What is a hysterectomy?
Hysterectomy is the surgical removal of the uterus, which may be recommended to resolve a particular health issue you are experiencing.
There are many different terms used around hysterectomy, and they have different meanings for the general public and the medical professionals that use them:
Abdominal hysterectomyThis involves an abdominal cut, usually low across the abdomen, but can sometimes be a vertical incision below the belly button.
Laparoscopic hysterectomyThis is when instruments are placed through small 5-20mm sized incisions in 2-4 locations around the abdomen. A camera on a telescope is used to provide vision while the operation is performed using those instruments.
Keyhole hysterectomyThis is a common, non-medical, term for laparoscopic hysterectomy.
Total laparoscopicThis is when the entire operation is performed through the operating ports/incisions. This requires either a very small uterus or some form of morcellation, and this increases the risk of injury from those instruments.
LAVH, laparoscopic-assisted vaginal hysterectomyIn this procedure, the majority of the operation is performed through the operating ports, however, the operation is completed by removing the uterus through the vagina.
Vaginal hysterectomyThis is when the entire operation is done through the vagina. There are no cuts at all on the abdomen. This is the safest way to perform the operation and will have the quickest recovery.
Partial hysterectomyThe cervix is a part of the uterus and is normally removed during the operation. However, in a partial hysterectomy, only the section of the uterus that is above the cervix is removed. During laparoscopic hysterectomy retaining the cervix seen as an easier option, but it does not offer any true advantage.
Complete or total hysterectomyThe general public often use this term to mean the removal of the uterus AND the tubes and ovaries. I remove the uterus completely when completing a hysterectomy. In a woman before menopause, it is routine to retain the ovaries.
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Reasons for a hysterectomy
Menorrhagia or heavy periods
Menorrhagia is the most common reason for hysterectomy, which overlaps with some of the conditions below.
Fibroids, a benign growth of the muscle cells of the uterus are very common. It can result in heavy periods or problems related to a very large uterus.
When fertility is no longer an issue, hysterectomy may be the appropriate way to deal with pain associated with endometriosis.
Adenomyosis is a condition associated with both heavy and painful periods, and often will not be diagnosed until the hysterectomy is performed.
Pelvic Inflammatory DiseasePain caused by scarring from pelvic infection is best resolved by hysterectomy when fertility is no longer an issue.
CancerCancer surgery is a sub-specialty area of care. If cancer is proven or strongly suspected, I would refer you to the specialist care of a gynae-oncologist
How is a hysterectomy performed?
Whether vaginal or laparoscopic, the procedure aims to separate the uterus from its connection points without damaging the surrounding organs, and remove it from the body.
The uterus has little in the way of support above the pelvis. Its main support ligaments and blood supply are at the level of the cervix, at the top of the vagina. Above this, there are some thin and flexible attachments to the tube and ovaries. The uterus is relatively freely mobile so that it can grow and stretch as required for pregnancy.
The hardest part of the operation is separating the uterus from its attachments at the level of the vagina, and doing it in a way that the blood supply can be safely controlled. It is important not to injure any nearby attachments. The ureters overlie the main blood vessels to the uterus, just before they enter the bladder, and are especially vulnerable.
The advantage of completing this part of the operation vaginally (compared to laparoscopic or abdominally) is that the action of pulling down on the uterus and pushing up the bladder changes the dynamic anatomy in an important way. It increases the separation of the ureters and the blood vessels, so there is less chance of injuring the ureters.
Abdominal or Laparoscopic hysterectomy
I prefer to perform hysterectomies vaginally, but I will carry out an Abdominal or Laparoscopic hysterectomy if required.
When operating laparoscopically, expensive disposable instruments are used. These are heavily promoted by the companies that sell them, with many company-sponsored studies to demonstrate their quality. When I perform hysterectomies vaginally, I use simple stitches and no expensive disposable equipment, so there are no companies promoting studies into what I do.
Recovery after a hysterectomy
Recovery will depend on how the operation is performed. If it is done abdominally, the main limiting factor is recovering from the abdominal wound. If done laparoscopically, it is less. Recovery is optimal when the operation is performed vaginally as there are no abdominal incisions.
Any major surgery will trigger a negative catabolic state. People often feel tired and flat, and this is a common reaction after hysterectomy, no matter how it is done. After a vaginal hysterectomy, most women will have very little pain, so the negative catabolic state will dominate recovery. It is possible to push through this effect by exercising and staying active despite feeling tired.
Return to work is dictated by recovery. Early return is possible and I have had women who chose to return to work within a week of vaginal hysterectomy. After an abdominal hysterectomy, or with a more physical job, it may take up to six weeks to return to work.
Bleeding after a hysterectomy
There is usually very little bleeding after hysterectomy. There will always be a wound at the top of the vagina where the cervix was, and this may bleed a little, but more than a couple of days is unusual. An infection at the top of the vagina can occur and will commonly present with bleeding.
Little special care is required after hysterectomy. There are only two rules: no heavy lifting and no sex for six weeks. Heavy lifting, or any lifting that might be heavy or not your usual daily routine, could disrupt the wound at the top of the vagina. Likewise, the wound at the top of the vagina can be disrupted by intercourse. As most women are usually feeling well, the need for this restriction is less obvious to them.
Exercise and weight gain after a hysterectomy
Exercise is very good and I encourage it as soon as it can be easily managed. Avoid heavy lifting but walking, for example, is just fine as soon as you feel able.
Hysterectomy will not cause weight gain. A hysterectomy is usually performed on women in their 40s and weight gain at this stage of life is common. Loss of muscle mass with ageing results in less energy consumption by the body at rest, and so, unless the diet is adjusted to reflect that, weight gain will occur.
Should I have a hysterectomy?
Patient satisfaction from hysterectomy is usually very high and that primarily relates to the reasons that the operation was performed.
These days there are many good alternatives to hysterectomy that can also produce long-term satisfaction. The decision to have a hysterectomy is a complex one, and I am very happy to help guide you through this process.