Patient information: Abdominal hysterectomy

ABDOMINAL HYSTERECTOMY OVERVIEW

Abdominal hysterectomy is a surgical procedure in which the uterus is removed through an incision in the lower abdomen. One or both ovaries and fallopian tubes may also be removed during the procedure (figure 1).

FEMALE ANATOMY

A brief review of female reproductive anatomy may be of help in understanding hysterectomy.

The uterus is a hollow, pear-shaped muscular organ located in the lower abdomen or pelvis (picture 1). One end of each fallopian tube opens into the side of the uterus, at the upper end, and the other end lies next to an ovary. At its lower end, the uterus narrows and opens into the vagina. The lower end of the uterus is called the cervix. The ovaries lie next to and slightly behind the uterus.

REASONS FOR ABDOMINAL HYSTERECTOMY

A hysterectomy may be recommended for a number of conditions. For some of these conditions, there may be an alternative to hysterectomy, described below. (See 'Alternatives to hysterectomy' below.)

Abnormal uterine bleeding — Excessive uterine bleeding, called menorrhagia, can lead to anemia (low blood iron count), fatigue, and contribute to missed days at work or school. Menorrhagia is generally defined as bleeding that lasts longer than seven days or saturates more than one pad per hour for several hours.

Heavy or irregular bleeding are generally treated first with medication or other surgical alternatives to hysterectomy. (See "Patient information: Menorrhagia (excessive menstrual bleeding)".) However, abnormal uterine bleeding that does not improve with conservative treatments may require hysterectomy.

Fibroids — Fibroids (also known as leiomyoma) are noncancerous growths of uterine muscle that occur in up to one-third of all women. Fibroids may become larger during pregnancy, and typically shrink after menopause. They may cause excessive bleeding and pelvic pain or pressure. (See "Patient information: Fibroids".)

Pelvic organ prolapse — Pelvic organ prolapse occurs due to stretching and weakening of the pelvic muscles and ligaments. This allows the uterus to fall (or prolapse) into the vagina. Prolapse is more common in women who have been pregnant, had vaginal childbirth, and in those with certain genetic factors, lifestyle factors (repeated heavy lifting over the lifetime), or chronic constipation.

Cervical abnormalities — Hysterectomy is rarely needed for carcinoma in situ (CIN 3) that does not resolve after other procedures (such as cone biopsy, laser or cryosurgery). (See "Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)" and "Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)".)

Endometrial hyperplasia — Endometrial hyperplasia is the term used to describe excessive growth of the endometrium (the tissue that lines the uterus). It can sometimes lead to endometrial cancer. Although endometrial hyperplasia can often be treated with medication, a hysterectomy is sometimes needed or preferred to medical therapy.

Cancer — Cancer of the uterus (endometrium), cervix, or ovaries may require hysterectomy. (See "Patient information: Cervical cancer treatment; early stage cancer" and "Patient information: Endometrial cancer treatment" and "Patient information: Ovarian cancer treatment".)

Severe bleeding after childbirth — Hysterectomy may rarely be required in women who have uncontrollable bleeding after childbirth.

Chronic pelvic pain — Chronic pelvic pain can be due to the effects of endometriosis or scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can also be caused by other sources, including the gastrointestinal and urinary systems. (See "Patient information: Chronic pelvic pain in women".) It is important for a woman with pelvic pain to ask about the probability that her pain will improve after hysterectomy.

PRE-OPERATIVE PLANNING AND EVALUATION

Before surgery, there are two main decisions that need to be made about the procedure: whether the cervix should be removed, and whether the ovaries should be removed. If the ovaries are removed, a woman may need to decide if she should take estrogen replacement therapy.

Supracervical/subtotal hysterectomy — A standard abdominal hysterectomy includes removal of the entire uterus and cervix. However, there are situations in which the entire uterus is not removed. A supracervical, subtotal, or partial hysterectomy refers to a procedure in which the cervix is left in place, while the top of the uterus is removed. Supracervical hysterectomy may be done if difficulties arise during surgery, making removal of the cervix complicated. Prior to planned supracervical hysterectomy, you should discuss the risks and benefits of leaving the cervix in place with your doctor.

Women who undergo supracervical hysterectomy must continue to have routine screening (Pap smear) for cervical cancer. Some women continue to have menstrual bleeding since the retained cervix is attached to a small remaining portion of the uterus.

There was initial concern that removing the cervix would interfere with sexual satisfaction. However, studies have demonstrated that sexual satisfaction does not appear to differ after hysterectomy between women with and without a cervix.

Removal of ovaries — The ovaries may be removed during hysterectomy, a procedure known as an oophorectomy. Oophorectomy is not always required; the decision depends upon several considerations. A list of questions to help make this decision may be found on the following table (table 1).

Premenopausal women may decide to keep the ovaries to provide a continued, natural source of hormones, including estrogen, progesterone, and testosterone. These hormones are important in maintaining sexual interest and preventing hot flashes and loss of bone density loss. On the other hand, women who have menstrual cycle-related migraines, epilepsy, or severe premenstrual syndrome (PMS) may have an improvement in symptoms when hormone levels are reduced by removing the ovaries. Discuss the risks and preferences of removing the ovaries with your doctor before surgery.

Postmenopausal women are usually advised to have their ovaries removed because of a small risk of developing ovarian cancer at some point during their lifetime. This benefit of removing the ovaries appears to outweigh the benefit of continued hormone production, as described above.

Estrogen replacement therapy — Estrogen replacement therapy (ERT) may be recommended after surgery for women who have not reached menopause who had their ovaries removed. ERT can help to prevent hot flashes, night sweats, and loss of bone density, which may occur when the ovaries are surgically removed. Women who plan to use ERT should talk with their clinician about the risks and benefits, and about how long to use this treatment. (See "Patient information: Premature ovarian failure".)

In younger women who retain their ovaries, ERT may be needed at a later date if the ovaries stop functioning earlier than expected.

Women who have completed menopause generally do not require ERT after hysterectomy. (See "Patient information: Postmenopausal hormone therapy".)

Pre-operative testing — Standard pre-operative testing may include a physical examination, EKG, chest x-ray, and blood testing, depending upon age and other medical conditions.

ABDOMINAL HYSTERECTOMY PROCEDURE

Abdominal hysterectomy is performed in a hospital setting, and generally requires one to two hours in the operating room. Patients are given general or spinal anesthesia plus sedation so that they feel no pain. Heart rate, blood pressure, blood loss, and respiration are closely observed throughout the procedure. After surgery, patients are transferred to the recovery room (also known as the post-anesthesia care unit) so that they can be monitored while waking up. Most patients will then be transferred to a hospital room, where they will spend one to two nights.

ABDOMINAL HYSTERECTOMY COMPLICATIONS

A number of complications can occur as a result of hysterectomy. Fortunately, most can be easily managed and do not cause long-term problems.

Hemorrhage — Excessive bleeding (hemorrhage) occurs in a small number of cases and may require a return to the operating room to identify and stop the bleeding.

Infection — Low-grade fever is common after hysterectomy, is not always caused by infection, and usually resolves without treatment. However, a high or persistent fever may signal an infection. Serious infection occurs in less than ten percent of women, and can usually be treated with intravenous antibiotics. Much less commonly, patients require another surgical procedure.

Constipation — Constipation occurs in most women following hysterectomy, and can usually be controlled with a regimen of stool softeners, dietary fiber, and laxatives.

Urinary retention — Urinary retention, or the inability to pass urine, can occur after abdominal hysterectomy. It is more common in women who have vaginal hysterectomy. (See 'Alternatives to hysterectomy' below.) Urine can be drained using a catheter until retention resolves, usually within 24 to 48 hours.

Blood clots — Pelvic surgery increases the risk of developing blood clots in the large veins of the leg or lung. The risk is increased for approximately six weeks after surgery. Medications may be given to some women to prevent blood clots. In addition, women taking oral contraceptives or hormone replacement should ideally discontinue them one month prior to surgery since they can further increase the risk of blood clots. Women who are sexually active and premenopausal should use alternative methods of birth control (e.g. condoms) to prevent pregnancy before surgery. (See "Patient information: Deep vein thrombosis (DVT)".)

Damage to adjacent organs — The urinary bladder, ureters (small tubes leading from the kidneys to the bladder), and large and small intestines are located in the lower abdomen and pelvis and can be injured during hysterectomy. Injury occurs in less than one percent of all women undergoing hysterectomy, and can usually be detected and corrected at the time of surgery. If detected after surgery, another operation may be needed.

Early menopause — Women who have undergone hysterectomy may experience menopause earlier than the average age of menopause (age 51). This may be due to an interruption in blood flow to the ovaries as a result of removing the uterus.

RECOVERY AFTER ABDOMINAL 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, either intravenously, or by intramuscular (IM) injection, or as a pill. Patients are encouraged to resume their normal daily activities as soon as possible. Being active is particularly important since it helps to prevent complications, such as blood clots, pneumonia, and gas pains.

More information about recovery from hysterectomy is available separately. (See "Patient information: Care after gynecologic surgery".)

LIFE AFTER ABDOMINAL HYSTERECTOMY

Studies of women's response to hysterectomy show that most women are satisfied with their results (table 2). 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. (See "Patient information: Premature ovarian failure".)

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 abdominal hysterectomy include the following:

• In some cases the uterus may be removed through the vagina, avoiding the need for an incision in the abdomen. This procedure is called a vaginal hysterectomy. (See "Patient information: Vaginal hysterectomy".) A vaginal approach may be used if the uterus is not too big, there is not too much scar tissue, and if the condition prompting the surgery is benign and limited to the uterus. Most women can return to normal activities sooner after a vaginal hysterectomy than after an abdominal hysterectomy.
• Uterine artery embolization and myomectomy may be used to treat symptomatic leiomyoma (fibroids). (See "Patient information: Fibroids".)

• Pain clinics may be able to treat patients with severe and chronic pelvic pain without surgery. (See "Patient information: Chronic pelvic pain in women".)

• 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. (See "Patient information: Menorrhagia (excessive menstrual bleeding)".)

• Medical therapy using hormonal medications, such GnRH analogs (for example, leuprolide) or progestins can help reduce the pain associated with endometriosis. (See "Patient information: Endometriosis".)

• 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 (see "Patient information: Cervical cancer screening".

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Menorrhagia (excessive menstrual bleeding)
Patient information: Fibroids
Patient information: Management of atypical squamous cells (ASC-US and ASC-H) and low grade cervical squamous intraepithelial lesions (LSIL)
Patient information: Management of high grade cervical squamous intraepithelial lesions (HSIL) and glandular abnormalities (AGC)
Patient information: Cervical cancer treatment; early stage cancer
Patient information: Endometrial cancer treatment
Patient information: Ovarian cancer treatment
Patient information: Chronic pelvic pain in women
Patient information: Premature ovarian failure
Patient information: Postmenopausal hormone therapy
Patient information: Deep vein thrombosis (DVT)
Patient information: Care after gynecologic surgery
Patient information: Vaginal hysterectomy
Patient information: Endometriosis
Patient information: Cervical cancer screening

Professional Level Information:
Abdominal hysterectomy
Dilation and curettage
Endometrial ablation
Laparoscopic approach to hysterectomy
Myomectomy
Overview of hysterectomy
Overview of hysteroscopy
Peripartum hysterectomy
Radical hysterectomy
Vaginal hysterectomy

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The American College of Obstetricians and Gynecologists

      (www.acog.org)

• US Department of Health & Human Services, Federal Government Source for Women's Health Information

      (www.4woman.gov)

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