Hysterectomy is one of the most common operations performed on a woman. Hysterectomy is the surgical removal of the womb, i.e., the uterus. Uterus is the seat of the child before birth, and after the woman has completed her family, many consider it a redundant organ, which has a high potential to cause detrimental effects to the life of the woman. On the other hand, many consider the uterus to be pivotal in maintaining their "feminity" and are unduly concerned about hysterectomy. The various aspects of hysterectomy, from indications for hysterectomy, routes of removal, the after effects and potential complications are discussed below.
Q: What are the common indications for hysterectomy?
A:Indications for hysterectomy are:

  • Excessive bleeding during periods
  • Severe

Excessive bleeding during periods.  Some of the conditions, which may necessitate hysterectomy in a patient with abnormal bleeding, are listed below.
Hormone related bleeding:
It means disorderly or heavy menstrual bleeding in a woman, where there does not appear to be any structural abnormality in her pelvic organs. It is usually caused due to abnormal levels of hormones in a woman’s blood . When medical treatment or other conservative measures fail, hysterectomy is indicated.
Fibroids
Fibroids are tumours found in the uterus. They are NOT cancerous by nature. Routine ultrasonography done for various symptoms show that fibroids are commonly seen in almost 40% of all women. In many women, fibroids may remain symptom free. However, in some women, it may cause symptoms like excessive bleeding during periods, excessive pain during periods, etc. Some patients get symptoms like increased urinary frequency, or excessive backache or pressure sensation in the pelvis.
Hysterectomy as a treatment for fibroids is usually done only in patients who have completed their family. However, hysterectomy being a major surgery, it should be performed on a patient only if she is severely symptomatic even if she has fibroid.  Mere finding of fibroids incidentally on doing ultrasonography without any symptoms  should not be an indication for hysterectomy.
Certain guidelines for performance of hysterectomy in patients with fibroids are:

  • Very fast growth of fibroids.Fibroids in reproductive age grow by just 1-2 cm per year.

If the growth is very fast, it needs hysterectomy

  • Post menopausal patient with uterus >12cm size or for fibroids which continue to grow even after menopause.
  • Heavy intermittent bleeding not responding to medical treatment.
  • Severe pelvic pain not responding to medical treatment.
  • Very large uterus.
  • Retention of urine.
  • Persistent back ache with no back problems accounting for it
  • Anemia due to menorrhagia requiring blood transfusion.

In patients in the reproductive age group, who desire to retain their uterus, myomectomy,a  surgery, which removes only the fibroids, is done. Surgery for removing only the fibroids is technically associated with more blood loss. Besides that, the tendency for formation of fibroids being inherent, the patient is also liable to have a recurrence of symptoms. Thus, weighing the pros and cons of hysterectomy vs myomectomy, a mature decision has to be taken.
Adenomyosis:
In this condition, the walls of the uterus are thickened as a whole due to depositions of endometrium(lining of the uterus). The women generally present with severe abdominal cramps, starting much before the menstrual periods and continuing through out the days of menstruation. Some of them also present with abnormal and heavy uterine bleeding in addition to pain. The only remedy is to take medicines to relieve pain. But if the pain is incapacitating and cannot be controlled with medications, hysterectomy may have to be resorted to.
Severe lower abdominal pain.
Fibroids and adenomyosis, described above could also be causes for painful menstruation and even severe abdominal pain;Besides these causes, abdominal pain could be caused by
1. Endometriosis. 2. Long standing infections. 3. Post-operative adhesions. 4. Pelvic venous congestion.
Endometriosis:
In this condition, there are lots of abnormal tissues found outside the womb or uterus. These are called endometrial implants. These implants cause the organs around the uterus, like ovary, tubes, intestines etc to get stuck to each other and to the uterus. Sometimes, this may cause incapacitating pain to the patient. In severe cases of endometriosis, mostly after the woman has completed her family, hysterectomy may be needed for advanced endometriosis. .
Long-standing infections:
When a woman suffers from repeated infections in her pelvic organs, it may lead to chronic pelvic pain. Hysterectomy for this condition is being done less and less frequently. However, some patients tired of long standing medical therapy may prefer hysterectomy.
Prolapse of the uterus:
The uterus, descends to due weakness in it’s supporting structures called ligaments. This gives the patient a feeling of some organ coming down in her vagina. In later years of the post menopausal stage, in a majority of patients, descent of the uterus is usually accompanied by descent of bladder and rectum causing symptoms of incomplete evacuation of urine and also incomplete defaecation
Tumours in the pelvis:
Cancerous lesions of the cervix :
Established Cancer of the cervix should be treated by an extended hysterectomy along with  removal of all the lymph nodes, which drain the organ. These are small white peanut like structures lying in clusters in various parts of the body. Removal of these nodes along with hysterectomy needs expertise and is fraught with a higher complication rate compared to ordinary hysterectomy.
Cancer of the endometrium : In this condition, hysterectomy with removal of both ovaries is the only answer.
Cancer of the ovary: In this condition, uterus and both ovaries along with a lot of extensive surgery may sometimes be needed.
What are the organs removed at the time of hysterectomy?
Usually, uterus and cervix are removed at the time of hysterectomy.  The tubes are also removed by most surgeons.  The ovaries are best retained at the time of hysterectomy, but in special circumstances, they may need to be removed.
What will happen if ovaries are removed at the time of hysterectomy?
If ovaries are removed, the patient will experience immediate menopause symptoms.  She may have severe hot flashes.  There is also risk of weakening of the bones due to loss of the hormone called oestrogen. 
Ovaries also produce androgenic hormones which are necessary for strong muscles and bones, sexual desire and overall wellbeing.  35% of a woman’s testosterone is produced by ovaries. Loss of ovaries  can cause decreased sexual desire, specially in younger women.   Dryness of vagina is also possible after hormone deficiency.  Hormone therapy has to be started if ovaries are removed, specially in younger women.
Unless there are absolute indications for removing ovaries, like cancer, they should be retained at the time of hysterectomy.  Many patients have relatives who have died of cancer and they ask for their ovaries to be removed because they feel ovaries can become cancerous and should therefore be removed.  This is a very wrong attitude, as ovaries are not useless organs to be removed because of mental fear of cancer. 
What can be expected soon after hysterectomy?
Following surgery, women may feel nauseous as a side effect of the general anaesthetic and experience some abdominal pain and discomfort. These are relieved with medications.. There may also be some vaginal bleeding which should reduce after a few days. Women are encouraged to get up and walk around on the first day following surgery to avoid constipation and gas and decrease the risk of blood clots and lung infections

 

Will I put on weight after hysterectomy?
Studies have shown that there is a slightly higher risk for weight gain in the first year after surgery, but this is more common in women who were already heavier at the time of surgery. It s may not be entirely an after effect of surgery. Being housebound and decreasing the level of activities during recuperation can also lead to weight gain.   Proper diet and exercise can prevent this weight gain. 
In women who have had their ovaries removed, androgenic hormones can start acting leading to weight gain. Bulging of the abdomen due to weak abdominal muscles can happen after open surgery, but is less likely after vaginal hysterectomy or laparoscopic hysterectomy.
Will I get backpain after hysterectomy?
Positioning of the legs for hysterectomy or unfamiliar or hard hospital beds may cause temporary backpain, which can be cured.
If hysterectomy is done by opening the abdomen, women may  hunch over to protect their abdomen and if they do this for long enough do develop back pain because they have changed their centre of gravity.  It is therefore important to walk up-right as soon as you are able to.  This is unlikely after vaginal or laparoscopic hysterectomy. 
It is common for women in their middle age to get lumbosacral strain . This may happen with or without hysterectomy.  However, if a woman has undergone hysterectomy, she may attribute it to hysterectomy. 
Can I have sex after hysterectomy?
You will be advised not to have sex for around four to six weeks after having a hysterectomy. This should allow time for scars to heal and any vaginal discharge or bleeding to stop.   Having the uterus removed can cause women to worry about feeling less womanly, or losing their sexual attractiveness.  However, these feelings don’t last long.  Interest in sex may return as recovery progresses.

What are the complications of hysterectomy?
Serious but uncommon complications include:
Bleeding
Damage to nearby organs like bladder, urethra .
Pelvic infection.
Repeat surgery for bleeding or wound problems.
Clot formation in the leg veins.

  • Rarely damage to bowel also can happen.

The other frequent minor side effects include wound infection, urinary infection and abnormal sensations around the wound area.

What are the various ways in which hysterectomy could be done?
A: Hysterectomy or removal of the uterus is being done by various methods today.


Laparoscopic hysterectomy:
Hysterectomy is completed using an instrument called the laparoscope. Laparoscope is an instrument through which the contents of the abdomen are visualized through a telescope introduced through a small 1cm incision below or in the umbilicus. The intra-abdominal organs are visualized on a TV screen via a CCD camera fitted on to the telescope. The connections of the uterus are severed through instruments inserted through small 5mm incisions on the abdomen and the final removal achieved through the vagina.


Laparoscopic assisted vaginal hysterectomy: To view a video on LAVH by Dr.Shobhana Mohandas, click on https://www.youtube.com/watch?v=0GPJ0r7-Lls&t=24s
Sometimes, parts of the connections are released laparoscopically and the rest released vaginally. This is called laparoscopic assisted vaginal hysterectomy (LAVH). The after effects of hysterectomy are the same as if the procedure is done vaginally. There is minimal pain and hospital stay is reduced.


Total laparoscopic hysterectomy: The connections of the vagina to the body are not interfered with, and the whole procedure of hysterectomy is performed laparoscopically,.

Advantages of laparoscopic procedures:

1. There are just a few incisions on the abdomen. Because of that, the patient has very minimal pain and can start doing her duties soon after surgery.

2. She can bend, move about, climb stairs, and pick up utensils from the gas and clothes from the washing machine soon after surgery.

3. The organs in the abdomen can be seen with an enlarged view through the laparoscope, so the surgeon can seen minute changes in organs

very clearly on the screen.

4. There being very few incisions on the abdomen, chances for infection are very little and chance for incisional hernia is nil.


Vaginal hysterectomy:
Uterus is closest to the natural opening in the woman, the vagina. When hysterectomy is done vaginally, a cut is made into the vagina, and the attachments of the uterus to the body are severed through the opening thus made and the uterus delivered out. The incision on the vagina does not cause pain to the patient, as it is generally not as sensitive as the skin.

Advantages:
1.When the procedure is done entirely through the vaginal route, there is no incision on the abdomen. As there is no incision on the abdomen, there is no chance of wound infection or incisional hernia.
2.The patient has very little pain and is very comfortable while bending, turning over, walking, etc from the second day itself after surgery. The patients normally go home on the 3rd post-operative day and are even allowed to travel by busThey can resume normal duties within 7-10 days of surgery.pa
3.Internationally, various studies have shown that ureteric injuries are fewer when hysterectomy is performed this way

 


Abdominal hysterectomy:
Hysterectomy is traditionally performed through the abdominal route when the uterus is not prolapsed. A 6-10cm cut is made in the abdomen either just above the hairline or in some cases, vertically somewhere in the middle of the lower abdomen.
Hysterectomy done in this manner is associated with pain in the days following surgery at the incision site. The patient is kept in the hospital for 5-7 days depending on the time taken for removing the stitches and wound healing. The patient has to convalesce at home for a month and she has to avoid lifting heavy objects for 6 months, the time taken for internal defects to heal. In the first few days after surgery, generally there is some amount of pain and assistance may be needed for getting up from bed, moving towards the toilet, etc, as abdominal incisions tend to be painful. The degree of mobility achieved by a patient after surgery varies from patient to patient depending on each patient’s pain threshold, length of incision, etc.
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Which is the best route of hysterectomy?
Hysterectomy done by the vaginal or laparoscopic method is definitely advantageous to the patient by way of comfort in the post-operative period as compared to abdominal hysterectomy. However, it can be done only by trained gynaecologists.
The degree of pain after hysterectomy depends also  on the indication for which it  is done and the amount of manipulations the operating surgeon does while doing surgery. Patients who have a lot of adhesions in the abdomen do tend to get more pain than patients who have no adhesions. Adhesions are found in patients with history of previous surgery, history of infections, in patients with endometriosis, etc.
The choice of hysterectomy largely lies in the hands of the surgeon doing the surgery, depending on the skill and expertise available in her/his hands and the facilities available in that particular center. Opening the abdomen for hysterectomy is not needed often in good laparoscopic centers and laparoscopic/vaginal surgery should be the best option for the patient who has access to such centers.

 

Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.
Consultant Gynaecologist,Sun Medical centre, Thrissur, Kerala.