Hysterectomy, the surgical removal of the uterus, is a very emotional subject for many reasons. First, there are many hysterectomies done for questionable indications. It is best if a woman has a hysterectomy only if there is not a less invasive option. But many women have hysterectomies when other treatments might have succeeded. So what other treatments are available?
If a hysterectomy has been recommended for bleeding, there are other ways to treat heavy uterine or menstrual bleeding such as birth control pills, a progestin containing IUD known as Mirena, or endometrial ablation. Ablation is an outpatient procedure that destroys the uterine lining and ends the heavy bleeding.
If a hysterectomy has been recommended for fibroids, there are many ways to remedy the situation short of removing the uterus if uterine preservation is desired. Fibroids can be removed from the uterine cavity with a cutting/ cautery instrument during a D & C like procedure with no incision. This is known as a resectoscope myomectomy and is performed as an outpatient procedure with anesthesia. Normal activity may be resumed the next day. Fibroid embolization is available as an outpatient procedure as well. A radiologist threads a small tube into the blood vessels near the fibroid and blocks the blood supply to the fibroids to encourage shrinkage. A myomectomy, removal of the fibroid tissue with reconstruction of the uterus may be performed either through an incision or with a laparoscope, which is minimally invasive. More about fibroid treatment is in the section on fibroids.
If a hysterectomy has been recommended for prolapse or dropping of the uterus, this is a reasonable recommendation but if uterine preservation is preferred, the uterus can be resuspended in the normal position without removal. There is more on this in the section on prolapse.
If hysterectomy has been recommended for ovarian cysts, the current approach now is to remove the cyst laparoscopically and leave normal organs alone. This is also done as an outpatient procedure. There is more on this subject in the section on ovarian cysts.
If hysterectomy has been recommended for cancer of the uterus, ovary, or cervix it is most likely the best choice for a cure. Sometimes even women with cancer can have laparoscopic or robotic surgery. Depending on the age of the patient, and the origin of the cancer, ovarian preservation may be a possibility. In the case of most ovarian and uterine cancers, the uterus, tubes and ovaries are removed. In the case of some early cervical cancers, there may be a possibility of preserving the ovaries and in unusual cases the uterus as well, after a large portion of cervix is removed and analyzed.
If a hysterectomy is required or in some cases even desired for the treatment of any of the above conditions, there are many ways this can be accomplished.
The oldest approach is the abdominal hysterectomy which involves an incision into the abdomen and the removal of the uterus and possibly the ovaries and tubes. This requires 2 – 3 nights in the hospital and several weeks at home to recover. It usually takes about 6 weeks for full recovery and a return to all activities.
Another well-known option is the vaginal hysterectomy. This is desirable whenever possible as it does not require an incision on the abdomen at all. The uterus is removed through the vagina by separating the cervix from the surrounding tissue at the top of the vagina, and entering the abdomen through this opening. The advantage of this approach is the improved recovery time. One may leave the hospital the same day in some cases or the next morning in most cases. There is less pain without external incisions, and the return to normal activity is shortened to about 2 – 3 weeks.
There are times when a vaginal hysterectomy is logistically difficult such as when there is scarring from prior surgery or a condition such as endometriosis which causes scarring. It is also difficult to accomplish through the vagina if there is an ovarian condition that merits evaluation. If a woman wants to preserve her cervix, it is not possible to perform a vaginal hysterectomy. Laparoscopic hysterectomy can offer a minimally invasive option in these circumstances. This might be a laparoscopic total hysterectomy, removing the uterus and cervix or a supracervical hysterectomy, preserving the cervix. The advantage of laparoscopic hysterectomy is that the surgeon can clearly see all parts of the surgery, the cervix may be left in place if desired, and the patient may still have a very short hospital stay of 24 hours. The recovery is otherwise similar to a vaginal hysterectomy but there will be small incisions on the abdomen. There will be a half-inch opening in the umbilicus to place the camera and another two quarter-inch or half-inch opening in the lower abdomen for the surgical instruments. The advantage of laparoscopic surgery is that there is perfect illumination and magnification making the surgery safe. However, laparoscopic hysterectomy has a learning curve. One must feel secure that the surgeon has enough experience to do this safely. It is quite reasonable to ask if this is a surgery the doctor does frequently and to ask what their actual experience is. We have extensive laparoscopic experience performing laparoscopic hysterectomies for over fifteen years.
A recent development in the evolution of the laparoscopic hysterectomy is the advent of an instrument that can remove the uterus in small strips, small enough to remove through the tiny laparoscopic incisions, called a morcellator. This makes the removal of bulky tissues possible through small openings. We can thus remove the uterus, tubes and ovaries if necessary while leaving the cervix in place. The advantages of keeping the cervix are somewhat controversial and personal. If there is no history of HPV (human papilloma virus infection) and if the pap smears have been normal, many women prefer to keep their cervix. Although the scientific evidence of advantages is mixed, there is no cutting into the vagina, no change in vaginal anatomy, and less tissue removal during surgery. The nerves that supply the cervix and bladder are left untouched. Many women find this option beneficial to their sexual identity and function. Some women and their partners are aware of the cervix during intercourse and want as little change as possible after surgery. Supracervical hysterectomy allows for this. Of course annual pap smears will continue to be necessary.
After evaluating all the options a collaborative decision is optimal. Some women benefit greatly from hysterectomy when appropriately indicated. They will experience relief from pain, bleeding, and the discomfort of fibroids if they are present. If the decision is discussed, understood, and is the choice of the individual patient it is very well accepted. If another option such as a uterine preserving choice is better in an individual situation, there is usually a way to accommodate this as well.