Hysterectomy
Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to the removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries, fallopian tubes, and other surrounding structures. The terms "partial" or "total" hysterectomy are lay terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus is a form of sterilization, rendering the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall, given the development of alternative treatment options.
Medical uses
Hysterectomy is a major surgical procedure that has risks and benefits. It affects the hormonal balance and overall health of patients. Because of this, hysterectomy is normally recommended as a last resort after pharmaceutical or other surgical options have been exhausted to remedy certain intractable and severe uterine/reproductive system conditions. There may be other reasons for a hysterectomy to be requested. Such conditions and/or indications include, but are not limited to:- Endometriosis: growth of the uterine lining outside the uterine cavity. This inappropriate tissue growth can lead to pain and bleeding.
- Adenomyosis: a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature. This can thicken the uterine walls and also contribute to pain and bleeding.
- Heavy menstrual bleeding: irregular or excessive menstrual bleeding for greater than a week. It can disturb the regular quality of life and may be indicative of a more serious condition.
- Uterine fibroids: benign growths on the uterus wall. These muscular noncancerous tumors can grow in single form or in clusters and can cause extreme pain and bleeding.
- Uterine prolapse: when the uterus sags down due to weakened or stretched pelvic floor muscles potentially causing the uterus to protrude out of the vagina in more severe cases.
- Reproductive system cancer prevention: especially if there is a strong family history of reproductive system cancers, or as part of recovery from such cancers.
- Gynecologic cancer: depending on the type of hysterectomy, can aid in the treatment of cancer or precancer of the endometrium, cervix, or uterus. To protect against or treat cancer of the ovaries, one would need an oophorectomy.
- Transgender male affirmation: aids in gender dysphoria, prevention of future gynecologic problems, and transition to obtaining new legal gender documentation.
- Severe developmental disabilities: this treatment is controversial at best. In the United States, specific cases of sterilization due to developmental disabilities have been found by state-level Supreme Courts to violate the patient's constitutional and common-law rights.
- Postpartum: to remove either a severe case of placenta praevia or placenta percreta, as well as a last resort in case of excessive obstetrical haemorrhage.
- Chronic pelvic pain: should try to obtain the pain etiology, although it may have no known cause.
- PMS and menstrual pain and other psychic and physical conditions caused by the menstrual period and causing suffering and diminishing life quality.
Risks and adverse effects
The mortality rate is several times higher when performed in patients who are pregnant, have cancer or other complications.
The long-term effect on all case mortality is relatively small. Women under the age of 45 years have a significantly increased long-term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy. This effect is not limited to pre-menopausal women; even women who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy.
Approximately 35% of women after hysterectomy undergo another related surgery within 2 years.
Ureteral injury is not uncommon and occurs in 0.2 per 1,000 cases of vaginal hysterectomy and 1.3 per 1,000 cases of abdominal hysterectomy. The injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage.
Recovery
Hospital stay is 3 to 5 days or more for the abdominal procedure and between 1 and 2 days for vaginal or laparoscopically assisted vaginal procedures. After the procedure, the American College of Obstetricians and Gynecologists recommends not inserting anything into the vagina for the first 6 weeks.Unintended oophorectomy and premature ovarian failure
Removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovary sparing.The average onset age of menopause after hysterectomy with ovarian conservation is 3.7 years earlier than average. This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. The function of the remaining ovaries is significantly affected in about 40% of people, and some of them even require hormone replacement therapy. Surprisingly, a similar and only slightly weaker effect has been observed for endometrial ablation which is often considered as an alternative to hysterectomy.
A substantial number of women develop benign ovarian cysts after a hysterectomy.
Effects on sexual life and pelvic pain
After hysterectomy for benign indications, the majority of patients report improvement in sexual life and pelvic pain. A smaller share of patients report worsening of their sexual life and other problems. The picture is significantly different for hysterectomy performed for malignant reasons; the procedure is often more radical with substantial side effects. A proportion of patients who undergo a hysterectomy for chronic pelvic pain continue to have pelvic pain after a hysterectomy and develop dyspareunia.Premature menopause and its effects
Hysterectomies that also include the surgical removal of the ovaries result in significant hormonal changes to the body. Estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce hormones even after the cessation of menstrual periods.One study showed that the risk of subsequent cardiovascular disease is substantially increased for women who had a hysterectomy at age 50 or younger. No association was found for women undergoing the procedure after age 50. The risk is higher when ovaries are removed, but still noticeable even when ovaries are preserved.
Several other studies have found that osteoporosis and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.
Hysterectomies have also been linked with higher rates of heart disease and weakened bones. Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact. Reduced levels of testosterone in women are predictive of height loss, which may occur as a result of reduced bone density, while increased testosterone levels in women are associated with a greater sense of sexual desire.
Oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders.
Urinary incontinence and vaginal prolapse
Urinary incontinence and vaginal prolapse are well known adverse effects that develop with high frequency a very long time after the surgery. Typically, those complications develop 10–20 years after the surgery. For this reason exact numbers are not known, and risk factors are poorly understood. It is also unknown if the choice of surgical technique has any effect. It has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. One long-term study found a 2.4-fold increased risk for surgery to correct urinary stress incontinence following hysterectomy.The risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor. Overall incidence is approximately doubled after hysterectomy.