Hysterectomy

What is a hysterectomy?

Hysterectomy is a surgical procedure in which the uterus is removed, and in some cases, the fallopian tubes and ovaries may also be taken out. It is performed for a range of medical reasons, including gynaecological conditions that have not responded to other treatments, and can offer significant relief from persistent symptoms. Following a total hysterectomy, menstrual periods will no longer occur, as the uterus is no longer present.

Types of Hysterectomy

There are several types of hysterectomy, each tailored to the underlying condition and the extent of surgery required:

• Total hysterectomy — involves the complete removal of the uterus along with the cervix. This is the most common form of hysterectomy and is often recommended for conditions such as fibroids, endometriosis, or abnormal bleeding.

• Subtotal (partial) hysterectomy — removes the uterus but leaves the cervix intact. Women who undergo this procedure may still experience occasional light bleeding, as a small portion of uterine tissue remains active.

• Radical hysterectomy — entails the removal of the uterus, cervix, surrounding tissues, and, in some cases, the fallopian tubes and ovaries. This more extensive surgery is usually reserved for certain cancers of the reproductive tract.

• Laparoscopic hysterectomy — a minimally invasive technique performed through small abdominal incisions with the aid of a camera. This method often results in less postoperative discomfort, a shorter recovery period, and smaller scars compared to traditional open surgery.

 

When is hysterectomy recommended?

Hysterectomy may be advised when certain gynaecological conditions significantly affect a woman’s health or quality of life, particularly when other treatments have not provided relief. The decision is based on the nature and severity of the condition, the patient’s symptoms, and her overall health and reproductive plans.

• Uterine fibroids — non-cancerous growths in the uterus that cause persistent pain, heavy menstrual bleeding, or pressure symptoms, especially when medical treatment has been unsuccessful.

• Endometriosis and adenomyosis — conditions where tissue similar to the lining of the uterus grows outside it or within the uterine muscle, leading to chronic pain and heavy bleeding, unresponsive to conservative therapies.

• Uterine prolapse — descent of the uterus into the vaginal canal due to weakened pelvic floor muscles, often causing discomfort, urinary symptoms, or difficulty with daily activities.

• Abnormal uterine bleeding — persistent and heavy bleeding without a clear cause, or bleeding that does not improve with medical management.

• Chronic pelvic pain — severe, ongoing pelvic discomfort linked to underlying uterine conditions that have not responded to other interventions.

• Gynaecological cancers — certain cancers of the cervix, uterus, or ovaries may require hysterectomy as part of definitive treatment.

How should you prepare for a hysterectomy?

Proper preparation before a hysterectomy helps ensure the safest possible procedure and smooth recovery. This involves medical assessment, lifestyle adjustments, and a clear understanding of what the surgery entails.

• Consultation — meet with your gynaecologist to discuss the procedure in detail, including its intended benefits, potential risks, and available alternatives, so you can make an informed decision.

• Medical history — provide a full account of your health background, including current medications, allergies, and any previous operations, to help your surgical team plan appropriately.

• Physical examination and tests — you may be advised to undergo blood tests, ultrasound, MRI, or other investigations to confirm the diagnosis and determine the most suitable surgical approach.

• Fasting — most patients are instructed not to eat or drink for a set period before the operation, typically from midnight the night before surgery.

• Anaesthesia evaluation — for patients with higher medical risks, an assessment by an anaesthesiologist may be arranged to ensure that anaesthesia can be administered safely.

How is a hysterectomy performed?

Hysterectomy is carried out under general anaesthesia, ensuring you are asleep and comfortable throughout the procedure. An intravenous (IV) line will be placed for fluids and medication, a urinary catheter will drain urine during surgery, and flowtron devices (leg compression sleeves) may be used to reduce the risk of deep vein thrombosis (DVT).

• Incisions — small abdominal incisions, usually three to four, are made to allow access to the pelvic organs.

• Laparoscope insertion — a laparoscope, a slender tube equipped with a camera, is inserted through one of the incisions to provide a clear view of the surgical area.

• Uterus removal — specialised surgical instruments are used to carefully detach and remove the uterus. Depending on the case, the cervix, fallopian tubes, or ovaries may also be removed.

• Closure — the incisions are closed using sutures or surgical glue, and dressings are applied. You will then be transferred to the recovery room for close monitoring as you awaken from anaesthesia.

What are the risks associated with hysterectomy?

Hysterectomy can be highly effective in treating certain gynaecological conditions, but like any major surgery, it carries potential risks. These may occur during or soon after surgery, or they may develop over the longer term. Understanding these possibilities helps patients make informed decisions and prepare for their recovery.

Immediate surgical risks 

These occur during the operation or in the days following it.

• Blood loss — up to 1–2% of patients may require a blood transfusion during or after surgery.

• Infection — postoperative infections occur in about 1–5% of patients and may involve the incision site or internal tissues.

• Hernia — a hernia can develop at the scar site if wound healing is poor.

• Damage to surrounding organs — rare (less than 1%) but possible injuries to the bladder, ureters, or intestines; more likely in difficult cases involving endometriosis, large fibroids, or previous caesarean sections.

• Deep vein thrombosis (DVT) — formation of blood clots in the legs that can travel to the lungs; preventative measures may include leg compression devices and blood-thinning injections.

• Anaesthesia complications — risks vary and may include breathing difficulties, allergic reactions, or cardiovascular events.

Long-term risks

These may develop weeks, months, or years after surgery.

• Urinary urgency or stress incontinence — may affect up to 2–20% of women after hysterectomy.

• Vaginal vault prolapse — can occur in 5–10% of women, where the top of the vagina descends after the uterus is removed.

• Ovarian failure — if the ovaries are removed (oophorectomy), menopause is immediate. Even when preserved, premature ovarian failure can occur in about 5–10% of cases.

• Psychological impact — around 5–10% of women may experience depression or anxiety post-surgery, particularly due to the loss of fertility.

• Sexual function changes — up to 30% report issues such as vaginal dryness or reduced libido, although some experience improved sexual satisfaction once previous symptoms are relieved.

• Cardiovascular events — risk may be 2–4% higher than baseline population levels.

• Thromboembolic events — risk of DVT or pulmonary embolism can be elevated by 1–3%.

• Post-hysterectomy syndrome — may affect 20–30% of women, involving hormonal changes and other related symptoms.

What are the pros and cons of keeping the ovaries after hysterectomy?

Ovarian conservation refers to leaving the ovaries intact during hysterectomy. The choice depends on factors such as age, overall health, family history of cancer, and the underlying reason for surgery.

Pros of ovarian conservation 

Keeping the ovaries offers several health benefits by maintaining natural hormone production and its protective effects.

• Hormonal balance — preserving the ovaries maintains natural hormone production, which helps reduce the likelihood of menopausal symptoms.

• Reduced risk of osteoporosis — continued hormone production supports bone density and lowers the chance of developing osteoporosis.

• Cardiovascular health — ovarian hormones can provide protective effects for the heart, potentially reducing cardiovascular disease risk.

Cons of ovarian conservation

Retaining the ovaries also carries certain risks that should be carefully weighed against the benefits.

• Ovarian pathology — there remains a 5–10% lifetime risk of developing ovarian cancer or other ovarian conditions.

• Persistence of certain conditions — hormone-dependent conditions such as endometriosis may continue if the ovaries are left in place.

• Potential complications — retained ovaries may develop issues such as cysts or ovarian torsion, which could require future surgical intervention.

What should you expect after a hysterectomy?

Post-operative care is essential for a smooth recovery following hysterectomy. Careful monitoring, gradual return to normal activities, and timely follow-up help ensure the best possible outcome.

• Recovery room — you will remain in the recovery area until the effects of anaesthesia have worn off, during which your vital signs will be closely monitored.

• Pain management — some discomfort is expected in the days after surgery and can be effectively controlled with prescribed pain-relieving medications.

• Activity — physical activity should be resumed gradually. Avoid heavy lifting, vigorous exercise, and sexual intercourse for at least six weeks or until your doctor advises otherwise.

• Follow-up appointments — attending all scheduled check-ups allows your surgeon to assess healing progress, address any concerns, and provide further recovery guidance.

• Signs to watch for — contact your healthcare provider promptly if you develop excessive bleeding, severe or worsening pain, fever, or any signs of infection, such as redness, swelling, or discharge at the incision sites.

Summary 

Hysterectomy is a surgical procedure to remove the uterus, sometimes along with the fallopian tubes, ovaries, and surrounding tissues, depending on the underlying condition. It may be recommended for problems such as fibroids, endometriosis, adenomyosis, uterine prolapse, abnormal bleeding, chronic pelvic pain, or certain gynaecological cancers when other treatments have not been successful. 

The procedure can be performed through different approaches, including total, subtotal, radical, or laparoscopic hysterectomy, with preparation involving thorough medical evaluation, diagnostic testing, and anaesthesia planning. While the surgery is effective in relieving symptoms and improving quality of life, it carries both immediate and long-term risks, which should be discussed in detail. Decisions such as whether to conserve the ovaries require careful consideration of their benefits and risks. Post-operative recovery involves pain management, gradual return to activity, and monitoring for any signs of complications. 

If you are experiencing persistent gynaecological symptoms and wish to explore whether hysterectomy is an appropriate treatment, schedule a consultation with Holistic Gynaecology & Fertility for expert advice and personalised care.