loss of bone density. On the other hand, women who have menstrual cycle-related migraines, epilepsy, or severe premenstrual syndrome (PMS) may have an improvement in symptoms when hormone levels are reduced by removing the ovaries. In addition, women who are at increased risk of ovarian or fallopian tube cancer are generally advised to have their ovaries and tubes removed.

Postmenopausal women are often advised to have their ovaries removed because of a small risk of developing ovarian cancer at some point during their lifetime. The benefits of removing or keeping ovaries should be discussed with a physician.

It's important to talk with your doctor before surgery about the risks and benefits of having your ovaries removed.

Estrogen therapy — Estrogen therapy (ET) may be recommended after surgery for women who have not reached menopause who had their ovaries removed. ET can help to prevent hot flashes, night sweats, and loss of bone density, which may occur when the ovaries are surgically removed. If you plan to use ET, your doctor will talk to you about the risks and benefits, and about how long to use this treatment. 

Women who have completed menopause generally do not require ET after hysterectomy. 

Preoperative testing — Standard preoperative testing may include a physical examination, EKG, chest X-ray, and blood testing, depending upon your age and other medical conditions.

Supracervical/subtotal hysterectomy — A standard abdominal hysterectomy includes removal of the entire uterus and cervix. However, there are situations in which the entire uterus is not removed. A supracervical, subtotal, or partial hysterectomy refers to a procedure in which the cervix is left in place, while the top of the uterus is removed. Supracervical hysterectomy may be done if you want to keep your cervix or if difficulties arise during surgery that make removal of the cervix complicated. Prior to planned hysterectomy, you should talk with your doctor about the risks and benefits of leaving the cervix in place.

Women who undergo supracervical hysterectomy must continue to have routine screening (Pap smear) for cervical cancer. Some women continue to have menstrual bleeding since the retained cervix is attached to a small remaining portion of the uterus.

In the past, there was concern that removing the cervix would interfere with sexual satisfaction. However, studies have demonstrated that sexual satisfaction does not appear to differ after hysterectomy between women with and without a cervix.

ABDOMINAL HYSTERECTOMY PROCEDURE

Abdominal hysterectomy is performed in a hospital setting, and generally requires approximately two hours in the operating room. Before surgery starts, you will receive antibiotics to prevent infection and medication or compression devices to prevent abnormal blood clots. Next, you will be given general or spinal anesthesia plus sedation so that you feel no pain. Heart rate, blood pressure, blood loss, and respiration are closely observed throughout the procedure. After surgery, you will be transferred to the recovery room (also known as the post-anesthesia care unit) so you can be monitored while waking up. Most women will then be transferred to a hospital room for one to two nights.

ABDOMINAL HYSTERECTOMY COMPLICATIONS

A number of complications can occur as a result of hysterectomy. Fortunately, most can be easily managed and do not cause long-term problems.

Hemorrhage — Excessive bleeding (hemorrhage) occurs in a small number of cases and may require a return to the operating room to identify and stop the bleeding.

Infection — Low-grade fever is common after hysterectomy, is not always caused by infection, and usually resolves without treatment. However, a high or persistent fever may signal an infection. Serious infection occurs in less than 10 percent of women, and can usually be treated with intravenous antibiotics. Much less commonly, a woman will require another surgical procedure.

Constipation — Constipation occurs in most women following hysterectomy, and can usually be controlled with a regimen of stool softeners, dietary fiber, and laxatives.

Urinary retention — Urinary retention, or the inability to pass urine, can occur after abdominal hysterectomy. It is more common in women who have vaginal hysterectomy (see 'Alternatives to hysterectomy' below). Urine can be drained using a catheter until retention resolves, usually within 24 to 48 hours.

Blood clots — Pelvic surgery increases the risk of developing blood clots in the large veins of the leg or lung. The risk is increased for approximately six weeks after surgery. Before surgery starts, women undergoing abdominal hysterectomy should receive treatment to prevent blood clots from forming; these treatments can include compression stockings, pneumatic compression devices, and medication. In addition, women taking oral contraceptives or hormone replacement should ideally discontinue them prior to surgery since they can further increase the risk of blood clots. Women who are sexually active and premenopausal should use alternative methods of birth control (eg, condoms) to prevent pregnancy before surgery. 

Damage to adjacent organs — The urinary bladder, ureters (small tubes leading from the kidneys to the bladder), and large and small intestines are located in the lower abdomen and pelvis and can be injured during hysterectomy. Injury occurs in less than one percent of all women undergoing hysterectomy, and can usually be detected and corrected at the time of surgery. If detected after surgery, another operation may be needed.

Early menopause — Women who have had a hysterectomy, but kept their ovaries, may go through menopause (when ovaries stop making hormones) earlier than average (age 51). This may be due to an interruption in blood flow to the ovaries as a result of removing the uterus.

RECOVERY AFTER ABDOMINAL HYSTERECTOMY

Fluids and food are generally offered soon after surgery. You may get fluids intravenously (by IV) during the first day, particularly if you have nausea or vomiting. You will also get pain medicine as needed, either intravenously, by intramuscular (IM) injection, or as a pill. You will likely be encouraged to resume your normal daily activities as soon as possible. Being active is particularly important since it helps to prevent complications, such as blood clots, pneumonia, and gas pains.

LIFE AFTER ABDOMINAL HYSTERECTOMY

Studies of women's response to hysterectomy show that most women are satisfied with their results (table 1). Most reported improvement in symptoms, such as pain and vaginal bleeding.

Sexual function and enjoyment, interest in sex, and pain with sex improved after hysterectomy for most women. However, everyone's situation is different, and your results will likely may depend upon several factors, including your age at the time of surgery, the reason for surgery, and whether you have a history of mood problems.

Younger women may grieve after hysterectomy due to their loss of fertility. If you have feelings of sadness, anxiety, or depression after surgery, it's important to talk to your doctor or nurse. It might help to talk with a therapist; some women may also benefit from with antidepressant medication. 

ALTERNATIVES TO HYSTERECTOMY

Women who wish to avoid or postpone hysterectomy may be able to use medications or less invasive surgical procedures. Medical and surgical alternatives to hysterectomy depend upon the underlying disorder. The decision as to which treatment is "best" should be based upon your particular medical problem, all available treatment options, and the risks and benefits of each type of treatment.

Some alternatives to abdominal hysterectomy include the following:

●In some cases the uterus may be removed through the vagina, avoiding the need for an incision in the abdomen. This procedure is called a vaginal hysterectomy. A vaginal approach may be used if the uterus is not too big, there is not too much scar tissue, and if the condition prompting the surgery is benign and limited to the uterus. Most women can return to normal activities sooner after a vaginal hysterectomy than after an abdominal hysterectomy.

●Uterine artery embolization and myomectomy may be used to treat symptomatic leiomyoma (fibroids). 

●Pain clinics may be able to treat patients with severe and chronic pelvic pain without surgery. 

●Endometrial ablation, in which a physician destroys or removes most of the endometrium using an instrument inserted through the vagina and cervix and into the uterus. 

●Medical therapy using hormonal medications, such GnRH analogs (for example, leuprolide) or progestins can help reduce the pain associated with endometriosis. 

●Cone biopsy (eg, cold knife cone), cryosurgery, laser surgery, or loop electrocautery (eg, LEEP or LLETZ) are usually used to treat women with cervical dysplasia (an abnormal Pap smear). These procedures remove the abnormal part of the cervix rather than the entire cervix and uterus.