"I see my body as an instrument, rather than an ornament."
~Alanis Morissette
Hysterectomy?
Scary Common...
A hysterectomy is a common surgical procedure that removes a woman's uterus. It is the second most common major surgery among women in the United States, second only to cesarean section.
Hysterectomies are performed to treat various medical conditions including uterine fibroids, abnormal uterine bleeding, pelvic prolapse and several kinds of cancer.
Yikes!!! About one-third of American women will have a hysterectomy by the time they are 60. The United States has one of the highest hysterectomy rates in the world. Within the United States, hysterectomy rates vary geographically with the highest rates occurring in the South. Hysterectomy rates are higher for African-American women.
Why Hysterectomy?
Several medical conditions can be treated or cured with a hysterectomy. About one-third are performed to treat uterine fibroids. Hysterectomies are also performed to treat endometriosis and to stop abnormal uterine bleeding. Other reasons to have a hysterectomy include:
- endometrial hyperplasia with atypia, an overgrowth of the uterine lining in which uterine cells contain precancerous changes
- cancerof the uterus, ovaries, fallopian tubes or cervix
- pelvic prolapse, in which the ligaments that support pelvic structures like the uterus weaken and the organs drop into the vaginal canal. This weakening can occur with age, estrogen deficiency, obesity or after multiple births. Once this pelvic support weakens, pelvic organs, including the uterus, bladder and rectum, may sag, resulting in pressure, rectal discomfort and problems with bladder and bowel control.
- Losing weight, stopping smoking and avoiding constipation by getting plenty of liquids and fiber in your diet can sometimes help. Additionally, you can strengthen your pelvic muscles with Kegel exercises. To do these exercises, tighten and relax the muscles used to stop the flow of urine. This strengthens the vaginal canal and pelvic floor muscles, helping control urine flow and enhancing orgasm. You may also be fitted with a pessary, a device placed in the vagina that holds the organs in place.
- Another treatment is short-term hormone therapy to make the vaginal tissue suppler. Estrogen prevents drying and thinning of the vaginal tissues. Supplemental estrogen can help strengthen vaginal tissues. However, because of the potential risks of estrogen therapy, such as increased risk of blood clots, breast cancer and gallbladder disease, the decision to use estrogen must be made only after you and your doctor have weighed all the pros and cons.
- uncontrollable bleeding after childbirth. very rarely, hysterectomy is needed to control bleeding during a cesarean delivery following rare pregnancy complications. There are other methods doctors use to control bleeding in most of these cases; a hysterectomy is only done as a life-preserving measure.
- adenomyosisIn thiscondition, the tissue that lines the uterus grows inside the walls of the uterus, which can cause severe pain. If other treatments have not helped, a hysterectomy is the only certain cure.
- endometriosis: occurs when cells from the endometrium, your uterine lining, grow outside the uterus and implants adhere to other parts inside the peritoneal cavity of your pelvis, usually found on the ovaries, bowel, tubes or bladder. hysterectomy is generally recommended for endometriosis only when the disease is severe. The Agency for Healthcare Research and Quality (AHRQ) estimates that only 18 % of hysterectomies are performed to correct endometriosis, which may cause pelvic pain and infertility. hormone-suppressing drugs used to treat fibroids are also considered effective for endometriosis since both conditions are affected by your body's production of estrogen. As with fibroids, benefits from these treatments may be temporary. these procedures can usually be done laparoscopically and are often used when preserving fertility is important. Endometriosis frequently recurs, but the addition of postsurgical medical therapy, such as birth control pills, GnRH agonists, like leuprolide (Lupron) or danazol (Danocrine), for six months may increase the pain-free interval.
- the only definitive treatment for endometriosis is removing the ovaries to reduce your body's production of estrogen, which triggers the growth of endometrial tissue.
- chronic pelvic pain. Surgery is a last resort for women who have chronic pelvic pain that clearly comes from the uterus. Many forms of pelvic pain are not cured by a hysterectomy, so it could be unnecessary and create new problems.
- abnormal vaginal bleeding. Treatment depends on the cause. Changes in hormone levels, infection, cancer, or fibroids are some things that can cause abnormal bleeding. There are medications that can lighten heavy bleeding, correct irregular bleeding, and relieve pain. These include hormone medications, birth control pills, and nonsteroidal anti-inflammatory medications (NSAIDs).
- One procedure for abnormal bleeding is dilatation and curettage (D&C), in which the lining and contents of the uterus are removed. Another procedure, endometrial ablation, also removes the lining of your uterus and can help stop heavy, prolonged bleeding. But, it should not be used if you want to become pregnant or if you have gone through menopause.
Pros and Cons of a Hysterectomy
- For some women, a hysterectomy is the answer to years of suffering from uterine problems.
- For others, hysterectomy is a last resort to treat cancer or another life-threatening condition. Unless you have a severe pelvic infection, cancer or uncontrollable bleeding, there is usually no reason to rush into the decision.
- Because most hysterectomies are elective procedures (as opposed to emergencies), there is usually plenty of time to explore all options.
Second Opinions: Give yourself a second.
Before you embark on a major surgery, whether it is done by one the minimally invasive methods (DaVinci robot or laparoscopy), or by the open procedure, consider consulting another physician about the need, and route your physician recommends. It is not impolite or disrecpectful to take an active role in your well-being. Physicians want our patients empowered and confident when they decide to have surgery done.
A great video to watch "GIve me a Second" on the topic of asking for a second opinion, it's only 1.5 minutes, but gives alot of perspective in a short time: http://www.givemeasecond.com/
Surgical Options
Hysterectomy is a surgical procedure in which the uterus is removed. This can be accomplished via one of 3 common approaches:
- abdominal
- vaginal
- laparoscopic-assisted vaginal (LAVH)
- robotic-assisted hysterectomy
Your ovaries and may also be removed during the procedure, depending on several factors including your age, findings at surgery and the reason for hysterectomy. In the event you need a hysterectomy, we will review with you the risks and benefits of each alternative.
Therapeutic
A hysterectomy is used to treat several conditions. If you decide to have a hysterectomy, you and your health care professional should discuss which type is most appropriate. There are three types:
Total hysterectomy
This is the classic form of hysterectomy, involving an abdominal incision. This allows the surgeon to easily view the pelvic organs and provides more operating space than a vaginal hysterectomy. It is generally used for large fibroids or cancer. During this procedure, your uterus and cervix are removed.
If your ovaries and fallopian tubes are also removed, called a bilateral salpingo-oophorectomy, you won't have monthly hormonal changes. Removing only the uterus can reduce the blood supply to the ovaries, however, ultimately decreasing their function.
As far as disease risk is concerned, a study published in the May 2009 issue of Obstetrics & Gynecology reported that removing both ovaries during a hysterectomy is associated with a decreased risk of ovarian and breast cancer but an increased risk of lung cancer, coronary artery disease and death from other causes.
Radical hysterectomy
This type of hysterectomy is performed in some cases of cancer. During this procedure, your uterus, cervix, supporting ligaments and tissues, the upper portion of the vagina and the pelvic lymph nodes are removed. Cancer specialists usually perform this type of hysterectomy.
Subtotal, partial or supracervical hysterectomy
In this procedure, only the part of your uterus above the cervix is removed. There is a small risk that cancer could develop in the remaining part of the cervix, but routine Pap smears will detect pre-cancer in an easily treatable form. Nonetheless, there may be some benefits to leaving the cervix intact, including a reduced risk of vaginal prolapse (the vagina falling out), shorter recovery time and less postoperative pain. Some studies suggest that leaving the cervix allows intercourse to remain pleasurable.
In addition to discussing which organs should be removed during a hysterectomy, you and your health care professional should discuss how the surgery will be performed. The surgical technique you choose should depend on your individual diagnosis, personal preference and your surgeon's training. They include:
Vaginal hysterectomy
In this procedure, the surgeon removes the uterus and the cervix through an incision in the vagina, so there's no large external scar. This form of hysterectomy is ideal when there is uterine prolapse and minimal uterine enlargement.
Vaginal hysterectomy can be performed in two ways: entirely through the vagina or using a laparoscope, a small, telescope-like device inserted into the abdomen through a small incision, enabling the surgeon to visualize the pelvic region, also called a laparoscopic-assisted vaginal hysterectomy. Laparoscopically assisted vaginal hysterectomy (LAVH) may be used if standard vaginal hysterectomy cannot be done. During this procedure, the uterus is removed through the vagina.
Vaginal hysterectomy and abdominal hysterectomy each take between one and two hours and are performed under regional (epidural or spinal) or general anesthesia. One study found that women who had vaginal hysterectomies had significantly fewer complications than those having abdominal hysterectomies. Additionally, the women had shorter hospital stays and returned to their normal activities quicker than the women who had abdominal hysterectomies.
Women with large ovarian cysts, a serious case of endometriosis or large fibroids may not be candidates for vaginal hysterectomy.
Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
This newer type of hysterectomy also uses laparoscopic techniques to remove the uterus but leaves the cervix intact; in the past, some studies suggested leaving the cervix might help reduce the complications associated with total hysterectomies, such as pelvic prolapse and urinary incontinence.
However, the most recent research shows there is no compelling reason to leave the cervix if it can be easily removed along with the uterus. Hospital stay is usually no more than one night, and recovery takes about two weeks.
Computer-Assisted (Robotic) Surgery
In April 2005, the FDA approved the da Vinci surgical computer operating system for gynecological laparoscopic procedures. The da Vinci system enables the surgeon to perform surgery through smaller incisions. The system involves up to four robotic "arms" that are inserted into the woman through small incisions. One arm holds a miniature camera, and the other arms hold a variety of instruments.
The surgeon directs the procedure from a console several feet away, which provides a magnified three-dimensional view of the surgical field. One series of studies done between 2001 and 2002 showed that certain surgical tasks required during hysterectomy, such as suturing and knot tying, were enhanced with the robotic da Vinci system. However, if the surgeon is skilled at laparoscopic hysterectomy, then there is no benefit to the patient from robotic hysterectomy. Hospital stay is usually one night or less, and recovery takes about two weeks.
Pre-Op Planning
Before surgery, there are two main decisions that need to be made about the procedure:
1. Leave the Cervix?
Does removal of cervix affect vaginal function, length, sexual satisfaction?
In the past two decades, studies have been done to assess the concern that removing the cervix would interfere with sexual satisfaction. The general consensus is that sexual satisfaction does not appear to differ after hysterectomy between women with and without a cervix.
2. Leave the Ovaries and Tubes?
If the patient is younger than 65, the ovaries have proven benefit against heart disease, should the ovaries be remove? If so, does the patient want to consider if she may benefit from HRT: estrogen replacement therapy.
Pre-operative testing
Standard pre-operative testing usually includes a physical examination by your internist, an EKG, chest x-ray, and blood testing, depending upon your age and other medical conditions.
Recovery after Hysterectomy
Fluids and food are generally offered soon after surgery. Intravenous (IV) fluids may be administered during the first day, particularly if there is nausea or vomiting. Pain medicine is given as needed, usually by PCA (“patient-controlled analgesia”) or as a pill. Patients are encouraged to get out of bed as soon as able.
Being active is particularly important since it helps prevent complications, such as blood clots, pneumonia, and gas pains. How long does it take to recover from a hysterectomy?
Recovering from a hysterectomy takes time. Most women stay in the hospital from 1 to 2 days for post-surgery care. Some women may stay longer, often when the hysterectomy is done because of cancer.
The time it takes for you to resume normal activities depends on the type of surgery. If you had:
Abdominal surgery
Recovery takes from 4 to 6 weeks. You will gradually be able to increase your activities.
Vaginal, laparoscopic, robotic surgery
Recovery takes 2 to 4 weeks.
You should get plenty of rest and not lift heavy objects for a full 6 weeks after surgery. About 6 weeks after either surgery, you should be able to take tub baths and resume sexual intercourse.
Life after hysterectomy
Studies of women's response to hysterectomy show that most women are satisfied with their results. Most reported improvement in symptoms, such as pain and vaginal bleeding. Sexual function and enjoyment, interest in sex, and pain with sex were improved for most women. However, this improvement may depend upon several factors, including the age of a woman at the time of surgery, the reason for surgery, and history of any prior difficulties with mood.
Younger women may grieve after hysterectomy due to their loss of fertility. A woman who has new feelings of sadness, anxiety, or depression after surgery should speak with her healthcare provider. These feelings may be treated by talking with a therapist, with antidepressant medication, or may resolve with time.
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 a woman's particular medical problem, all available treatment options, and the risks and benefits of each type of treatment.
Some alternatives to hysterectomy include the following:
Myomectomy is a surgery on the uterus to remove symptomatic fibroids, while leaving the uterus in place. If fibroids are located in the uterine cavity, they may be removed through the vagina without an abdominal incision in a procedure called hysteroscopic myomectomy. The technique involves the use of an instrument called a hysteroscopic resectoscope and is primarily useful for women with bleeding or pregnancy-related problems, such as recurrent miscarriage.
- They may also be removed laparoscopically, using a small telescope called a laparoscope. During this procedure, a few small incisions (5 mm) are made in your abdomen or pelvis, which allow the laparoscope and other small instruments to be slipped inside, thus enabling the surgeon to remove the fibroids without having to make a large incision.
- The benefit of a myomectomy is that it preserves the uterus and cervix so pregnancy is still possible. Although the goal of myomectomy is to preserve your uterus and your ability to have children, the procedure may cause scarring in the uterus that could require you to have a cesarean with your next pregnancy.
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. This procedure controls excessive bleeding 85-90% time, but is not safe for women who desire future pregnancy due to the scarring that has been found to cause catastrophic bleeding in pregnancy.
Progestin Intrauterine Device (IUD): can be placed in the office as an effective measure to control excess uterine bleeding and some causes of pelvic pain.
Uterine artery embolization: In this minimally invasive procedure, a narrow, flexible tube called a catheter is passed through the femoral artery in the groin into the uterine artery. Once there, tiny plastic particles the size of grains of sand are slowly released into the blood vessels feeding the fibroid. The particles wedge in the vessels (but can't travel to other parts of the body), blocking blood flow to the tumor. Without a blood supply, the tumor dies and shrinks by about 40 %.
Fibroid embolization usually requires an overnight hospital stay. Most women return to normal activities within a week. Risks include moderate to severe pain and cramping in the first few hours after the procedure, nausea, fever and infection. Rarely, a woman might enter menopause after embolization. About 2.4 to 3.5 percent of women are readmitted to the hospital after the procedure for complications, and 1 to 2.5 percent require additional surgery.
Magnetic resonance guided forced ultrasound. This noninvasive outpatient procedure is performed by an interventional radiologist who uses magnetic resonance imaging (MRI) to zap fibroid tissue with high-intensity focused ultrasound waves. As well as delivering the treatment, the MRI allows the doctor to monitor the temperature in the uterus and ensure the waves hit the targeted fibroids.
The MRI procedure has not been as thoroughly studied as the others; therefore the long-term success or complication rates are not known. However, the procedure is available at hospitals and medical centers across the country. To find a site near you, visit the Society of Interventional Radiology Web site at www.sirweb.org,
Medical therapy using hormonal medications, such GnRH analogs, leuprolide or progestins can help reduce the pain associated with endometriosis.
Pain clinics may be able to treat patients with severe and chronic pelvic pain without surgery.
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.
Complications:
What are the possible complications from these surgeries?
Hysterectomy is not without its risks; some women who undergo the procedure experience complications. Most of these problems are minor or reversible. They can include:
- fever and infection following surgery
- urinary tract infection or discomfort
- menopausal symptoms, such as hot flashes, night sweats and vaginal dryness
- constipation
- depression or other emotional problems
- pain or discomfort during intercourse
- loss of sexual pleasure or interest in sex
More serious, but rarer, complications may include:
- hemorrhage requiring transfusion
- injury to the bowel, bladder or other internal organs during surgery, requiring repair
- bowel obstruction
- life-threatening cardiopulmonary events such as a heart attack
To tell a woman everything she may not do is to tell her what she can do. ~Spanish Proverb
