Hysterectomy is often the only solution for long-term gynaecological problems. It is a big operation and the decision to have it is often traumatic – but in most cases will have cured a painful or distressing condition, leading to a happier love life.
Hysterectomy is the name for the surgical removal of the womb. Few people realize, however, that the operation owes its name to the ancient Greek belief that disorders of the uterus caused women to suffer from hysteria!
The most common major gynaecological procedure, hysterectomy is one of the most frequently performed of all operations. Gynaecologists will subdivide the hysterectomy operation according to whether the cervix is removed or conserved – ‘total’ or ‘subtotal’ – and whether the operation is performed through the abdominal wall or via the vagina. Doctors will talk of a TAH, or total abdominal hysterectomy, when the uterus and cervix are removed through an incision in the wall of the abdomen, or a VAH, when the whole operation is performed via the vagina.
Nowadays, because of fears over cancer in the stump of the cervix left behind, most hysterectomies are ‘total’. The only exceptions are if chronic pelvic infections have stuck the cervix to the surrounding tissues and it is physically impossible to remove, or if a dire surgical emergency, such as a ruptured uterus, means that speed is of the essence.
Why perform it?
In the end, the hysterectomy is the ultimate gynaecological treatment. Orthopaedic, or bone, specialists can never have the luxury of solving their problems by removing all the bones in the body but, if circumstances force it, a gynaecologist can perform the equivalent operation.
The most common reason of all for performing a hysterectomy is abnormal bleeding; either too much or too often, or both. The decision as to whether to operate or not under these circumstances is based on several factors, but in general the older the patient and the more
definite she is that she doesn’t want more children, the more likely the surgeon is to suggest a hysterectomy.
Fibroids, benign growths in the muscles of the uterus, are another common reason for hysterectomy. These growths are rare in younger women but become more frequent after the age of 40. As they grow, they distort the uterus, causing bleeding and pain.
The symptoms of fibroids vary from woman to woman and in many cases the severity bears little relationship to their size. If the patient has completed her family the simplest operation, both for her and for her surgeon, is a hysterectomy.
If fertility is important, an operation called myomectomy, which removes the fibroid but leaves the uterus intact, can be attempted. Even in the best hands, myomectomy only leaves a woman with a 50/50 chance of conception after the operation and now and again complications can mean that a hysterectomy will have to be performed anyway. Nonetheless, for a young, childless woman it might still be preferable to a hysterectomy.
Hysterectomy is sometimes used in the treatment of pelvic infections and endometriosis. It is very much a last option and is only resorted to where intensive drug therapy has failed.
In almost all cases of gynaecological cancer the surgeon will opt to perform a hysterectomy, often combined with other forms of therapy such as chemotherapy or radiotherapy.
In most of these cases an operation called a panhysterectomy, or pelvic clearance, is undertaken. A panhysterectomy is always performed abdominally, and as well as removing the uterus and cervix the surgeon takes away the ovaries and Fallopian tubes. A panhysterectomy is often performed if the woman having a hysterectomy is post-menopausal, even if she doesn’t have cancer; the rationale being that there seems little sense in leaving the nonfunctioning ovaries behind when there is a chance that they may become cancerous later.
Cancer of the cervix, because it can spread both up and down, requires an even more radical operation than pan-hysterectomy. In Wertheim’s operation the contents of the pelvis are removed, together with the upper two-thirds of the vagina and much of the surrounding tissue – a tragedy as the disease often strikes the young and is totally preventable if it is caught and treated early.
Given the chance, most women would choose a vaginal hysterectomy and so would most surgeons. Aside from the advantage of avoiding a scar, women who have a vaginal hysterectomy suffer less from complications and are up and about more quickly. Unfortunately, the choice of operation is often dictated by the disease.
Cancers are almost always removed through the abdominal wall. The surgeon can see the entire operating field and check other pelvic organs to make sure the tumour hasn’t spread.
Large, benign growths, such as fibroids, may also be unsuitable for vaginal hysterectomy, as they can be so big that it is impossible to pull them through the cervix.
Untreated pelvic infections also make vaginal hysterectomies difficult, because the uterus and tubes are often stuck to the surrounding tissues and have to be peeled off.
The final obstacle to vaginal hysterectomy is sometimes a healthy, well supported uterus with a firm pelvic floor. In such cases it may be technically very difficult to pull the cervix down far enough to perform the operation. In this respect women who have had children are at a distinct advantage compared with those who are childless.
Hysterectomy is a major operation but nevertheless serious complications are rare. Occasionally internal bleeding occurs and this may require further exploratory surgery.
However careful the surgeon, though, and however clean the operating theatre, some wounds become infected. Signs of infection usually show themselves after a day or two and include temperature, swelling and pain. Most respond to antibiotic treatment, but occasionally further surgery is needed. Infections are less common after vaginal hysterectomy.
A condition known as ileus, that can complicate all surgery around the gut, is also more common after abdominal hysterectomy than vaginal. In this condition the bowel becomes paralysed, sometimes not functioning for several days. The patient suffers nausea and constipation and cannot eat or drink. Given time an ileus will settle on its own but the patient may need to stay on a drip for a day or two.
There are no hard and fast rules about recovery, but generally speaking patients recover more quickly from vaginal rather than abdominal hysterectomy and younger women recover faster than older women. Assuming all goes well the average woman would be in hospital for a day before the operation and about a week afterwards. Back at home, recovery is speeded by gentle mobility and slowed by too rigid bed rest. With the exception of heavy lifting, no activity is forbidden as long as the patient feels up to it. Most women are ready to return to work after four to six weeks. Full recovery, however, can take between three and six months.
There are no set guidelines about when sexual activity can be resumed after hysterectomy. Both types leave a scar inside the vagina and penetrative sex may be unpleasant for several weeks. When it feels comfortable is soon enough, usually after three or four weeks.