Hysterectomy 

A hysterectomy is an operation to remove the womb (uterus).

Hysterectomies treat problems with the female reproductive system that cannot be controlled by medication, such as cervical cancer, heavy menstrual bleeding (menorrhagia) and fibroids.

The operation should only be considered after other options have been explored. Around 50,000 hysterectomies are performed in the UK every year on the NHS (1).

During the operation, the fallopian tubes and ovaries may also be removed, depending on other health conditions.

The procedure can be done either through the abdomen or the vagina and, again, this will depend on the patient's medical history and the reasons for surgery.

Under what circumstances will I need a hysterectomy?

A patient may need a hysterectomy for a number of reasons, but it is normally a last resort after surgical and non-surgical treatments have failed:

Fibroid tumours - usually non-cancerous, fibroids grow inside the uterus and vary in size from a pea to a grapefruit. As they grow, they can put pressure on other organs, as well as causing heavy menstrual bleeding or pelvic pain

Menorrhagia - excessive menstrual bleeding caused by hormonal changes, fibroids, infection or disease. If other treatments fail a hysterectomy may be necessary

Endometriosis - tissue normally found inside the uterus grows in other parts of the abdomen. It can be extremely painful and also lead to infertility

Endometrial hyperplasia - the term for a thickening of uterine lining often through high levels of oestrogen. Again, it causes abnormally heavy bleeding

Pelvic support problems - the uterus drops down into the vagina, because the muscles supporting it are weak or damaged. This can affect the uterus, bladder, urethra and, on rare occasions, the intestines

Cancer - cervical, ovarian, or endometrial cancers are often treated with a hysterectomy

How many different types of hysterectomy are there?

Total hysterectomy is the most commonly performed (2) and, as the name suggests, involves removal of both the uterus and cervix (neck of the womb)

Radical hysterectomy is the most extensive surgery as it includes the removal of the uterus, the cervix and most surrounding tissue, some of the upper vagina and possibly the pelvic lymph nodes, which is normally performed if cancer is diagnosed

Partial hysterectomy or subtotal hysterectomy is the removal of the uterus, but the cervix is left intact

The surgeon can access the uterus in a number of different ways, depending on diagnosis:

Abdominal hysterectomy involves an incision of around six to eight inches through the abdomen. The incision can be vertical from the pubic bone up to the navel or horizontal across the top of the pubic hairline. The technique is common when the ovaries and fallopian tubes are also being removed, when the uterus is enlarged or disease has spread

Vaginal hysterectomy has no visible scarring as the uterus is removed through the vagina. This is common when the vagina also needs repair

Laparoscopic supracervical hysterectomy (LSH) uses thin, flexible tubes, which are lit and contain a tiny camera. They are inserted through small incisions around the abdomen or through the vagina.

Small surgical instruments remove the uterus without removing or damaging the cervix. This surgery is less invasive than other procedures, can be performed relatively quickly and requires a much shorter recovery time.

The surgeon will need special training and the whole operation will cost more to perform. If the surgeon has not had training in this procedure, there may be an increased risk of complication due to injury (3).

Complication rates for this type of hysterectomy are higher than for an abdominal hysterectomy (3), so ask your surgeon how many times they have done the operation and what the success rate is.

What are the alternatives to hysterectomy?

There are a number of surgical alternatives that can help women avoid hysterectomy. A patient should explore all the alternatives with their GP or gynaecologist.

• Microwave endometrial ablation (MEA) is very quick and uses a probe, heated by microwaves, to reduce the thickness of the uterine lining. Other ablation techniques that remove unnecessary tissue include laser and thermal balloon
• Uterine artery embolisation works by injecting a fluid into the blood vessels that feed the fibroids in or around the uterus. The fluid blocks the blood vessels and the fibroids shrink, as they no longer have a blood supply. The technique is used to treat large fibroids and can shrink them by up to 60 per cent. This is a new procedure and is not available in all hospitals, so you should ask your doctor about availability (4)
• Myoma coagulation (myolysis) attempts to shrink fibroids by cutting off blood supply. A needle that transmits electrical current is inserted into the fibroid and seals blood vessels with heat. A different procedure called cryomyolysis uses liquid nitrogen instead of electricity (3) to shrink the fibroids
• Myomectomy is where fibroids are removed but the uterus is left intact. It can be performed through the abdomen or the vagina depending on the location and size of the fibroids

When should I stop taking the contraceptive pill?
You should stop taking your contraceptive pill one month before your operation. During this time you should use condoms or other barrier methods of contraception.

Infolinks:
The Hysterectomy Association
Cancer Help (Cancer Research UK)
Cancer Backup
Endometriosis UK

References:
1) Hysterectomy Association
What is a Hysterectomy
Accessed Apr 24 2009
2) Hysterectomy Association
How is a hysterectomy performed?
Accessed Apr 24 2009
3) National Institute of Health and Clinical Excellence (NICE)
Guidance notice
Accessed Apr 27 2009
Interventional Procedures Advisory Committee
Published November 2003
4) National Institute of Health and Clinical Excellence (NICE)
Uterine artery embolisation for the treatment of fibroids(PDF)
Accessed Apr 27 2009
Issue date: Oct 2004