Patient education: Vaginal hysterectomy (Beyond the Basics)
- Lori R Berkowitz, MD
Lori R Berkowitz, MD
- Assistant Professor
- Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Caroline E Foust-Wright, MD, MBA
Caroline E Foust-Wright, MD, MBA
- Assistant Professor of Urology/Obstetrics and Gynecology
- Tufts School of Medicine
Vaginal hysterectomy is a procedure in which the uterus is surgically removed through the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as well; removal of both ovaries and fallopian tubes is called bilateral salpingo-oophorectomy (BSO) (figure 1). Removal of the fallopian tubes only is called a bilateral salpingectomy. A vaginal (rather than abdominal) approach may be used if the uterus is not greatly enlarged.
Studies have shown that vaginal hysterectomy has fewer complications, requires a shorter hospital stay, and allows a faster recovery compared with removal of the uterus through an abdominal incision (abdominal hysterectomy). (See "Patient education: Abdominal hysterectomy (Beyond the Basics)".)
A brief review of female reproductive anatomy may be of help in understanding hysterectomy (figure 2).
The uterus is a hollow, pear-shaped muscular organ located in the lower abdomen or pelvis. One end of each fallopian tube opens into the side of the uterus, at the upper end, and the other end of the fallopian tube 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 VAGINAL HYSTERECTOMY
A hysterectomy may be advised for a number of conditions. For some of these conditions, there may be alternatives to hysterectomy, which are described below. (See 'Alternatives to hysterectomy' below.)
Abnormal uterine bleeding — Excessive uterine bleeding, called menorrhagia, can lead to anemia (low blood iron count) and 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. (See "Patient education: Anemia caused by low iron in adults (Beyond the Basics)".)
Irregular uterine bleeding, called metrorrhagia, can also occur in women with menorrhagia. Metrorrhagia is defined as bleeding or spotting that occurs at times other than during the expected menstrual period.
Menorrhagia and metrorrhagia are generally treated first with medication or other surgical alternatives to hysterectomy (see "Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)"). 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. Fibroids may become larger during pregnancy, and typically shrink after menopause. They may cause excessive and irregular uterine bleeding. Symptoms can include heavy uterine bleeding, lower abdominal pain or pressure, or difficulty moving the bowels or emptying the bladder. (See "Patient education: Uterine fibroids (Beyond the Basics)".)
Pelvic organ prolapse — Pelvic organ prolapse occurs due to stretching and weakening of the pelvic muscles and ligaments. This allows the pelvic organs such as the uterus, bladder, rectum, or a combination to drop down (or prolapse) and bulge into the vagina. Prolapse is usually related to pregnancy, vaginal childbirth, genetic factors, chronic constipation, or lifestyle factors (such as repeated heavy lifting over the lifetime). While there is nothing wrong with the uterus, removal of the uterus makes it easier to repair a prolapse and possibly reduces the likelihood that the prolapse will return.
Cervical abnormalities — Precancer or carcinoma in situ (CIN 3) of the cervix that does not resolve after other procedures (such as cone biopsy, laser, or cryosurgery) may require hysterectomy. (See "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)".)
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.
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 education: Chronic pelvic pain in women (Beyond the Basics)"). 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, the woman and her surgeon decide whether the ovaries and/or the fallopian tubes should be removed, and whether estrogen replacement therapy is needed.
Removal of ovaries — A hysterectomy does not involve removing the ovaries, but they may be removed at the same time as hysterectomy; this procedure is known as oophorectomy. The decision to remove the ovaries depends upon several considerations. Occasionally, it may not be possible to remove the ovaries due to scar tissue or other factors that increase the risk of removal. If the ovaries are removed at the time of the hysterectomy, the fallopian tubes will be removed as well.
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 flushes and loss of bone density loss. On the other hand, some women who have menstrual cycle-related migraines, epilepsy, or severe premenstrual syndrome may have an improvement in symptoms when hormone levels are reduced by removal of the ovaries. Individuals should discuss the risks and preferences with a doctor before surgery.
Older 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.
Women in the menopausal transition (called "perimenopause") and in earlier menopause, typically between 45 and 65 years of age, should discuss with their clinician their individual risks for keeping their ovaries versus having them removed. Increasing evidence suggests that the small amount of hormones produced by the ovaries during this perimenopausal period may improve heart as well as bone health.
Removal of fallopian tubes — It is possible to remove the fallopian tubes with the hysterectomy but leave behind the ovaries. Removing the fallopian tubes may decrease the small risk of later developing one type of ovarian cancer, while preserving the hormone production of the ovaries. Occasionally, it may not be possible to remove the fallopian tubes due to scar tissue or other factors that increase the risk of removal.
Estrogen therapy — Estrogen therapy (ET) may be recommended after surgery for women who had their ovaries removed. Women who have not reached menopause may use ET to avoid hot flashes, night sweats, and loss of bone density, which may occur when the ovaries are surgically removed. Women who plan to use ET should talk with their clinician about the risks and benefits, and about how long to use this treatment.
In younger women who retain their ovaries, ET may be needed at a later date if the ovaries stop functioning earlier than expected.
Women who have completed menopause generally do not require ET after hysterectomy. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)
Preoperative testing — Standard preoperative testing may include a physical examination, electrocardiogram, chest x-ray, and blood testing, depending upon age and other medical conditions.
VAGINAL HYSTERECTOMY PROCEDURE
Vaginal 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. Many patients will be able to go home the same day of surgery. Some patients may need to remain in the hospital for one to two days, depending on their age, other medical conditions, and other procedures that may have been done at the same time as their hysterectomy.
LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY
Laparoscopically assisted vaginal hysterectomy (LAVH) is done by some surgeons to assist with the vaginal hysterectomy procedure. A laparoscope is a surgical instrument inserted through a small incision in the abdomen and pelvis. Using the scope, the surgeon can more easily see the uterus, ovaries, and the tissues that surround these organs within the pelvis (figure 3).
In addition, instruments may be used, along with the laparoscope, to facilitate the removal of the uterus through the vagina. LAVH might be recommended for a woman with an enlarged uterus, history of prior pelvic surgery, endometriosis, or other factors that could complicate a traditional vaginal hysterectomy. Women generally recover faster after a vaginal hysterectomy or LAVH compared with women who have abdominal hysterectomy.
However, not all surgeons use laparoscopy since additional training, experience, and equipment is necessary. Patients should talk to their surgeon regarding the best procedure for their individual situation.
NEED FOR ABDOMINAL HYSTERECTOMY
After surgery has begun, the surgeon may find conditions, such as extensive scar tissue, that require him or her to remove the uterus through abdominal incisions. Sometimes these conditions are not apparent before surgery.
Abdominal hysterectomy can be done with a traditional incision or through very small incisions that allow insertion of an operative camera (laparoscope) to remove the uterus. Laparoscopic surgery may be done for women with a large uterus, prior pelvic surgery, concern for scar tissue from prior infections, or need for other procedures to be performed at the same time. The recovery from a total laparoscopic hysterectomy is similar to after a vaginal hysterectomy. Morcellation of the uterus (cutting the uterus into small pieces in the abdomen) may be done to help remove the uterus through the vaginal opening or through a small laparoscopy incision. This is usually done in a bag placed in the abdomen to prevent spread of uterine tissue in the abdomen. Patients should talk to their surgeon about the procedure.
VAGINAL 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. Excessive bleeding may require a blood transfusion and/or a return to the operating room to find and stop it.
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 5 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. Narcotic (opioid) pain medications taken following surgery can increase the likelihood of constipation.
Urinary retention — Urinary retention, or the inability to pass urine, can occur after vaginal hysterectomy. 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 (eg, condoms) to prevent pregnancy before surgery. (See "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)".)
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. Bladder injury occurs in 1 to 2 percent of women who have vaginal hysterectomy, while bowel injury occurs in less than 1 percent of women. Injury 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. Occasionally, one or both ovaries may need to be unexpectedly removed during the surgery due to injury, bleeding, or an abnormality found during the surgery.
RECOVERY AFTER VAGINAL HYSTERECTOMY
Fluids and food are generally offered soon after surgery. Intravenous 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 injection or 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. Many patients are able to go home on the same day of their procedure or the following morning.
More information about recovery from hysterectomy is available separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)
LIFE AFTER VAGINAL HYSTERECTOMY
Studies of women's response to hysterectomy show that most women are very satisfied with their results (table 1). Most reported improvement in symptoms directly related to the uterus, including pain and vaginal bleeding.
Sexual function and enjoyment, interest in sex, and pain with sex were improved for most women. However, this improvement may be dependent 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
Some women who wish to avoid or postpone hysterectomy may 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 vaginal hysterectomy include the following:
●Uterine artery embolization and myomectomy may be used to treat symptomatic leiomyoma (fibroids). (See "Patient education: Uterine fibroids (Beyond the Basics)".)
●Pain clinics may be able to treat patients with severe and chronic pelvic pain without surgery. (See "Patient education: Chronic pelvic pain in women (Beyond the Basics)".)
●Endometrial ablation, in which a clinician destroys or removes most of the endometrium using an instrument inserted through the vagina and cervix and into the uterus. (See "Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)".)
●Medical therapy using hormonal medications, such gonadotropin-releasing hormone (GnRH) analogs (for example, leuprolide) or progestins can help reduce the pain associated with endometriosis. (See "Patient education: Endometriosis (Beyond the Basics)".)
●Prolapse repair with uterine preservation may be performed by some specialized surgeons. This can be done either vaginally or laparoscopically, depending on the location and amount of prolapse.
●Cone biopsy (eg, cold knife cone), cryosurgery, laser surgery, or loop electrocautery (eg, LEEP or LLETZ) are usually used to treat women with high-grade cervical intraepithelial neoplasia or carcinoma in situ of the cervix. These procedures remove the abnormal part of the cervix rather than the entire cervix and uterus. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Fertility preservation in women with early-stage cervical cancer (Beyond the Basics)
Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)
Patient education: Anemia caused by low iron in adults (Beyond the Basics)
Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)
Patient education: Uterine fibroids (Beyond the Basics)
Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)
Patient education: Chronic pelvic pain in women (Beyond the Basics)
Patient education: Menopausal hormone therapy (Beyond the Basics)
Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)
Patient education: Care after gynecologic surgery (Beyond the Basics)
Patient education: Endometriosis (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Management of abnormal uterine bleeding
Oophorectomy and ovarian cystectomy
Differential diagnosis of genital tract bleeding in women
Choosing a route of hysterectomy for benign disease
Peripartum hysterectomy for management of hemorrhage
Sexual dysfunction in women: Epidemiology, risk factors, and evaluation
Postmenopausal uterine bleeding
Approach to abnormal uterine bleeding in nonpregnant reproductive-age women
The following organizations also provide reliable health information.
●National Library of Medicine
●The American College of Obstetricians and Gynecologists
●United States Department of Health & Human Services, Federal Government Source for Women's Health Information
- Meeks GR, Harris RL. Surgical approach to hysterectomy: abdominal, laparoscopy-assisted, or vaginal. Clin Obstet Gynecol 1997; 40:886.
- Harris WJ. Complications of hysterectomy. Clin Obstet Gynecol 1997; 40:928.
- Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: I. Outcomes of hysterectomy. Obstet Gynecol 1994; 83:556.
- Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual functioning. JAMA 1999; 282:1934.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.
- FEMALE ANATOMY
- REASONS FOR VAGINAL HYSTERECTOMY
- PRE-OPERATIVE PLANNING AND EVALUATION
- VAGINAL HYSTERECTOMY PROCEDURE
- LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY
- NEED FOR ABDOMINAL HYSTERECTOMY
- VAGINAL HYSTERECTOMY COMPLICATIONS
- RECOVERY AFTER VAGINAL HYSTERECTOMY
- LIFE AFTER VAGINAL HYSTERECTOMY
- ALTERNATIVES TO HYSTERECTOMY
- WHERE TO GET MORE INFORMATION