A hysterectomy is an operation to remove a woman's uterus.

The uterus is the place

where a baby grows when a woman is pregnant. Sometimes, the ovaries and fallopian
tubes also are taken out. Hysterectomies are very common - one in three women in the
United States has had one by age 60.

Your health care provider might recommend a hysterectomy if you have

• Fibroids
• Endometriosis not cured by medicine or surgery
• Uterine prolapse - when the uterus drops into the vagina
• Cancer of the uterus, cervix, or ovaries
• Vaginal bleeding that persists despite treatment
• Chronic pelvic pain; surgery can be a last resort

Before having a hysterectomy, it is important to discuss other possible treatments with

your health care provider. A hysterectomy will stop your periods, and you will no longer
be able to get pregnant. If the surgery removes both ovaries, you will enter menopause.

A hysterectomy (from Greek ὑστέρα hystera "womb" and εκτομία ektomia "a cutting
out of") is the surgical removal of the uterus, usually performed by a gynecologist.
Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often
called "complete") or partial (removal of the uterine body while leaving the cervix intact;
also called "supracervical"). It is the most commonly performed gynecological surgical
procedure. In 2003, over 600,000 hysterectomies were performed in the United States
alone, of which over 90% were performed for benign conditions.[1] Such rates being
highest in the industrialized world has led to the major controversy that hysterectomies
are being largely performed for unwarranted and unnecessary reasons.[2]

Removal of the uterus renders the patient unable to bear children (as does removal of
ovaries and fallopian tubes), and changes her hormonal levels considerably, so the
surgery is normally recommended for only a few specific circumstances:

• Certain types of reproductive system cancers (uterine, cervical, ovarian) or tumors

• Severe and intractable endometriosis (growth of the uterine lining outside the
uterine cavity) and/or adenomyosis (a form of endometriosis, where the uterine
lining has grown into and sometimes through the uterine wall musculature) after
pharmaceutical or other surgical options have been exhausted
• Postpartum to remove either a severe case of placenta praevia (a placenta that has
either formed over or inside the birth canal) or placenta percreta (a placenta that
has grown into and through the wall of the uterus to attach itself to other organs),
as well as a last resort in case of excessive postpartum bleeding
• For trans men, as part of their gender transition
• For severe developmental disabilities

Although hysterectomy is frequently performed for fibroids (benign tumor-like growths

inside the uterus itself made up of muscle and connective tissue), conservative options in
treatment are available by doctors who are trained and skilled at alternatives. It is well
documented in medical literature that myomectomy, surgical removal of fibroids with
reconstruction of the uterus, has been performed for over a century.[specify]

The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the
majority of estrogen and progesterone that is available in genetic females of reproductive
age.

Some women's health education groups such as the Hysterectomy Educational Resources
and Services (HERS) Foundation seek to inform the public about the many consequences
and alternatives to hysterectomy, and the important functions that the female organs have
all throughout a woman's life.[3][4][5]

Contents
[hide]

• 1 Incidence
o 1.1 Canada
o 1.2 United States
o 1.3 United Kingdom
• 2 Indications
• 3 Types of hysterectomy
• 4 Technique
o 4.1 Comparison of techniques
• 5 Benefits
• 6 Risks and side effects
o 6.1 Mortality and surgical risks
o 6.2 Reconvalescence
o 6.3 Unintended oophorectomy and premature ovarian failure
o 6.4 Premature menopause and its effects
o 6.5 Urinary incontinence and vaginal prolapse
o 6.6 Effects on social life and sexuality
o 6.7 Other rare problems
• 7 Alternatives
o 7.1 Heavy bleeding
o 7.2 Uterine fibroids
o 7.3 Prolapse
• 8 As part of transitioning from female-to-male
• 9 See also
• 10 References

• 11 External links

[edit] Incidence
 The examples and perspective in this article may not represent a worldwide
view of the subject. Please improve this article and discuss the issue on the talk
page. (May 2010)

[edit] Canada

In Canada, the number of hysterectomies between 2008 and 2009 was almost 47,000. The
national rate in for the same timeline was 338 per 100,000 population, down from 484
per 100,000 in 1997. The reasons for hysterectomies differed depending on whether the
woman was living in an urban or rural location. Urban women most common reason was
due to uterine fibroids and rural women had hysterectomies mostly for menstrual
disorders.[6]

[edit] United States

According to the National Center for Health Statistics, of the 617,000 hysterectomies
performed in 2004, 73% also involved the surgical removal of the ovaries. In the United
States, 1/3 of women can be expected to have a hysterectomy by age 60.[7] There are
currently an estimated 22 million people in the United States who have undergone this
procedure. An average of 622,000 hysterectomies a year have been performed for the
past decade.[7]

[edit] United Kingdom

In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are
removed in about 20% of hysterectomies.[8]

[edit] Indications
Hysterectomy is usually performed for problems with the uterus itself or problems with
the entire female reproductive complex. Some of the conditions treated by hysterectomy
include uterine fibroids (myomas), endometriosis (growth of tissue resembling the uterine
lining tissue outside of the uterine cavity), adenomyosis (a more severe form of
endometriosis, where the uterine lining has grown into and sometimes through the uterine
wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at
least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a
surgical last resort in uncontrollable postpartum obstetrical haemorrhage.[9]

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and
discomfort to some of those with the condition. Many alternative treatments are
available: pharmaceutical options (the use of NSAIDs or opiates for the pain and
hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids
while leaving the uterus intact); uterine artery embolization, high intensity focused
ultrasound or watchful waiting. In mild cases, no treatment is necessary. If the fibroids
are inside the lining of the uterus (submucosal), and are smaller than 4 cm, hysteroscopic
removal is an option. A submucosal fibroid larger than 4 cm, and fibroids located in other
parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal
incision is made above the pubic bone for better access to the uterus.

Hysterectomy was in the past sometimes performed as a prophylactic treatment for those
with either a strong family history of reproductive system cancers (especially breast
cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from
such cancers. With the availability of new medications such as raloxifene, aromatase
inhibitors and more recent prophylactic strategies for high risk BRCA mutations this is
should be an extremely rare indication for hysterectomy.

[edit] Types of hysterectomy

Schematic drawing of types of hysterectomy

Hysterectomy in the literal sense of the word means merely removal of the uterus,
however other organs such as ovaries, fallopian tubes and the cervix are very frequently
removed as part of the surgery.

• Radical hysterectomy : complete removal of the uterus, cervix, upper vagina, and
parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are
also usually removed in this situation.
• Total hysterectomy : Complete removal of the uterus and cervix.
• Subtotal hysterectomy : removal of the uterus, leaving the cervix in situ.

Many women want to retain the cervix believing that it may affect sexual satisfaction
after hysterectomy. It has been postulated that removing the cervix causes excessive
neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault
prolapse, and vaginal cuff granulations. These issues were addressed in a systematic
review of total versus supracervical hysterectomy for benign gynecological conditions,
which reported the following findings[10]:

• There was no difference in the rates of incontinence, constipation or measures of

sexual function.
 • Length of surgery and amount of blood lost during surgery were significantly
reduced during supracervical hysterectomy compared to total hysterectomy, but
there was no difference in post-operative transfusion rates.
• Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year
after surgery was more likely after supracervical hysterectomy.
• There was no difference in the rates of other complications, recovery from
surgery, or readmission rates.

In the short-term, randomized trials have shown that cervical preservation or removal
does not affect the rate of subsequent pelvic organ prolapse.[11] However, no trials to date
have addressed the risk of pelvic organ prolapse many years after surgery, which may
differ after total versus supracervical hysterectomy. It is obvious that supracervical
hysterectomy does not eliminate the possibility of having cervical cancer since the cervix
itself is left intact. Those who have undergone this procedure must still have regular Pap
smears to check for cervical dysplasia or cancer.

[edit] Technique
Hysterectomy can be performed in different ways. The oldest known technique is
abdominal incision. Subsequently the vaginal (performing the hysterectomy through the
vaginal canal) and later laparoscopic vaginal (with additional instruments inserted
through a small hole, frequently close to the navel) techniques were developed.

Most hysterectomies in the United States are done via laparotomy (abdominal incision,
not to be confused with laparoscopy). A transverse (Pfannenstiel) incision is made
through the abdominal wall, usually above the pubic bone, as close to the upper hair line
of the individual's lower pelvis as possible, similar to the incision made for a caesarean
section. This technique allows doctors the greatest access to the reproductive structures
and is normally done for removal of the entire reproductive complex. The recovery time
for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut
through the abdominal wall. Historically, the biggest problem with this technique were
infections, but infection rates are well-controlled and not a major concern in modern
medical practice. An open hysterectomy provides the most effective way to explore the
abdominal cavity and perform complicated surgeries. Before the refinement of the
vaginal and laparoscopic vaginal techniques it was also the only possibility to achieve
subtotal hysterectomy, meanwhile any of the techniques can be used for subtotal
hysterectomy.

Vaginal hysterectomy is performed entirely through the vaginal canal and has clear
advantages over abdominal surgery such as less complications, shorter hospital stays and
shorter healing time. Abdominal hysterectomy, the most common method, is used in
cases such as after caesarean delivery, when the indication is cancer, when complications
are expected or surgical exploration is required. The average vaginal-to-abdominal
hysterectomy quotient (VAQ) in US residency programs is 0.50.[12]
With the development of the laparoscopic techniques in the 1970-1980s, the
"laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among
gynecologists because compared with the abdominal procedure it is less invasive and the
post-operative recovery is much faster. It also allows better exploration and slightly more
complicated surgeries then the vaginal procedure. LAVH begins with laparoscopy and is
completed such that the final removal of the uterus (with or without removal of the
ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix
must be removed with the uterus. Total laparoscopic hysterectomy (TLH) is more
advanced than an LAVH and does not require a double-setup, laparoscopic and vaginal.
[13]
In OBGYN residency programs, the average laparoscopy-to-laparotomy quotient
(LPQ) is 0.55.[12]

The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to

remove the uterus without removing the cervix using a morcellator which cuts the uterus
into small pieces that can be removed from the abdominal cavity via the laparoscopic
ports.

Total laparoscopic hysterectomy (TLH) is performed solely through the laparoscopes in

the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its
attachments using long thin instruments through the "ports". Then all tissue to be
removed is passed through the small abdominal incisions.

Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similar to the

total laparoscopic surgery but the uterus is amputated between the cervix and fundus.

"Robotic hysterectomy" is a variant of laparoscopic surgery using special remotely

controlled instruments that allow the surgeon finer control as well as three-dimensional
magnified vision.[14]

cervical stump
transvaginal (white) after
extraction of the removement of end of an
uterus before laparoscopical
uterus in total the uterine corpus laparoscopical
hysterectomy hysterectomy
laparoscopical at laparoscopic hysterectomy
hysterectomy supracervical
hysterectomy

[edit] Comparison of techniques

The abdominal technique is very often applied in difficult circumstances or when
complications are expected. Given this circumstances the complication rate and time
required for surgery compares very favorably with other techniques, however time
required for healing is much longer.

Vaginal hysterectomy was shown to be superior to LAVH and some types of

laparoscopic surgery (sufficient data was not available for all types of laparoscopic
surgery), causing fewer short- and long-term complications, more favorable effect on
sexual experience with shorter recovery times and fewer costs.[15][16][17] It is however not
possible or very difficult to perform some more complicated surgeries using this
technique.

A recent Cochrane review recommends vaginal hysterectomy over other variants where
possible. Laparoscopic surgery offers certain advantages when vaginal surgery is not
possible but has also the disadvantage of significantly longer time required for the
surgery.[18]

In direct comparison of abdominal (laparotomic) and laparoscopic techniques

laparoscopic surgery causes longer operation time and substantially higher rate of major
complications while offering much quicker healing.[18][19]

Vaginal hysterectomy is the only available option that is feasible without total
anaesthesia or in outpatient settings (although so far recommended only in exceptional
cases).

Time required for completion of surgery in the eVAL trial is reported as following:[19]

• abdominal 55.2 minutes average, range 19-155

• vaginal 46.6 minutes average, range 14-168
• laproscopic (all variants) 82.5 minutes average, range 10-325 (combined data
from both trial arms)

Large multifibroid uteri and subtotal hysterectomies did previously require abdominal
incision but with the use of in situ morcellation they can be sometimes also performed
using laparoscopic or vaginal techniques.[20] Even impacted fibroid uteri with severe
adhesions, oblitered cul-de-sac and no motion whatsoever on pelvic exam can be
removed laparoscopically by experienced laparoscopic surgeons.[21] An advanced
laparoscopist can replace the majority of inpatient total abdominal hysterectomies
performed for benign indications with outpatient total laparoscopic hysterectomy.[22]

Non-robotic laparoscopic hysterectomy has a higher likelihood a requiring a large

incision and conversion to open technique than robotic hysterectomy. In addition blood
loss and duration of hospital stay were lower when using robotic technique when
compared to non-robotic laparoscopic hysterectomy.[23]
The other techniques are not long enough in use to allow a general assessment, it appears
that laparoscopic subtotal hysterectomy(LSH) is a promising technique.[16]

[edit] Benefits
Hysterectomy is usually performed for serious conditions and is highly effective in curing
those conditions.

The Maine Women's Health Study of 1994 followed for 12 months time approximately
800 women with similar gynecological problems (pelvic pain, urinary incontinence due
to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids,
painful intercourse), around half of whom had a hysterectomy and half of whom did not.
The study found that a substantial number of those who had a hysterectomy had marked
improvement in their symptoms following hysterectomy, as well as significant
improvement in their overall physical and mental health one year out from their surgery.
The study concluded that for those who have intractable gynecological problems that had
not responded to non-surgical intervention, hysterectomy may be beneficial to their
overall health and wellness. Somewhat surprisingly, ovarian cancer risk after
hysterectomy appears to be substantially lowered even when the ovaries are preserved.[24]

[edit] Risks and side effects

Hysterectomy has like any other surgery certain risks and side effects.

[edit] Mortality and surgical risks

Short term mortality (within 40 days of surgery) is usually reported in the range of 1-6
cases per 1000 when performed for benign causes.[25] The mortality rate is several times
higher when performed in patients that are pregnant, have cancer or other complications.
[26]

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.[27]

Approximately 35% of women after hysterectomy undergo another related surgery within
2 years.

[edit] Reconvalescence

Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days
for vaginal or laparoscopically assisted vaginal procedures.
Time for full recovery is very long and practically independent on the procedure that was
used. Depending on the definition of "full recovery" 6 to 12 months have been reported.
Serious limitations in everyday activities are expected for a minimum of 4 months.

[edit] 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 ovariesparing.[28]

The average onset age of menopause in those who underwent hysterectomy is 3.7 years
earlier than average even when the ovaries are preserved.[29] 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% women, some of them even require hormone
replacement treatment. Surprisingly, a similar and only slightly weaker effect has been
also observed for endometrial ablation which is often considered as an alternative to
hysterectomy.

Substantial number of women develop benign ovarian cysts after hysterectomy.[30]

[edit] Premature menopause and its effects

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.

When only the uterus is removed there is a three times greater risk of cardiovascular
disease. If the ovaries are removed the risk is seven times greater. Several studies have
found that osteoporosis (decrease in bone density) and increased risk of bone fractures
are associated with hysterectomies.[31][32][33][34][35][36] 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.[28] Reduced levels of
testosterone in women is predictive of height loss, which may occur as a result of reduced
bone density,[37] while increased testosterone levels in women are associated with a
greater sense of sexual desire.[38]

Oophorectomy before the age of 45 is associated with a fivefold mortality from

neurologic and mental disorders.[39]
[edit] Urinary incontinence and vaginal prolapse

Urinary incontinence and vaginal prolapse are well known adverse effects that develop
with high frequency very long time after the surgery. Typically those complications
develop 10–20 years after the surgery.[40] For this reason exact numbers are not known
and risk factors poorly understood, it is also unknown if the choice 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
[41][42]

The risk for vaginal prolapse is over 80% within 20 years of hysterectomy.

[edit] Effects on social life and sexuality

Some women find their natural lubrication during sexual arousal is also reduced or
eliminated. Those who experience uterine orgasm will not experience it if the uterus is
removed. The vagina is shortened and made into a closed pocket and there is a loss of
support to the bladder and bowel.[specify]

[edit] Other rare problems

Hysterectomy may cause an increased risk of the relatively rare renal cell carcinoma.
Hormonal effects or injury of the ureter were considered as possible explanations.[43][44]

Removal of the uterus without removing the ovaries can produce a situation that on rare
occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to
descend into the uterus before surgery. Two cases have been identified and profiled in an
issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have
been discussed in additional medical literature.[45]

[edit] Alternatives

Myomectomy
Sutured uterus wound after myomectomy

Depending on the problem there are alternatives to hysterectomy :

[edit] Heavy bleeding

Dysfunctional uterine bleeding (DUB) may be treated with endometrial ablation, which is
an outpatient procedure in which the lining of the uterus is destroyed with heat,
mechanically or by radio frequency ablation. Endometrial ablation will greatly reduce or
entirely eliminate monthly bleeding in ninety percent of patients with DUB. It is not
effective for patients with very thick uterine lining or uterine fibroids.

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less
invasive endometrial ablation.[46]

See also Mirena coil which releases low dose progesterone.

[edit] Uterine fibroids

Uterine fibroids may be removed and the uterus reconstructed in a procedure called
"myomectomy." A myomectomy may be performed through an open incision,
laparoscopically or through the vagina (hysterescopy).[47]

Uterine artery embolization is a minimally invasive procedure for treatment of uterine

fibroids. Under local anesthesia a catheter is introduced into the femoral artery at the
groin and advanced under radiographic control into the uterine arterty. A mass of
microspheres or polyvinyl alcohol (PVA) material (an embolus) is injected into the
uterine arteries in order to block the flow of blood through those vessels. The restriction
in blood supply usually results in in significant reduction of fibroids and improvement of
heavy bleeding tendency. The 2006 Cochrane review comparing hysterectomy and UAE
did not find any major advantage for either procedure.[48] The subsequently finished
HOPEFUL study found substantially fewer serious adverse effects for UAE with lesser
overall cost and comparable satisfaction. In this study 86% UAE treated women and 70%
hysterectomy treated women recommend their treatment to a friend. [49]
Uterine fibroids can be treated also with a non-invasive procedure called Magnetic
Resonance guided Focused Ultrasound (MRgFUS). This procedure involves no cutting or
general anesthesia and the uterus remains intact.

[edit] Prolapse

Prolapse may also be corrected surgically without removal of the uterus. [50]

[edit] As part of transitioning from female-to-male

Main article: Sex reassignment surgery female-to-male

Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to

or as a part of sex reassignment surgery for transmen. Some in the FTM community
prefer to have this operation along with hormone replacement therapy in the early stages
of their gender transition to avoid complications from heavy testosterone use while still
having female-hormone-producing organs in place (e.g. uterine cancer and hormonally
induced coronary artery disease) or to remove as many sources of female sex hormones
as possible in order to better "pass" during the real life experience portion of their
transition.[51] Just as many, however, prefer to wait until they have full "bottom surgery"
(removal of female sexual organs and construction of male-appearing external anatomy)
[52]
to avoid undergoing multiple separate operations.[53]

What is a hysterectomy?

A hysterectomy is a surgical procedure whereby the uterus (womb) is removed.

Hysterectomy is the most common non-obstetrical surgical procedure of women in the
United States.

How common is hysterectomy?

Approximately 300 out of every 100,000 women will undergo a hysterectomy.

Why is a hysterectomy performed?

The most common reason hysterectomy is performed is for uterine fibroids The next
most common reasons are:

• abnormal uterine bleeding (vaginal bleeding),

• cervical dysplasia (pre-cancerous conditions of the cervix),

• endometriosis, and uterine prolapse (including pelvic relaxation).

Only 10% of hysterectomy is performed for cancer. This article will primarily focus on
the use of hysterectomy for non-cancerous, non-emergency reasons, which can involve
even more challenging decisions for women and their doctors.

Uterine fibroids (also known as uterine leiomyomata) are by far the most common reason
a hysterectomy is performed. Uterine fibroids are benign growths of the uterus, the cause
of which is unknown. Although the vast majority are benign, meaning they do not cause
or turn into cancer, uterine fibroids can cause medical problems. Indications for
hysterectomy in cases of uterine fibroids are excessive size (usually greater than the size
of an eight month pregnancy), pressure or pain, and/or bleeding severe enough to produce
anemia. Pelvic relaxation is another condition that can require treatment with a
hysterectomy. In this condition, a woman experiences a loosening of the support muscles
and tissues in the pelvic area. Mild relaxation can cause first degree prolapse, in which
the cervix (the uterine opening) is about halfway down into the vagina. In second degree
prolapse, the cervix or leading edge of the uterus has moved to the vaginal opening, and
in third degree prolapse the cervix and uterus protrude past the vaginal opening. Second
and third degree uterine prolapse must be treated with hysterectomy. A loosening, vaginal
wall weakness such as a cystocele, rectocele, or urethrocele, can lead to symptoms such
as urinary incontinence (unintentional loss of urine), pelvic heaviness, and impaired
sexual performance. The urine loss tends to be aggravated by sneezing, coughing, or
laughing. Childbearing is probably involved in increasing the risk for pelvic relaxation,
though the exact reasons for this remain unclear. Avoidance of vaginal birth and having a
caesarean section doesn't eliminate the risk of developing pelvic relaxation.

A hysterectomy is also performed to treat uterine cancer or very severe pre-cancers

(called dysplasia, carcinoma in situ, or CIN III, or microinvasive carcinoma of the
cervix). A hysterectomy for endometrial cancer (uterine lining cancer) has an obvious
purpose, that of removal of the cancer from the body. This procedure is the foundation of
treatment for cancer of the uterus.

here It's Done Who Does It How Long It Takes Discomfort/Pain

Cramping lasting
several minutes when
dye is instilled in
Gynecologist and
Hospital radiology uterus. May cause
radiologist with nurse 15-30 minutes.
suite. additional pain if
or technician.
fallopian tubes are
blocked or go into
spasm.
Results Ready When Special Equipment Risks/Complications Average Cost
Preliminary results Contrast dye, Test should not be $$
immediately; final speculum, tenaculum, done on women who
report in 2-4 days. catheter, and X-ray are pregnant or who
machine. have an infection.
Slight risk of
 introducing or
spreading pelvic
infection. Rare risk of
allergic reaction to
iodine in dye.
Other names

Hysterogram, hysterosalpingography, uterography, uterotubography, and

uterosalpingography.

Purpose

• To diagnose tubal obstruction as a cause of infertility.

• To detect suspected fibroids, polyps, or developmental abnormalities in the uterus
and fallopian tubes.
• To evaluate the fallopian tubes before or after sterilization reversal surgery.
• To evaluate incompetent cervix in women with a history of miscarriage.

How it works

Contrast dye is used to highlight the areas in question for the X-ray machine.

Preparation

• The test will be scheduled during the early part of your menstrual cycle (between
menstruation and ovulation), when pregnancy is unlikely.
• You undress from the waist down and don a hospital gown.

Test procedure

• You lie on your back on an examination table with an X-ray machine suspended
over your abdomen. Your legs will be placed in special stirrups that go behind
your knees.
• A speculum is inserted into your vagina to hold open the vaginal walls. Then a
thin, grasping instrument called a tenaculum is inserted to hold the cervix in
place.
• A thin catheter is inserted through the cervix into the uterus. A small balloon
inside the catheter is inflated to keep it in place, and radiopaque contrast dye is
instilled through the catheter. This usually causes several minutes of cramping
and may result in spasm.
• The gynecologist and radiologist watch the dye on a fluoroscope screen as it
enters the uterus and spreads through the fallopian tubes, looking for
abnormalities.
• Four to eight X-rays are taken at various intervals as the dye travels through your
reproductive tract.
Special precautions

• If you suspect that you have a pelvic infection or may be pregnant, ask your
doctor to reschedule the test.
• Tell your doctor if you are prone to pelvic infections. You may be given
prophylactic antibiotics to take before the test is done. It may also affect the
choice of dye since water-based dyes are believed less likely to spread infection.
• Be sure to take an analgesic such as ibuprofen about 30 minutes before the test to
lessen the effect of the cramps.

Variations

Sonohysterogram, a test in which a catheter is inserted into the uterine cavity to instill
fluid to distend the uterus, which is then examined via transvaginal ultrasound for space-
occupying structures.

After the test

• You will remain on the examination table until any cramping subsides and to be
sure that you do not experience any adverse effects from the dye.
• You may be asked to stay until the X-ray films are developed to be sure that no
others are needed.
• Then you are free to dress and return to normal activities.
• If you experience severe cramping, you should not drive home.
• Wear a sanitary napkin for 24 hours after the procedure.
• Notify your doctor if you experience or notice excessive bleeding, fever, or
unpleasant vaginal odor.

Factors affecting results

None.

Interpretation

The radiologist will study the X-rays for a final report, but certain diagnoses can be made
by watching the progress of the dye on the fluoroscope to see whether the shape of the
uterine cavity appears normal or has apparent protrusions that might indicate a fibroid
tumor or scar tissue; whether the dye leaks, indicating a tear in the uterine lining; and
whether the dye flows through and out the fallopian tubes, indicating that they are patent
(open).

Advantages

• It's relatively noninvasive.

• Negative results (showing that the fallopian tubes are open) are highly reliable.
 • It shows the internal contours and patency of the fallopian tubes (ultrasound does
not).
• The test itself may open small blockages.

Disadvantages

It may produce false-positive results: what appears to be a tubal blockage close to the
uterus may only be a spasm in that area.

The next step

• If the tubes appear to be open, and the uterine contour is normal, no further testing
is necessary.
• If they appear to be closed, or the uterine cavity is irregular, additional tests
(laparoscopy or hysteroscopy) or surgery may follow.

What tests or treatments are performed prior to a hysterectomy?

A woman must have a pelvic examination, Pap smear, and a diagnosis prior to
proceeding with a hysterectomy. Prior to having a hysterectomy for pelvic pain, women
usually undergo more limited (less extensive) exploratory surgery procedures (such as
laparoscopy) to rule out other causes of pain. Prior to having a hysterectomy for
abnormal uterine bleeding, women require some type of sampling of the lining of the
uterus (biopsy of the endometrium) to rule out cancer or pre-cancer of the uterus. This
procedure is called endometrial sampling. Also, pelvic ultrasounds and/or pelvic
computerized tomography (CT) tests can be done to make a firm diagnosis. In a woman
with pelvic pain or bleeding, a trial of medication treatment is often given before a
hysterectomy is considered.

Therefore, a premenopausal (still having regular menstrual periods) woman whose

uterine fibroids are causing bleeding but no pain is generally first offered medical therapy
with hormones. Non-hormonal treatments are also available, such as tranexamic acid and
more moderate surgical procedures, such as ablations (removal of the lining of the
uterus). If she still has significant bleeding that causes major impairment to her daily life,
or the bleeding continues to cause anemia (low red blood cell count due to blood loss),
and she has no abnormality on endometrial sampling, she may be considered for a
hysterectomy.

A postmenopausal woman (whose menstrual periods have ceased permanently) who has
no abnormalities in the samples of her uterus (endometrial sampling) and still has
persistent abnormal bleeding after trying hormone therapy, may be considered for a
hysterectomy. Several dose adjustments or different types of hormones may be required
to decide on the optimal medical treatment for an individual woman.

How is a hysterectomy performed?

In the past the most common hysterectomy was done by an incision (cut) through the
abdomen (abdominal hysterectomy). Now most surgeries can utilize laparoscopic assisted
or vaginal hysterectomies (performed through the vagina rather than through the
abdomen) for quicker and easier recovery. The hospital stay generally tends to be longer
with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges
tend to be higher. The procedures seem to take comparable lengths of time (about two
hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may
take longer.

What are the types of hysterectomies?

There are now a variety of surgical techniques for performing hysterectomies. The ideal
surgical procedure for each woman depends on her particular medical condition. Below,
the different types of hysterectomy are discussed with general guidelines about which
technique is considered for which type of medical situation. However, the final decision
must be made from an individualized discussion between the woman and the physician
who best understands her individual situation.

Remember, as a general rule, before any type of hysterectomy, women should have the
following tests in order to select the optimal procedure:

1. Complete pelvic exam including manually examining the ovaries and uterus.

2. Up-to-date Pap smear.

3. Pelvic ultrasound may be appropriate, depending on what the physician finds on

the above.

4. A decision regarding whether or not to remove the ovaries at the time of

hysterectomy.

5. A complete blood count and an attempt to correct anemia if possible.

Total abdominal hysterectomy

This is the most common type of hysterectomy. During a total abdominal hysterectomy,
the doctor removes the uterus, including the cervix. The scar may be horizontal or
vertical, depending on the reason the procedure is performed, and the size of the area
being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids
are treated with total abdominal hysterectomy. Total abdominal hysterectomy may also
be done in some unusual cases of very severe pelvic pain, after a very thorough
evaluation to identify the cause of the pain, and only after several attempts at non-
surgical treatments. Clearly a woman cannot bear children herself after this procedure, so
it is not performed on women of childbearing age unless there is a serious condition, such
as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be
examined, which is an advantage in women with cancer or investigating growths of
unclear cause.

Vaginal hysterectomy

During this procedure, the uterus is removed through the vagina. A vaginal hysterectomy
is appropriate only for conditions such as uterine prolapse, endometrial hyperplasia, or
cervical dysplasia. These are conditions in which the uterus is not too large, and in which
the whole abdomen does not require examination using a more extensive surgical
procedure. The woman will need to have her legs raised up in a stirrup device throughout
the procedure. Women who have not had children may not have a large enough vaginal
canal for this type of procedure. If a woman has too large a uterus, cannot have her legs
raised in the stirrup device for prolonged periods, or has other reasons why the whole
upper abdomen must be further examined, the doctor will usually recommend an
abdominal hysterectomy (see above). In general, laparoscopic vaginal hysterectomy is
more expensive and has higher complication rates than abdominal hysterectomy.

Laparoscopy-assisted vaginal hysterectomy (LAVH)

Laparoscopy-assisted vaginal hysterectomy (LAVH) is similar to the vaginal

hysterectomy procedure described above, but it adds the use of a laparoscope. A
laparoscope is a very thin viewing tube with a magnifying glass-like device at the end of
it. Certain women would be best served by having laparoscopy used during vaginal
hysterectomy because it allows the upper abdomen to be carefully inspected during
surgery. Examples of uses of the laparoscope would be for early endometrial cancer (to
verify lack of spread of cancer), or if oophorectomy (removal of the ovaries) is planned.
Compared to simple vaginal hysterectomy or abdominal hysterectomy, it is a more
expensive procedure, is more prone to complications, requires longer to perform, and is
associated with longer hospital stays. Just as with simple vaginal hysterectomy without a
laparoscope, the uterus must not be excessively large. The physician will also review the
medical situation to be sure there are no special risks prohibiting use of the procedure,
such as prior surgery that could have increased the risk for abnormal scarring (adhesions).
If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular
abdominal hysterectomy is probably best.

Supracervical hysterectomy

A supracervical hysterectomy is used to remove the uterus while sparing the cervix,
leaving it as a "stump." The cervix is the area that forms the very bottom of the uterus,
and sits at the very end (top) of the vaginal canal (see illustration above). The procedure
probably does not totally rule out the possibility of developing cancer in this remnant
"stump." Women who have had abnormal Pap smears or cervical cancer clearly are not
appropriate candidates for this procedure. Other women may be able to have the
procedure if there is no reason to have the cervix removed. In some cases the cervix is
actually better left in place, such as some cases of severe endometriosis. It is a simpler
procedure and requires less time to perform. It may give some added support of the
vagina, decreasing the risk for the development of protrusion of the vaginal contents
through the vaginal opening (vaginal prolapse).

Laparoscopic supra cervical hysterectomy

The laparoscopic supra cervical hysterectomy procedure is performed like the LAVH
procedure, although usually cautery is used to cut the cervix off at the cervical stump, and
the tissue is all removed through a laparoscopic tool. Recovery is very quick. Cervical
preservation is less likely to result in menses (menstruation) as the endocervix is usually
cauterized.

Radical hysterectomy
The radical hysterectomy procedure involves more extensive surgery than a total
abdominal hysterectomy because it also includes removing tissues surrounding the uterus
and removal of the upper vagina. Radical hysterectomy is most commonly performed for
early cervical cancer. There are more complications with radical hysterectomy compared
to abdominal hysterectomy. These include injury to the bowels and urinary system.

Oophorectomy and salpingo-oophorectomy (removal of the ovaries and/or

Fallopian tubes)

Oophorectomy is the surgical removal of the ovary(s), while salpingo-oophorectomy is

the removal of the ovary and its adjacent Fallopian tube. These two procedures are
performed for ovarian cancer, removal of suspicious ovarian tumors, or Fallopian tube
cancer (which is very rare). They may also be performed due to complications of
infection, or in combination with hysterectomy for cancer. Occasionally, women with
inherited types of cancer of the ovary or breast will have an oophorectomy as preventive
(prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast.

What are complications of a hysterectomy?

Complications of a hysterectomy include infection, pain, and bleeding in the surgical

area. An abdominal hysterectomy has a higher rate of post-operative infection and pain
than does a vaginal hysterectomy.

What are the alternatives to a hysterectomy?

As mentioned above, a hysterectomy for conditions other than cancer is generally not
considered until after other tests or medications are unsuccessful. There are also newer
procedures, such as uterine artery embolization (UAE) or surgical removal of a portion of
the uterus (myomectomy), that are being used to treat excessive uterine bleeding.
Endometrial ablation technique and newer medications are also alternatives.

Should women who have had a hysterectomy continue to have Pap

smears?

Any woman with a history of abnormal Pap smears is recommended to have Pap smears
for the remainder of her life. When the cervix has already been removed, these smears are
more accurately called "vaginal cuff" smears, instead of Pap smears. This is because of
the low, but real chance that cervical cancer can recur right at the surgical site where the
cervix was removed.

In addition to women with a history of abnormal Pap smears, other women who require
continued Pap smears are women with supracervical hysterectomy, in which the cervix
was left in place. In this case, in contrast to the woman who has had hysterectomy for
reasons of cervical cancer, the woman who has had supracervical hysterectomy will be
able to follow the same screening guidelines as for other woman who have not had
surgery. For example, the physician can stop doing Pap smears at age 65 if the woman
has been well-screened and has always had normal Pap smears.

Women who do not need to continue having Pap smears are those who have had vaginal
hysterectomy or abdominal hysterectomy for benign (not cancer) reasons, such as uterine
fibroids. Provided that they have had normal Pap smears prior to the procedure, they need
not continue to have Pap smears after their surgery.

Hysterectomy is the most common non–pregnancy-related major surgery performed on

women in the United States. This surgical procedure involves removal of the uterus and
cervix, and for some conditions, the fallopian tubes and ovaries.

Reasons for choosing this operation are treatment of uterine cancer and various common
noncancerous uterine conditions such as fibroids, endometriosis, prolapse that leads to
disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Although this procedure is highly successful in curing the disease of concern, it is a

surgical alternative with the accompanying risks, morbidity, and mortality that an
operative procedure carries and it leads to sterility in women who are premenopausal.
The patient may be hospitalized for several days and may require 6-12 weeks of
convalescence. Complications, such as excessive bleeding, infection, and injury to
adjacent organs, also may occur.

For related information, see Medscape's Women's Sexual Health Resource Center.

History of the Procedure

In November 1843, Charles Clay performed the first hysterectomy in Manchester,

England. In 1929, Richardson, MD, performed the first total abdominal hysterectomy
(TAH), in which the entire uterus and cervix were removed.1

Problem

Epidemiology of fibroids

Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of
gynecological visits, and they create an annual cost of $1.2 billion.2,3 They are benign
uterine tumors that increase in size and frequency as women age but revert in size
postmenopausally.4,5 Factors that have proven to contribute to fibroid growth include
estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and
transforming growth factor-beta.6

The frequency of fibroid appearance in African American women is 2-3 times higher
than in white women. Women who are obese or experience menarche when younger than
12 years are at increased risk of fibroid development due to prolonged exposure to
estrogen. Women who have had children are at a lesser risk for fibroid development than
women who have never been pregnant.7

Each fibroid arises from a single monoclonal cell line from the smooth-muscle cells of
the myometrium.8 Most (60%) fibroids are chromosomally normal. The rest have
nonrandom chromosomal abnormalities that can be separated into 6 cytogenic subgroups,
which are trisomy 12, translocation between chromosome 12 and 14, rearrangements of
the short arm of chromosome 6 and the long arm of chromosome 10, and deletions of
chromosomes 3 and 7.9

Asymptomatic fibroids are relatively slow growing and characterize most of the tumors
found in patients. Previously, uterine size (consisting of asymptomatic fibroids)
equivalent to 12 weeks' gestation (280 g) had been the standard threshold for
recommending a hysterectomy. Thus, asymptomatic fibroids of smaller size were handled
via observation, with an annual pelvic examination and/or transvaginal ultrasonography.

Currently, surgical procedures are not recommended for fibroids based on uterine size
alone in the absence of symptoms. According to Reiter et al, no increased incidence in
perioperative morbidity existed posthysterectomy in those women with a fibroid uterus
larger than 12 weeks' gestational size compared to those women with a fibroid uterus
smaller than 12 weeks' gestational size.10 They concluded that hysterectomy for a large
asymptomatic fibroid uterus may not be needed as a means of preventing increased
operative morbidity associated with future growth, unless a sarcomatous change is
observed.

In patients who experience symptoms with fibroids, the symptoms are related to the size,
location, and number of fibroids within the uterus. As many as one third of patients with
symptomatic uterine fibroids experience abnormal bleeding, cramping, and prolonged
and heavy menstrual periods, which can result in anemia. The growth of fibroids to large
sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic
pain or pressure, pain during sexual intercourse, reduced urinary capacity due to
increased bladder pressure, constipation due to increased colon pressure, and infertility or
late miscarriages.6

Epidemiology of endometriosis

Endometriosis is responsible for approximately one fifth of hysterectomies, and it affects

women during their reproductive years.11 It is a disease in which tissue similar to the
endometrium is present outside the endometrial cavity (in other areas of the body). Such
sites include all the reproductive organs, bladder, intestines, bowel, colon, and rectum.
Other sites may include uterosacral ligaments, the cul-de-sac, pelvic sidewalls, and
surgical scars. This ectopic endometrial tissue responds to monthly hormonal stimulation
and, thus, breaks down and bleeds into the peritoneal cavity when located there, causing
internal bleeding, inflammation of the surrounding areas, and formation of scar tissue.
Scar tissue then can become bands of adhesions that are capable of distorting internal
anatomy. Patients also may experience symptoms of pelvic pain; pain during bowel
movements, urination, and sexual intercourse; and infertility or miscarriages.12

Currently, no cure exists for endometriosis. Although many women seek hysterectomy
for pain relief, it does not provide a definite cure because some women in whom one or
both ovaries are preserved may continue to experience problems with endometriosis that
was left behind.

Epidemiology of pelvic relaxation

Genital prolapse is the indication for approximately 15% of hysterectomies. Various

stresses on the pelvic muscles and ligaments can cause significant weakening and, thus,
uterine prolapse. The prime cause of insult to the pelvic support structures is childbirth.
Therefore, multiple pregnancies and vaginal deliveries increase the risk for uterine
prolapse. A few less dramatic causes of increased pelvic pressure include straining during
bowel movements, chronic coughing, and obesity. Also, significant pelvic structure
weakening occurs postmenopause because estrogen, which pelvic tissues need to
maintain their tonicity, is not present in significant amounts after menopause.

Women with mild pelvic relaxation may be free of symptoms. However, patients with
moderate-to-severe relaxation may experience symptoms that include heaviness and
pressure in the vaginal area; low back pain, leakage of urine, which can worsen during
heavy lifting, coughing, laughing, or sneezing; urinary tract infections; retention of urine;
and problems with sexual intercourse.11 Although several techniques that provide
temporary improvement and control of pelvic relaxation exist, in moderate-to-severe
situations, hysterectomy may provide a more functional and longer-lasting results.

Epidemiology of cancer of reproductive organs

Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in
the United States, with an estimated 36,100 new cases in 2000.13 It affects women aged
35-90 years, with a mean age of 62 years. Cancer begins in the lining of the endometrium
and can spread to other reproductive organs and to the rest of the body.

Stage 1 endometrial cancer is confined to the corpus, or body, of the uterus. Symptoms
may include bleeding between periods or, as is in most cases, spotting in patients after
menopause. Stage 1 endometrial cancer is very slow growing and highly curable. A
hysterectomy is the preferred method of treatment. Not only is the uterus removed, but
the ovaries and fallopian tubes also are removed because ovaries are a possible site for
more cancer, or they may secrete hormones that play a synergistic role in the growth of
the cancer. Only in cases of early endometrial cancers in women who are in their second
or early part of the third decade of life are attempts made to preserve the ovaries.

In stage 2 endometrial cancer, the cancer has spread to the cervix. Approximately 12,800
new cases of cervical cancer diagnoses occur annually in the United States.14 Symptoms
of cervical cancer include bleeding between periods, bleeding postmenopause, or
bleeding after sexual intercourse. In some cases, radical hysterectomy (removal of the
uterus, cervix, top portion of vagina, ovaries, fallopian tubes, and tissues in the pelvic
cavity surrounding cervix) may be the treatment of choice, along with chemotherapy or
radiotherapy if needed.

In stage 3A endometrial cancer, the cancer has spread to the ovaries and fallopian tubes.
This may be treated with a TAH and bilateral salpingo-oophorectomy (removal of the
uterus, fallopian tubes, and ovaries), along with chemotherapy or radiotherapy if needed.
In stage 3B, the cancer has spread to the vagina. In this case, a vaginectomy or radical
hysterectomy must be performed, along with chemotherapy or radiotherapy if needed. By
stage 3C, the cancer has entered the lymph nodes. In this case, lymph node dissection and
hysterectomy is the treatment of choice, along with chemotherapy or radiotherapy if
needed.

Frequency

Approximately 600,000 hysterectomies are performed annually in the United States, with
a cost of approximately $5 billion per year.

The US Centers for Disease Control and Prevention (CDC) estimated 3.1 million US
women had a hysterectomy from 2000-2004.

• The hysterectomy rate decreased slightly from 5.4/1000 in 2000 to 5.1/1000 in

2004.
• From 2000-2004, rates of hysterectomy differed by age. Overall rates were
highest among women aged 40-44 years and lowest among women aged 15-24
years. Hysterectomy rates among women aged 50-54 years decreased
significantly from 8.9/1000 in 2000 to 6.7/1000 in 2004.
• Hysterectomy rates also differed by geographic region. The overall rate
was highest for women living in the South (6.3/1000) and lowest for those in the
Northeast (4.3/1000). Hysterectomy rates in the Northeast decreased from
4.9/1000 in 2000 to 3.7/1000 in 2004.
• From 2000-2004, the most common medical reasons for undergoing a
hysterectomy included benign fibroid tumors, endometriosis, and uterine
prolapse. Uterine cancer was not as common but is an important reason for
undergoing a hysterectomy.
• The proportion of hysterectomies with an indication of uterine leiomyoma
decreased from 44.2% in 2003 to 38.7% in 2004.

The relative proportions of all hysterectomies performed as laparoscopically assisted

vaginal hysterectomy (LAVH) peaked at 13% in 1995 and then steadily declined to 3.9%
in 2003 (p for trend <0.001), whereas the relative proportion of subtotal abdominal
hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (p for trend <0.001).

Presentation
Preoperative evaluation includes the following:

• Complete history and physical: Evaluate, in detail, any comorbid conditions such
as diabetes mellitus, hypertension, cardiac disease, or asthma.
• Medication history such as use of aspirin, oral hypoglycemics, heparin, or
warfarin
• PAP smear, endometrial sampling, ultrasonography, CBC count, blood type and
cross match, and, depending upon age and risk factors, ECG and chest radiograph.
• In case of malignancy, preoperative staging can be determined with the help of
biopsies, CAT scans, IVP, cystoscopy, barium enema, etc.

Indications
Reasons for choosing hysterectomy are treatment of uterine cancer, ovarian cancer, some
cases of cervical cancer, and various common noncancerous uterine conditions like
fibroids, endometriosis, uterine prolapse that leads to disabling levels of pain, discomfort,
uterine bleeding, and emotional stress.

Relevant Anatomy
• Total abdominal hysterectomy involves removal of the uterus and cervix through
an abdominal incision.
• Supracervical or subtotal hysterectomy is removal of the uterus through an
abdominal incision, while sparing the cervix.
• Radical hysterectomy is extensive surgery that, in addition to removal of the
uterus and cervix, might include removal of lymph nodes, loose areolar tissue
near major blood vessels, upper vagina, and omentum.
• Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical
removal of the ovary and salpingo-oophorectomy is the removal of the ovary and
the fallopian tube.
• Vaginal hysterectomy is removal of the uterus and the cervix through the vagina.
• Laparoscopy-assisted vaginal hysterectomy is vaginal hysterectomy with the help
of laparoscopy.

Contraindications
Vaginal hysterectomy is contraindicated in only 10-20% of cases, eg, uterine size greater
than 280 g15 , previous multiple abdominal or pelvic surgeries, advanced uterine or
cervical malignancies, and ovarian malignancies.