Hysterectomy is an operation where the uterus (womb) is removed.
There are different types of hysterectomy, and during the operation other organs – such as the ovaries or fallopian tubes – might also be removed (Figure 1).
A ‘total hysterectomy’ means that the uterus and the cervix (neck of the uterus) are removed – this is the most common type of hysterectomy. A ‘subtotal’ hysterectomy means that the uterus is removed, but the cervix is not – this is a less common operation.
At the time of hysterectomy, one or both of the ovaries might be removed. It is also common for one or both of the fallopian tubes to be removed. It is important that you are clear about the type of hysterectomy that might be performed, and whether the ovaries or fallopian tubes are to be removed as well.
The type of hysterectomy and whether the ovaries or fallopian tubes are removed will depend on your personal circumstances and will be discussed with you by your gynaecologist before your operation.
The conditions that may lead to a hysterectomy can have an immense influence on a woman’s quality of life, affecting your general health, daily routine or sense of well-being. These conditions may include:
* Heavy menstrual bleeding (menorrhagia) that has not responded to other treatments.
* An enlarged uterus that may be pressing on other organs.
* Uterine fibroids
* Uterine prolapse
* Cancer of the cervix, uterus, or ovary.
Make sure that you are clear on the reason for hysterectomy by talking with your gynaecologist.
There are three ways in which a hysterectomy can be performed.
This operation is performed through the abdomen. This will require an incision (cut) to be made in the lower part of your abdomen to allow the gynaecologist to perform the operation. In some cases the incision will be made across the abdomen (like a caesarean section) and in other cases it will be made in an up-and-down direction. This type of incision may be used when the uterus is enlarged, when cancer of the ovary is being treated, or for other reasons.
In some cases it is possible to remove the uterus through the vagina, with no need for any incisions through the abdomen. This operation is called a vaginal hysterectomy. This type of hysterectomy might be done when the uterus has some prolapse and comes down far enough into the vagina for a safe operation.
This hysterectomy is performed under the guidance of a special camera passed through a ‘keyhole’ in the abdomen, and with other instruments passed through separate ‘keyholes.’ The uterus is most commonly removed through the vagina, although sometimes it might be removed in small pieces (‘morcellated’) through the keyholes. In some cases, the entire operation is performed through the keyholes (‘total laparoscopic hysterectomy’). In other cases, part of the operation is done as a vaginal hysterectomy (this procedure is known as a
‘laparoscopically-assisted hysterectomy.’). Further information about laparoscopy can be found on the RANZCOG website under patient information
Hysterectomy is a common and safe procedure, however all operations have potential risks. Every operation is different, and no two patients are alike. All surgical procedures carry a small amount of risk. Some operations will be more difficult. It is important to discuss your own individual risks with your gynaecologist.
Thrombosis and embolism
Thrombosis is a clot that forms in a blood vessel, commonly known as a DVT (Deep Venous Thrombosis). It occurs in the blood vessels of the legs, but may occur elsewhere. In rare circumstances, part of the clot can break off and travel to the heart and lungs. This is called an embolism. The risk of developing thrombosis depends on the type of hysterectomy, the length of the surgery, and whether other underlying risk factors are present. Every effort is made to reduce the risk of thrombosis and embolism. For example, special stockings might be fitted during or after your surgery, and you might have injections of a blood-thinning agent. However, nothing will completely eliminate this risk. The risk of embolism for a healthy woman having a hysterectomy is estimated to be less than 1 in 100.
The most common infection is a urinary infection, usually associated with catheter drainage at the time of the hysterectomy. However, infection of the skin or vaginal wounds can occur. Fortunately, this happens less than 5 in 100 women. Rarely infection can gain access to the deeper tissues in the area where the uterus was removed.
Most surgical procedures cause a small amount of bleeding. In some cases, bleeding can be heavier than expected and in rare cases a transfusion with blood (or blood products) may be necessary. Most commonly the excessive bleeding begins during the operation but sometimes it can begin after the hysterectomy is completed, and a collection of blood in the body wall or deeper tissues may form. Transfusion is needed in less than 1 in 100 of routine hysterectomies.
Injury to surrounding organs
The uterus and ovaries lie close to a number of important structures in the abdomen. The bladder lies to the front. The ureters – connecting the kidneys to the bladder – lie on each side of the uterus. There is bowel close to the pelvic organs. Whenever surgery is performed on the organs of the pelvis, there is a small possibility of damage to other organs. This risk depends on the complexity of the operation, and whether scarring is present from previous operations or infections. In general, the risk of an injury to the adjacent organs in the pelvis is estimated at less than 1 in 100.
Other potential risks
If the hysterectomy is performed as a laparoscopy, or keyhole procedure, carbon dioxide gas is used to fill the abdomen and allow access to the tissues. There is a very small possibility of this gas entering the body wall, or very rarely a blood vessel. Very rarely, the incisions may be weakened, allowing the organs of the abdomen to bulge through - this is called a hernia.
For healthy women who have a hysterectomy that goes well, recovery is often complete within two to six weeks. Your own recovery will depend on a number of things:
* Your health and fitness before the operation
* The reasons for having a hysterectomy
* The type of hysterectomy you have - when an incision is made on the abdomen, recovery often takes a couple of weeks more.
* If the operation is more complex or has any complications, recovery may be slower.
Length of hospital stay
In most cases you will be admitted to hospital on the day of your operation. Most women can go home from hospital within a couple of days of hysterectomy, depending on the type of hysterectomy, and whether other procedures were performed at the same time (for example, a vaginal operation to repair prolapse). For laparoscopic and vaginal hysterectomies, there is usually little or no pain within a week.
Anaesthesia and pain relief
The anaesthetist will provide the most appropriate form of anaesthesia suited to you during the operation. After a hysterectomy you can expect pain and discomfort for a few days but this can usually be managed well with medications. The anaesthetist will provide you with a number of options to help control your pain. Taking regular pain relief is very important to your recovery and will enable you to get out of bed sooner and walk around. This will help speed up your recovery and reduce the risks of thrombosis.
After your operation you may have a catheter (tube) in your bladder to drain urine until you are able to walk to the toilet. This may stay in for up to 24 hours after your operation. If you have difficulty passing urine, the catheter may need to stay in for a few days.
Care of your wound
If you have had an abdominal or laparoscopic hysterectomy, you will have a cut(s) on your abdomen. Your wound will be closed by stitches, staples or glue. Some stitches and glue dissolve by themselves. Staples, and some types of stitches will need to be removed. This usually occurs either prior to discharge from hospital, or by your gynaecologist, general practitioner or district nurse five to seven days after your operation. Your incision will be covered by a dressing which the nurses will often remove before you leave hospital. If this cannot be done before discharge, they will talk to you about how to care for it.
Keep your wound clean and dry. Wear loose clothing and look for signs of infection (such as redness, pain, swelling of the wound or bad smelling discharge). Report these to your doctor or nurse. If you have had a vaginal hysterectomy, any stitches within your vagina will be dissolvable and will not need to be removed. You may notice stitches coming away after a few weeks. This is normal and nothing to worry about.
It is normal to experience some vaginal bleeding for one to two weeks after your operation, like a light period. Some women have no initial bleeding at all but will then experience a gush of old blood or fluid after a week. This will usually stop quickly. You should use sanitary pads rather than tampons to reduce the chance of infection. Any heavy bleeding should be reported to your doctor.
It is important to be as active as possible, but to get adequate rest if tired. It is also important to avoid dehydration, so drinking enough fluid is advisable.
To avoid the complication of hernia (a weakness in the incision), women should not do heavy lifting or straining for four to six weeks.
Depending on the type of hysterectomy, and the type of work a woman does, it might be usual to need between two and six weeks away from work. This can be discussed with your gynaecologist.
Will having a hysterectomy send me into menopause?
Menopause happens when women no longer release eggs from the ovaries. Unless both ovaries are removed as part of the hysterectomy, menopause will not happen at the time of the procedure.
Will I have emotional problems after a hysterectomy?
A hysterectomy is a major operation, so it is normal to have a period of recovery. During this time it is normal to experience tiredness, and sometimes tearfulness and a sense of depression. However, the great majority of women experience better moods and emotions once they have recovered because their medical concerns usually improve. Heavy menstrual bleeding, pain and discomfort, and prolapse are all unpleasant – once the hysterectomy has been performed these symptoms are usually better, and women very commonly feel much better as well.
Will having a hysterectomy have an effect on my enjoyment of sex?
Many women will have increased enjoyment of sex if hysterectomy improves problems such as heavy or painful periods, pain from fibroids, or discomfort from prolapse. Some women will find there is no change after hysterectomy. Very rarely, there may be decreased enjoyment of sex – however, this may not be directly due to the hysterectomy but to the repair operation to the vagina which is often performed at the same time as a vaginal hysterectomy for uterine prolapse.
Do I still need to have cervical screening tests after hysterectomy?
If the cervix is removed and normal then you will not usually need to have any further smears. If you have a sub-total hysterectomy (where the cervix is not removed) then you should continue to have smears as guided by the national screening program. Please check with your surgeon as to the recommendations for your own care.
DISCLAIMER: This document is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This document reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided.