Uterine Fibroids and Hysterectomy

Description

Alternative Names

Hysterectomy

Hysterectomy is the surgical removal of the uterus and is the second most frequently performed surgery in premenopausal women (Cesarean sections are first). About 600,000 hysterectomies are performed each year in the US, which is the highest rate among any nations with published data on this procedure. By age 60, about a third of American women have had this procedure. The highest hysterectomy rates are in women between ages 40 and 44. Women in the South and Midwest are more likely to have the operation than those in the Northeast and West.

The number of procedures has continued to increase, but the rise has slowed substantially in recent years. The percentage of hysterectomies performed because of fibroids, however, has risen significantly. Fibroids now account for 38% of these operations, but the rates vary widely by ethnic group. In a major 2002 government report 68% of fibroid-related hysterectomies were performed in African American women, 33% in Caucasians, and 45% among women of other ethnic groups.

Most women are satisfied with the procedure. A major analysis of evidence on hysterectomies reported that symptoms related to menstrual problems decline significantly in most women (although none completely disappear for all women). Most women also experience improved quality of life and mood, although in one study 8% of women who were not depressed and 12% of women who were not anxious before the procedure developed these emotional states afterward.

Still, in one study in 70% of cases when physicians recommended hysterectomies, they did not give their patients alternative choices or adequate diagnostic evaluations. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids should certainly seek a second opinion.

Determining the Extent of the Hysterectomy

Once a decision for a hysterectomy has been made, the patient should discuss with her physician what will be removed. The common choices are:

• Total Hysterectomy (removal of uterus and cervix).
• Supracervical Hysterectomy (removal of uterus and preservation of the cervix). Procedure is performed in about 20% to 25% of cases.
• Bilateral Salpingo-Oophorectomy (removal of the ovaries). It can be used with either total or supracervical hysterectomy.

Total Hysterectomy. In a total hysterectomy the uterus and cervix are removed; this eliminates the risk of uterine and cervical cancer. (Given technical advances and growing surgical experience, a total hysterectomy may eventually be unnecessary except in special circumstances, such as when cancer is present.)

Supracervical Hysterectomy. In a supracervical hysterectomy the uterine body is removed and the cervix is retained. Retaining the cervix helps support the pelvic floor and may help maintain full sexual sensation, but the risk for cervical cancer remains.

Bilateral Salpingo-Oophorectomy. Bilateral salpingo-oophorectomy is the removal of the fallopian tubes and ovaries. It may be performed with either total or supracervical hysterectomy. In deciding to remove the ovaries, a woman must be aware of various consequences, both positive and negative.

• Oophorectomy helps to reduce the risk for ovarian cancer by elimination of ovaries and breast cancer by causing estrogen loss. Ovarian cancer is very rare, in any case, except in women with a family history of the disease. Even in these women, removal is not 100% preventive. It can still develop from cancer cells that may be present in the lining of the pelvis (the peritoneum).
• Losing ovarian function means estrogen and testosterone loss, which can increase the risk for menopause-related conditions. These include osteoporosis, heart disease, skin wrinkling, and reduction in muscle tone. Estrogen replacement, however, can help offset these problems.

Abdominal vs. Vaginal Hysterectomy

There is still a further choice, which is whether the hysterectomy should be performed through an incision in the abdomen or performed through the vagina. A variant of vaginal hysterectomy, called laparoscopic-assisted vaginal hysterectomy (LAVH), is yet another option.

Abdominal Hysterectomy. Abdominal hysterectomy is the most common procedure and is used in over 80% of hysterectomies in African-American women and about 60% in Caucasian and other ethnic groups. It is best suited for women with large fibroids, when the ovaries need to be removed, or when cancer or pelvic disease is present. With the abdominal procedure, a wide incision is required to open the abdominal area from which the surgeon removes the uterus. If possible, the incision should cut horizontally across the top of the pubic hairline (the bikini incision). This incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases. The patient may need to remain in the hospital for three to four days, and recuperation at home takes about four to six weeks.

Vaginal Hysterectomy. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. This approach is most often performed for small fibroids (although advances in imaging and other techniques may allow it to be used on larger fibroids). At this time it is used in less than 20% of cases in African-American women and slightly under 40% between Caucasian and other groups.

A variation of the vaginal approach is called laparoscopic-assisted vaginal hysterectomy (LAVH). It uses several small abdominal incisions through which the surgeon severs the attachments to the uterus and ovaries. They can then be removed through the vaginal incision, as in the standard approach. Hospitalization stays may be longer and costs are greater than with standard vaginal hysterectomy. The use of LAVH has risen significantly over the past years and is now employed in over a quarter of the procedures. LAVH is very costly and time consuming, however, and some experts question whether it adds any significant benefits compared to the standard vaginal procedure.

Postoperative Care

If possible, a patient should ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:

• For a day or two after surgery, the patient is given medications to prevent nausea and pain killers to relieve pain at the incision site. (Various approaches are being tested to reduce postoperative pain. For example, a narcotic-free pump that administers a local anesthetic is proving to be very effective and allows shorter hospital stays. It is still in trials.)
• As soon as the physician recommends it, usually within a day of the operation, the patient should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and to hasten recovery.
• Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major distress for the first few days.
• Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery.
• Patients are advised not to lift heavy objects (including small children), not to douche or take baths, and not to climb stairs or drive for several weeks.
• For the first few days after surgery, many women weep frequently and unexpectedly. These mood swings may be due to depression from the loss of reproductive capabilities and from abrupt changes in hormones, particularly if the ovaries have been removed.

The patient should discuss with the physician when exercise programs more intense than walking can be initiated. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may experience an on-going feeling of overall weakness, which can be demoralizing, particularly in women used to physical health. Some women do not feel completely well for as long as a year; others may recover in only a few weeks.

Complications Following the Procedure

Minor complications after hysterectomy are very common. About half of women develop minor and treatable urinary tract infections. There is usually mild pain and light vaginal bleeding post operation. The infrequent occurrence of severe bleeding or hemorrhaging after vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy, may be promptly treated by laparoscopy.

More serious complications, such as those described below, are uncommon but patients should be aware of their symptoms and call the physician immediately if they occur.

Among the three procedures, a 2001 Australian study reported that complication rates were 44% for abdominal hysterectomy, 24% for vaginal hysterectomy, and only 2% for LAVH. (LAVH is used in less than 4% of hysterectomies, however.)

Infection. Infection occurs in 10% to 15% of patients, the risk being higher with abdominal than with vaginal surgery. Risk factors for infection appear to be obesity, a longer than normal operative time, and low socioeconomic status. Patients should be aware of any symptoms and call the physician immediately if they occur. Symptoms of infection might include:

• Continuing or increasingly severe pain.
• Fever.
• Heavy discharge.
• Bleeding (antibiotics given at the time of surgery help to reduce this risk).

Blood Clots. There is a slight risk for small blood clots, usually in veins of the legs (thrombophlebitis). A sudden swelling or discoloration in the leg can indicate this condition and require immediate medical attention.

Other Serious Complications. Other serious and even life-threatening complications are rare but can include:

• Pulmonary embolism (blood clots that travel to the lung).
• Surgical injury of the urinary or intestinal tracts. (They are uncommon and most are recognized and repaired during the hysterectomy.)
• Abscesses.
• Perforation of the bowel.
• Fistulas (a passage that bores from an organ to the skin or to another organ).
• Dehiscence (opening of the surgical wound).

Long-Term Complications. Women who have had a total hysterectomy are at higher risk for the following long-term complications:

• Muscle weakness in the pelvic area.
• Prolapse (descent) of the bladder, vagina, and rectum if the muscles walls are overly weakened. (This may require further surgery.)
• Bowel problems may develop if adhesions (extensive scarring) have formed and obstruct the intestines, sometimes requiring additional surgery.
• Shortening of the vagina is a possible complication specific to vaginal hysterectomy. It can cause pain during intercourse.

It should be noted that such complications are uncommon. In one study of 43 women, satisfaction was high, and none reported significant problems in the bladder or intestinal tract following hysterectomy.

Treating Menopausal Symptoms and Premature Menopause after Hysterectomy

After hysterectomy, women may experience hot flashes, a symptom of menopause, even if they retain their ovaries. Surgery may have temporarily blocked blood flow to the ovaries, therefore suppressing estrogen release. If both ovaries have been removed in premenopausal women, the procedure causes premature menopause. Symptoms come on abruptly and may be more intense than those of natural menopause. Symptoms include hot flashes, vaginal dryness and irritation, and insomnia. A significant number of women gain weight.

The most important complications occur in women who have had their ovaries removed. This causes estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease. Women have typically taken taking hormone replacement therapy (HRT) after surgery if their ovaries have been removed. There have been concerns, however, about health risks, including the risk for breast cancer and stroke that have now limited its use. Such risks in premenopausal women have not yet been clarified. Fortunately, a number of other agents are available that can help protect both bones and heart.

In premenopausal women, such preventive measures are not needed if the ovaries are left intact. The ovaries will usually continue to function and secrete hormones even after the uterus is removed, but the life span of the ovaries is reduced by an average of three to five years. In rare cases complete ovarian failure occurs right after hysterectomy, presumably because the surgery has permanently cut off the ovaries' blood supply.

Psychologic and Sexual Concerns after Hysterectomy

Sexual intercourse may resume four to six weeks following surgery. The effect of hysterectomy on sexuality is unclear. In one major study, 70.5% of women had been sexually active before the procedure, which increased to 77.6% within the year afterward. Other studies have reported that up to 25% of women experience increased sexual drive. Nevertheless, some women report no change and other women develop problems related to sexual function. For example, around 10% of women experience vaginal dryness, about 2% of women develop pain during sex, and another 2% also appear to lose capacity for orgasm. One study specifically examining physiological aspects of sexual arousal suggested little if any negative effect from hysterectomy.

Two procedures associated with hysterectomy may affect sexuality directly.

• If the cervix is removed, the clitoris can trigger orgasm, but many experts believe that uterine contractions stimulated by sexual intercourse also cause a so-called deep orgasm. Retaining the cervix may help to retain this sensation.
• Patients who have both ovaries removed may be at higher risk for loss of sexuality. Ovaries produce small amounts of testosterone (the male hormone responsible for sexual drive) even after menopause.

Testosterone Replacement. Testosterone replacement therapy may restore sexuality in women who experience a decline in sexual drive. Occasionally, oral or injection treatments can produce male characteristics such as facial hair and voice change. A slow-release pellet inserted every six months under the skin in the hip appears to reduce these side effects. A patch (Intrinsa) is also in development. Taking hormones long term almost always carries some risks, and it is not yet known what danger testosterone replacement may pose in women. Support groups and counseling can provide important help for this problem.

Pap Smears

Annual Pap smears are recommended for all women with cervix intact who have reached the age of 18 or over or who have become sexually active. After a total hysterectomy, in which the cervix has been removed, a woman will still need Pap smears of the vagina, but because of the low risk of vaginal cancer, these tests usually do not have to be performed annually. The interval between Pap smears depends on the patient's risk factors as determined by the physician. Women with a history of abnormal Pap smears usually require annual screening. Women with a supracervical hysterectomy, in which the cervix remains, still need annual Pap smears. Annual pelvic and breast examinations are important for all women, including those with a total hysterectomy.