Hysterectomy

A hysterectomy is the surgical removal of the uterus, usually done by a gynecologist. Hysterectomy may be total (removing the body and cervix of the uterus) or partial (also called supra-cervical). In many cases, surgical removal of the ovaries (oophorectomy) is performed concurrent with a hysterectomy. The surgery is then called "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO). However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system. According to the National Center For Health Statistics there were 617,000 hysterectomies performed in 2004 with the surgical removal of the ovaries (oophorectomy) performed in 73% of women undergoing hysterectomy. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60 . There are 22 million women alive in the United States whose female organs have been surgically removed.

Women who undergo total abdominal hysterectomy with bilateral salpingo-oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone. As a result, they enter what is known as "surgical menopauss." The uterus is a hormone responsive sex organ that supports the bladder and bowel. When only the uterus is removed women are at three times greater risk of cardiovasular disease--removal of the uterus often interferes with blood flow to the ovaries, so women who undergo hysterectomy reach menopause an average of 3.7 years sooner than the average age of natural menopause. When the ovaries are removed a woman is at a seven times great risk of cardiovascular disease. As with other hormone-producing glands, the endocrine functions of the ovaries cannot be fully replicated by hormone replacement therapy. The ovaries produce dozens of hormones a woman needs throughout her entire life, released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system.

Technique

Although many hysterectomies are performed via a full abdominal laparotomy with a lengthy incision, two common surgical approaches that are less invasive are laparoscopic or vaginal procedures. Surgery with ovarian conservation is an option for younger patients with benign diseases (non-cancerous). Whether the surgery is performed abdominally, vaginally, or laparoscopically a hormone responsive sex organ is removed, the vagina is shortened, and there is a loss of support to the bladder and bowel. Women who experience uterine orgasm will not experience it when the uterus is removed.

Indications

Indications for hysterectomy include uterine fibroids, certain kinds of pelvic pain (including endometriosis and adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer or pre-cancerous diseases. Hysterectomy is also a surgical resort used in cases of uncontrollable postpartum obstetrical haemorrhage. Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some women. Many treatments are possible: Pharmaceutical (the use of NSAIDs for the pain or hormones to suppress the menstrual cycle), uterine artery embolization, or surgery. The surgical treatment varies depending on the location of the fibroids. If the fibroids are inside the lining of the uterus, hysteroscopic removal might be an option. However, most doctors recommend hysterectomies as the first option despite the availability of other non-surgical alternative options.

Transsexuals undergoing sex reassignment surgery as part of a female-to-male (FTM) transition commonly have hysterectomies and oophorectomies to remove the primary sources of female hormone production. For health reasons, some FTMs have these organs removed prior to full sex reassignment surgery, as it reduces risk for developing Polycystic ovary syndrome and other ovarian and uterine problems due to the higher doses of testosterone being administered as part of the process; some, however, wait to have a hysterectomy and oophorectomy as part of the full sex reassignment surgery procedure to avoid having multiple surgeries over the course of their transitions.

Potential risks

Several studies have found that increased bone loss or fracture risk is associated with hysterectomy. It has also been demonstrated that women who have had a hysterectomy (with both ovaries conserved, and with pre-operative FSH levels <10 IU/L) reach hormonal menopause an average of 3.7 years earlier than women who have had no hysterectomy.

Women who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.

As compared to intact women (who were treated with endometrial ablation for dysfunctional uterine bleeding) reduced sexual wellbeing was found in women who had been given a hysterectomy with preservation of one or both ovaries. An even greater reduction in sexual wellbeing was reported in women who had been given a hysterectomy with both ovaries removed.

Women who have had a hysterectomy with both ovaries conserved typically have reduced testosterone levels as compared to intact women. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.

Other studies have examined these risks and found no correlation between them and hysterectomy. In the case of sexual function after hysterectomy, studies which find a favorable outcome (i.e., improved sexual wellbeing after hysterectomy) have compared women's sexual function after hysterectomy to the same women's sexual experience before surgery, when they were still dealing with serious uterine problems and may have been stressed about their upcoming surgery. In contrast, the study which found hysterectomy was associated with a reduction in sexual wellbeing, compared women treated with hysterectomy to those whose uterine problems were resolved without removing their uteruses. Collectively, these studies suggest that women experience the greatest sexual wellbeing when they have a healthy uterus (including those whose uteruses have become healthy after treatment) -- yet sexual experience may improve after hysterectomy, once the problems requiring treatment have been resolved and the stress leading up to surgery has passed.

In short, the research suggests that retaining both the uterus and the ovaries aids in sexual function, and in bone health, and delays the onset of hormonal menopause. In addition, retention of the ovaries at the time of hysterectomy, when performed for benign disease, is associated with greater longevity.

Alternatives

Many alternatives to hysterectomy exist. For example, women with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.

Each treatment option requires skills specific to it. It is unlikely that any one health care practitioner will offer all available therapies.

New treatment options have begun to decrease the number of hysterectomies performed in the United States, Canada, and Britain. Despite the availability of alternative treatments to hysterectomy, many women still have traditional hysterectomy, though some of these other techniques, such as myomectomy, uterine artery embolization and endometrial ablation might be equally as effective and less invasive or life-changing than hysterectomy. For some patients, these alternatives are not appropriate, or may have been previously tried and been found unsuccessful. All patients should be counseled on alternative therapies and offered them if appropriate.

Menorrhagia (heavy or abnormal menstrual bleeding) may be treated with the less invasive endometrial ablation.