Hysterectomy is a surgical procedure in which a woman’s uterus is removed.
The uterus is the organ in which the child grows during pregnancy. Sometimes ovaries and fallopian tubes are removed during the procedure.
When is a hysterectomy necessary?
Surgical removal of the uterus is a significant procedure for a woman and is performed only if no other method brings the desired treatment success.
The most common reasons for a hysterectomy include:
• considerable menstrual bleeding (menorrhagia), e.g. due to fibromas;
• pelvic pain, e.g. caused by endometriosis, unsuccessful treatment of inflammation in the small pelvis or fibromas;
• uterine prolapse;
• Cancer of the uterus, ovaries or cervix.
Heavy menstrual bleeding
Many women lose a significant amount of blood during menstruation. Other symptoms may also occur, such as pain and abdominal cramps.
Heavy menstrual bleeding can be caused by fibroma, but in many cases there is no obvious cause.
Removal of the uterus may be the only way to stop heavy bleeding in the following cases:
• other treatments were unsuccessful;
• bleeding significantly affects the quality of life;
• the woman does not want to have children anymore.
Inflammation in the small pelvis
However, if it spreads, the uterus and fallopian tubes can be damaged, resulting in long-lasting pain.
A hysterectomy to remove the uterus and fallopian tubes may be advisable if the woman is in pain due to inflammation in the small pelvis and has completed family planning.
Endometriosis is a disease in which cells of the uterine lining also occur outside the uterus, for example in the ovaries, fallopian tubes, bladder and colon.
If the mucosal cells of the uterine lining are trapped in other areas of the body, the surrounding tissue can become inflamed and damaged. Pain, heavy and irregular menstrual bleeding and infertility are possible consequences.
With a hysterectomy, the pain-causing regions of the mucosal tissue can be removed, but only after all other possible treatment options have been applied.
A prolapse of the uterus (uterine prolapse) occurs when the tissue structures and ligaments that form the supporting apparatus of the uterus give way, and the sexual organ leaves its natural position and slides downwards.
Possible symptoms include back pain, the feeling of a foreign object sagging in the vagina, involuntary urine leakage (urinary incontinence) and difficulty having sexual intercourse.
A uterine prolapse can occur after childbirth (post partum).
A hysterectomy eliminates the symptoms of prolapse because the uterus is completely removed.
An indication for removal of the uterus may exist for the following tumors:
• Cervical cancer
• Ovarian cancer • Fallopian tube cancer
• Uterine cancer
Once the cancer has spread and reached an advanced stage, hysterectomy may be the only recommended treatment option.
What forms of hysterectomy are there?
Depending on the reason for the procedure, the surgeon may decide to remove all or part of the uterus.
The procedure can be performed under spinal or general anesthesia.
In a subtotal hysterectomy, only the upper part of the uterus is removed, the cervix is preserved.
In a total hysterectomy, the entire uterus, including the cervix, is removed.
In a radical hysterectomy, the surgeon removes the uterus, the tissue structures on the side of the uterus, the cervix and the upper section of the vagina, including the egg tubes and ovaries (adnexectomy).
Radical hysterectomy is usually performed only when there is a tumor.
Removal of the ovaries
In an ovariectomy (or oophorectomy), the ovaries are removed.
Hysterectomy in women of childbearing potential
Whatever form of hysterectomy is performed, after the procedure the woman can no longer become pregnant.
If a woman’s ovaries are removed before menopause, ovulation no longer occurs.
That means a drop in sex hormones: estrogen and progesterone.
Possible consequences of this are a dry vagina, hot flashes, sweating and other symptoms typical of menopause.
Women who undergo bilateral ovariectomy, that is, both ovaries are removed, usually begin hormone replacement therapy to maintain hormone levels.
Alternative treatment options
Removal of the uterus should be the last treatment option after all other treatment options have been exhausted, with the exception of cancer.
The following forms of treatment can be an alternative to a hysterectomy:
• Fibromas – surgical removal (myomectomy), drugs to temporarily block the action of sex hormones, freezing, cauterization, laser treatment (myolysis) or resection (incision) if they are located in the uterine cavity (submucous fibroids).
• Heavy bleeding – birth control pill to regulate the menstrual cycle, other pharmacological hormone therapies, surgical removal of the lining of the uterus (endometrium).
• Uterine prolapse – pelvic floor exercises, use of a vaginal pessary to support the uterus or surgical repair.
• Endometriosis – hormonal preparations and surgical removal of endometriosis regions.
How is a hysterectomy performed?
There are several methods of removing the uterus:
Abdominal hysterectomy. The procedure is performed by means of an abdominal incision (approx. 12-16 cm); the incision can be made vertically or horizontally and is located immediately above the pubic hair base.
Vaginal hysterectomy. There is an incision through the vagina. The doctor removes the uterus and closes it with a suture.
Laparoscopic hysterectomy. The laparoscope is a thin tube equipped with light and camera that gives the doctor the opportunity to examine the organs located in the pelvis.
The doctor makes three or four small incisions (smaller than 1 cm) in the abdominal wall to insert the laparoscope and other instruments. Then the uterus is cut into small pieces and removed through the incisions.
This procedure takes about 45-60 minutes.
Laparoscopically assisted vaginal hysterectomy. The doctor removes the uterus through the vagina. The laparoscope is used to control the procedure.
Robot-assisted laparoscopic hysterectomy. The doctor uses a special machine (robot) to remove the uterus through small incisions in the abdomen; the method is similar to laparoscopic hysterectomy (see above). It is often used for cancer or in very overweight patients when the vaginal procedure is not safe.
Complications after a hysterectomy
As a result of a hysterectomy, the following complications may occur:
• nausea and vomiting;
• internal bleeding;
• accumulation of blood under the suture (bruising);
• internal scar tissue;
• allergic reaction to anesthesia;
• difficulty urinating;
• decreased sexual desire;
• persistent pelvic pain;
• abdominal pain;
• injuries to the bowel, bladder or ureters (tubes that carry urine from the kidneys to the bladder) – rarely;
• fistula (unnatural opening within internal structures, such as intestine or vagina) – rarely;
• vaginal prolapse (when the upper vaginal wall loses its shape, sings and protrudes).
Convalescence after removal of the uterus and sequelae
First and foremost, the doctor’s instructions should be followed, but there are basic rules of conduct for the first six weeks after the procedure:
rest – for at least two weeks, the patient should be as gentle as possible; ideal is bed rest.
Exercises – continue to perform the exercises learned in the hospital. Every day should be taken for a walk, if the doctor does not raise any objections.
Standing – immediately after surgery, patients should avoid prolonged standing (max. a few minutes).
Lifting loads – the lifting of heavy loads should be avoided.
Constipation – to prevent constipation, drink plenty of fluids and eat fresh fruits and vegetables.
Medication – if the doctor has prescribed antibiotics, the treatment must be completed, even if you feel better after a few tablets.
Sexual intercourse – sexual intercourse should be avoided until the follow-up examination (about 4 to 6 weeks after surgery) so that the vagina can heal completely.
If vaginal dryness becomes a problem, water- or almond oil-based lubricants can be used.
Hysterectomy and sexual intercourse
The removal of the uterus should not be an obstacle to sexual intercourse after the procedure.
On the contrary, many women report that the sexual situation has improved after hysterectomy.
The reason for this is that the ailments that led the woman to a hysterectomy (pain, heavy bleeding, etc.) have been eliminated.
However, there are also women who experience impairment of their sex life after removing the uterus.
For some women, orgasm is different after the procedure or they have difficulty getting an orgasm at all.
The removal of the uterus should not reduce the sexual desire (libido), unless the ovaries are removed.
As a rule, sexual intercourse is possible again about 6 weeks after surgery.
How long is the recovery time?
Recovery times vary from person to person. As a rule, they are shorter if the incision is made through the vagina.
Up to two weeks after the procedure, the patient must take care of herself.
The hospital stay is about 10 days for an abdominal hysterectomy, for a vaginal hysterectomy it is slightly shorter at about 4 days.
Possibly, the doctor advises to perform light exercises, which are gradually increased. Full recovery usually occurs within 6-8 weeks, some women also need up to 3 months.
The patient may only get behind the wheel of a motor vehicle again when she is able to perform emergency braking.
As a rule, this is the case about 6 weeks after the operation, but it is advisable to talk to the insurance company beforehand.
Return to work depends on the activity being pursued.
Low back pain after hysterectomy
After any operation, especially after abdominal surgery, severe back pain may occur.
These usually become noticeable within a month after surgery and can become chronic if not treated.
The cause of postoperative pain in the lumbar region is a scar, because even if the procedure is performed laparoscopically, a scar forms in the body.
Regardless of whether the procedure is good or bad, a scar is a fibrous tissue that forms in a region where it does not really belong; as a result, it is not natural and the body is often unable to adapt.
The fibrous scar tissue can be compared to a patch on a garment; it causes altered tension in the surrounding muscles, nerves and connective tissue structures.
To eliminate these disorders, the following measures must be taken:
• detachment of the surgical scar within one month after surgery;
• fascial manipulation at the level of the abdominal and lumbar muscles to loosen the adhesions that form as a result of the procedure.
Long-term effect of a hysterectomy
After removal of the uterus, contraception is no longer necessary. When the ovaries have been removed, menopause begins, the symptoms become noticeable a few days after the procedure.
It is normal for body weight to increase with menopause, in addition, the abdominal muscles slowly give way and the abdomen often becomes thicker.
One can discuss with the doctor whether hormone replacement therapy should be started to avoid the symptoms of menopause, but it comes with significant risks and contraindications.
Hysterectomy is effective in gynecological conditions, such as fibromas, endometriosis, and adenomyosis, but some diseases can recur, such as advanced cancer.
A regular check-up can help to detect cancer.
The doctor may schedule scheduled check-ups; in this case, the cells examined do not come from the cervix, but from the vagina.
Is a Pap test still necessary after a hysterectomy?
A Pap test is useful for control if:
• the woman had cervical cancer;
• a partial hysterectomy has been performed, in which the cervix has been preserved;
• the hysterectomy was performed for cancer.