Hysterectomy

Encyclopedia of Medicine, Apr 06, 2001 by Tish Davidson

Hysterectomy is the surgical removal of the uterus. In a total hysterectomy, the uterus and cervix are removed. In some cases, the fallopian tubes and ovaries are removed along with the uterus (called hysterectomy with bilateral salpingo-oophorectomy). In a subtotal hysterectomy, only the uterus is removed. In a radical hysterectomy, the uterus, cervix, ovaries, oviducts, lymph nodes, and lymph channels are removed. The type of hysterectomy performed depends on the reason for the procedure. In all cases, menstruation stops and a woman loses the ability to bear children.

Hysterectomy is the second most common operation performed in the United States. About 600,000 of these surgeries are done annually. By age 60, approximately one out of every three American women will have had a hysterectomy.

About 10% of hysterectomies are performed to treat cancer of the cervix, ovaries, or uterus. Women with cancer in one or more of these organs almost always have the organ(s) removed as one part of their cancer treatment.

The most frequent reason for hysterectomy in the United States is to remove fibroid tumors, accounting for 30% of these surgeries. Fibroid tumors are non-cancerous (benign) growths in the uterus, which can cause pelvic and low back pain and heavy or lengthy menstrual periods. They occur in 30-40% of women over age 40, and are three times more likely to be present in African-American women than in Caucasian women. Fibroids do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.

Treatment of endometriosis is the reason for 20% of hysterectomies. The endometrium is the lining of the uterus. Endometriosis is a condition that occurs when the cells from the endometrium begin growing outside the uterus. The outlying endometrial cells respond to the hormones that control the menstrual cycle, bleeding each month the way the lining of the uterus does. This causes irritation of the surrounding tissue, leading to pain and scarring.

Another 20% percent of hysterectomies are done because of heavy or abnormal vaginal bleeding that can not be linked to any specific cause and cannot be controlled by other means. The remaining 20% of hysterectomies are performed to treat prolapsed uterus, pelvic inflammatory disease, and endometrial hyperplasia, a potentially precancerous condition.

A total hysterectomy, sometimes called a simple hysterectomy, removes the entire uterus and the cervix. The ovaries are not removed and continue to secrete hormones. Total hysterectomies are always performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy.

Sometimes, in addition to a total hysterectomy a procedure called a bilateral salpingo-oophorectomy is performed. This surgery removes the ovaries and the fallopian tubes. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately. Removal of the ovaries and fallopian tubes is performed in about one-third of hysterectomy operations, often to reduce the risk of ovarian cancer.

If the reason for the hysterectomy is to remove uterine fibroids, treat abnormal bleeding, or relieve pelvic pain, it may be possible to remove only the uterus and leave the cervix. This procedure, called a subtotal hysterectomy (or partial hysterectomy), removes the least amount of tissue. The opening to the cervix is left in place. Some women feel that leaving the cervix intact aids in their achieving sexual satisfaction.

Subtotal hysterectomy is easier to perform than a total hysterectomy, but leaves a woman at risk for cervical cancer. She will still need to get yearly pap smears.

Radical hysterectomies are performed on women with cervical cancer or endometrial cancer that has spread to the cervix. A radical hysterectomy removes the uterus, cervix, top part of the vagina, ovaries, fallopian tubes, lymph nodes, lymph channels, and tissue in the pelvic cavity that surrounds the cervix. This type of hysterectomy removes the most tissue and requires the longest hospital stay and longer recovery period.

The frequency with which hysterectomies are performed in the United States has been questioned in recent years. It has been suggested that a large number of hysterectomies are performed unnecessarily. The United States has the highest rate of hysterectomies (number of hysterectomies per thousand women) of any country in the world. Also, the frequency of this surgery varies across different regions of the United States. Rates are highest in the South and Midwest.

Women for whom a hysterectomy is recommended should discuss possible alternatives with their doctor and consider getting a second opinion, since this is major surgery with life-changing implications. Alternative treatments exist for many conditions. Whether these alternatives are appropriate for any individual woman is a decision she and her doctor should make together.

As in all major surgery, the health of the patient affects the risk of the operation. Women who have chronic heart or lung diseases, diabetes, or iron-deficiency anemia may not be good candidates for this operation. Heavy smoking, obesity, use of steroid drugs, and use of illicit drugs add to the surgical risk.