The United States has the highest hysterectomy rate in the industrialized world. Statistics from 2004 indicate that about one-third of all U.S. women have had a hysterectomy by the age of 60. Today, about 90 percent of hysterectomies are done by choice and not as an emergency or lifesaving procedure.
Various studies have concluded that anywhere from 10 percent to 90 percent of those operations were not really needed, but many physicians continue to recommend them. For more information on when a hysterectomy can be helpful, see When is a Hysterectomy Needed?
If you do need a hysterectomy, it’s important to work with your physician to determine what kind of hysterectomy you need.
Types of Hysterectomy
Total hysterectomy, sometimes called complete hysterectomy: The surgeon removes the uterus and cervix, leaving the fallopian tubes and ovaries. You may continue to ovulate but will no longer have menstrual periods; instead, the egg will be absorbed by the body into the pelvic cavity.
Total hysterectomy with bilateral salpingo-oophorectomy: The surgeon removes the uterus, cervix, fallopian tubes, and ovaries. One ovary may be left in, if it is not diseased. In rare cases (usually to treat widespread cancer), the surgeon will remove the upper part of the vagina and perhaps the lymph nodes in the pelvic area. The latter is called radical hysterectomy.
Supracervical (or subtotal) hysterectomy: This procedure leaves in the cervix, to limit the effect of surgery on the function and anatomy of the vagina. It’s also less likely to interfere with nerves and arteries as well as ligaments that support the vagina. If the cervix is left in, you still need Pap tests.
Abdominal or Vaginal?
The uterus can be removed either through an abdominal incision or through the vagina. Surgeons sometimes prefer an abdominal approach because it enables them to see the pelvic cavity more completely. The incision is made either horizontally, across the top pubic hairline, where the scar hardly shows afterward, or vertically, between the navel and the pubic hairline. Vertical incisions tend to heal more slowly.
Vaginal hysterectomy has the advantage of a shorter recovery period and faster healing. Because the incision is inside the vagina, you won’t have a visible scar. Laparoscopically assisted vaginal hysterectomy (LAVH) enables the surgeon to see an image of the pelvic cavity without the downside of a large incision. Vaginal hysterectomies are performed increasingly frequently and require greater skill, so it’s important to find a surgeon who does them regularly. Mistakes during surgery can result in permanent urinary tract difficulties. Other disadvantages include a possible shortening of the vagina, which can result in painful intercourse afterward and temporary (but severe) back pain.
Minimally invasive laparoscopic techniques (where the pelvic organs are visualized through a small scope placed through the belly button) are used more frequently now to avoid the long recovery and large scar associated with the abdominal approach. Because only small incisions are required, the recovery is dramatically better. Just be sure to find a surgeon experienced in these relatively new techniques.
Risks and Complications
Although the death rate from hysterectomy is low (under one percent), surgical complications include the following:
- Infection. Most infections can be treated successfully with antibiotics, but some can be severe or even uncontrollable.
- Hemorrhage at the time of surgery or afterward (a transfusion or second operation may be necessary).
- Damage to your internal organs, most frequently the urinary tract and sometimes the bowel. Sometimes there is damage to the ureter (the tube connecting the kidney to the bladder) or the bladder.
Less common surgical complications include blood clots, complications from the anesthesia, and intestinal obstruction from post-surgical scarring.
For those of us who are in our early forties or younger, removal of the uterus and ovaries may increase the risk of heart attack. Even if our ovaries are not removed, there is an increased chance of an earlier menopause. This is usually due to the decreased supply of blood to the ovaries, so that they lose their ability to produce hormones, either immediately or over time. Many physicians assure us that we can avoid these risks by taking estrogen, but estrogen therapy does not substitute for functioning ovaries.
In the past, many surgeons routinely removed women’s healthy ovaries when performing a hysterectomy, in order to prevent ovarian cancer from developing in the future. However, new research indicates that removal of healthy ovaries has adverse long-term health consequences for women and ovarian conservation should be encouraged. For more information, see Hysterectomy and Ovarian Conservation.
Hormonal effects of hysterectomy with oophorectomy vary from one woman to the next. Some women suffer severe hot flashes and lack of lubrication. Some women use hormone therapy for a while, then gradually taper off. Long-term symptoms sometimes associated with hysterectomy and/or oophorectomy include constipation, urinary incontinence, bone and joint pain, pelvic pain, and depression.
Self-Help: Recovering from Hysterectomy/Oophorectomy
After a hysterectomy, you may be in the hospital for as few as one or as long as several days, depending on the kind of procedure, the amount of anesthesia, and your general health. For the first day, you will probably have an IV and a catheter inserted in your bladder. You will usually be given medication for pain and nausea.
Within a day, you can expect to be on your feet and encouraged to do exercises to get your circulation and breathing back to normal. You may also be told to cough frequently to clear your lungs. (Holding a pillow over an abdominal incision, or crossing your legs if you had a vaginal incision, will help reduce pain from coughing.)
You may also have gas pains to contend with. A self-help technique to dispel abdominal gas uses heat applied to an acupressure point beneath the navel. Walking, holding on to a pillow and rolling from side to side in bed, and slow deep-breathing exercises may also help.
You can begin to have light solid foods, as well as fluids, when you feel able to keep them down. Hospital stays are growing shorter and shorter. This can be scary, but once your IV is out and you can keep down oral pain medications, being at home with good help may provide many comforts and avoids the risk of catching an infection in the hospital. Plan ahead to make sure you have the support you need (family, friends, or community support services).
Recovery at Home
After you go home, you may have light vaginal bleeding or oozing that gradually tapers off. You may also have hot flashes caused by estrogen loss, even if your ovaries were not removed. You will probably continue to have some pain, despite taking pain medication. Consult your medical practitioner if you have fever, nausea and vomiting, or foul vaginal discharge, as this may signal an infection.
Try to arrange for someone to take care of you for the first few days. You can expect to feel tired, so ask family and friends for help with household chores and children for at least the first few weeks. Your healthcare provider may tell you to avoid tub baths, douches, driving, climbing, or lifting heavy things for several weeks. If you have to drive or need to carry small children, ask for suggestions about how and when you can do these tasks safely.
Full recovery generally takes four to six weeks, but some women feel tired for as long as six months or even a year after surgery. Most medical practitioners also recommend waiting six to eight weeks before resuming sex and/or active sports, but some women return to them earlier. Start with light exercise, such as walking, and gradually build up to your old routines.
Some women feel only relief following hysterectomy, especially when the operation eliminates a serious health problem or chronic, disabling pain. Even if you were prepared for it and did not expect to feel depressed, you might cry frequently and unexpectedly during the first few days or weeks after surgery. This may be due to sudden hormonal changes. Many of us are also upset by losing any part of ourselves, especially a part that is so uniquely female, and worry about how our sexuality will be affected. For more information, see Hysterectomy, Oophorectomy, and Sexuality.
Some gynecologists recommend psychiatric help and prescribe antidepressants or tranquilizers (or other habit-forming drugs) while ignoring treatment of underlying physical or sexual conditions caused by the surgery. Often, talk therapy alone—or conversations with friends and family—enables us to cope with any post-hysterectomy depression. Some women have started their own post-surgery support groups by networking in their community. Visit HERS Foundation for more resources.