The most frequent reason for hysterectomy in American women is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus that can cause pelvic, low back pain, and heavy or lengthy menstrual periods. They occur in 30–40% of women over age 40, and are three times more likely to be present in African-American women than in Caucasian women. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman’s normal activities.
Treatment of endometriosis is the reason for 20% of hysterectomies. The endometrium is the lining of the uterus. Endometriosis occurs when the cells from the endometrium begin growing outside the uterus. The outlying endometrial cells respond to the hormones that control the menstrual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding tissue, leading to pain and scarring.
Twenty percent of hysterectomies are done because of heavy or abnormal vaginal bleeding that cannot be linked to any specific cause and cannot be controlled by other means. Another 20% are performed to treat prolapsed uterus, pelvic inflammatory disease, or endometrial hyperplasia, a potentially pre-cancerous condition.
About 10% of hysterectomies are performed to treat cancer of the cervix, ovaries, or uterus. Women with cancer in one or more of these organs almost always have the organ(s) removed as part of their cancer treatment.
A hysterectomy is classified according to what structures are removed during the procedure and what method is used to remove them.
A total hysterectomy, sometimes called a simple hysterectomy, removes the entire uterus and the cervix. The ovaries are not removed and continue to secrete hormones. Total hysterectomies are usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy.
In addition to a total hysterectomy, a procedure called a bilateral salpingo-oophorectomy is sometimes performed. This surgery removes the ovaries and the fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.
If the reason for the hysterectomy is to remove uterine fibroids, treat abnormal bleeding, or relieve pelvic pain, it may be possible to remove only the uterus and leave the cervix. This procedure is called a subtotal hysterectomy (or partial hysterectomy), and removes the least amount of tissue. The opening to the cervix is left in place. Some women believe that leaving the cervix intact aids in their achieving sexual satisfaction. This procedure, which used to be rare, is now performed more frequently.
Subtotal hysterectomy is easier to perform than a total hysterectomy, but leaves a woman at risk for cervical cancer. She will still need to get yearly Pap smears.
Radical hysterectomies are performed on women with cervical cancer or endometrial cancer that has spread to the cervix. A radical hysterectomy removes the uterus, cervix, above part of the vagina, ovaries, fallopian tubes, lymph nodes, lymph channels, and tissue in the pelvic cavity that surrounds the cervix. This type of hysterectomy removes the most tissue and requires the longest hospital stay and a longer recovery period.
There are two ways that hysterectomies can be performed. The choice of method depends on the type of hysterectomy, the doctor’s experience, and the reason for the hysterectomy.
ABDOMINAL HYSTERECTOMY. About 75% of hysterectomies performed in the United States are abdominal hysterectomies. The surgeon makes a 4–6-in (10–15-cm) incision either horizontally across the pubic hair line from hip bone to hip bone or vertically from navel to pubic bone. Horizontal incisions leave a less noticeable scar, but vertical incisions give the surgeon a better view of the abdominal cavity. The blood vessels, fallopian tubes, and ligaments are cut away from the uterus, which is lifted out.
Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.
The advantages of an abdominal hysterectomy are that the uterus can be removed even if a woman has internal scarring (adhesions) from previous surgery or her fibroids are large. The surgeon has a good view of the abdominal cavity and more room to work. Also, surgeons tend to have the most experience with this type of hysterectomy. The abdominal incision is more painful than with vaginal hysterectomy, and the recovery period is longer.
VAGINAL HYSTERECTOMY. With a vaginal hysterectomy, the surgeon makes an incision near the top of the vagina. The surgeon then reaches through this incision to cut and tie off the ligaments, blood vessels, and fallopian tubes. Once the uterus is cut free, it is removed through the vagina. The operation takes one to two hours. The hospital stay is usually one to three days, and the return to normal activities takes about four weeks.
The advantages of this procedure are that it leaves no visible scar and is less painful. The disadvantage is that it is more difficult for the surgeon to see the uterus and surrounding tissue. This makes complications more common. Large fibroids cannot be removed using this technique. It is very difficult to remove the ovaries during a vaginal hysterectomy, so this approach may not be possible if the ovaries are involved.
Vaginal hysterectomy can also be performed using a laparoscopic technique. With this surgery, a tube containing a tiny camera is inserted through an incision in the navel. This allows the surgeon to see the uterus on a video monitor. The surgeon then inserts two slender instruments through small incisions in the abdomen and uses them to cut and tie off the blood vessels, fallopian tubes, and ligaments. When the uterus is detached, it is removed though a small incision at the top of the vagina.
This technique, called laparoscopic-assisted vaginal hysterectomy, allows surgeons to perform a vaginal hysterectomy that might otherwise be too difficult. The hospital stay is usually only one day. Recovery time is about two weeks. The disadvantage is that this operation is relatively new and requires great skill by the surgeon.
Any vaginal hysterectomy may have to be converted to an abdominal hysterectomy during surgery if complications develop.