Hysterectomy

Hysterectomy

 

By Dr. Teerasak Thamrongthirakul and the medical team at the Fertility and Gynecologic Laparoscopic Surgery Center.

 

About the uterus and ovaries: how do they function?

 

The uterus, an essential reproductive organ in women, is responsible for receiving and nurturing the embryo and fetus during pregnancy. It is located deep within the pelvic cavity and undergoes cyclic changes. If no pregnancy occurs during a menstrual cycle, the uterine lining is shed through the cervix, resulting in menstrual bleeding.

 

The uterine wall serves as a protective barrier for the developing fetus during pregnancy and contracts to facilitate the birth process. The uterus is positioned at the end of the birth canal, with its opening held in place by ligaments attached to the cervix, preventing displacement.

 

The fallopian tubes consist of two segments: the infundibulum and the ovarian end. The infundibulum captures eggs released from the ovaries and provides a pathway for sperm to enter the fallopian tubes from the cervix. The fertilization of eggs takes place in the distal part of the fallopian tubes, where they encounter sperm and develop into embryos. The embryos then travel through the fallopian tubes and implant into the uterine lining for further growth.

 

The ovaries have two main functions. First, they release eggs into the fallopian tubes during ovulation. Second, they produce hormones essential for women, such as estrogen and progesterone. The fallopian tubes are connected to the ovaries and uterus through ligaments and thin sheets of tissue, ensuring their proper alignment and support.

 

What is a hysterectomy?

 

A hysterectomy is a surgical procedure aimed at removing a diseased uterus. Sometimes, it also involves removing the fallopian tubes and ovaries.

 

 

There are four types of hysterectomy:

 

1.             Total hysterectomy: This involves removing the uterus and cervix completely, while at least one ovary is left intact. It is the most commonly performed method.

 

2.             Partial subtotal hysterectomy: This involves removing the upper part of the uterus above the cervix while preserving the cervix. It is done when there is no increased risk of cervical cancer.

 

3.             Total hysterectomy with bilateral salpingo-oophorectomy: This involves removing both the uterus and ovaries.

 

4.             Radical hysterectomy: This comprehensive procedure includes removing the uterus, cervix, ovaries, fallopian tubes, upper portion of the vagina, and nearby lymph nodes. It is often performed in cases of cancer.

 

Normally, if menstruation has not ceased, the ovaries are not removed unless there is an abnormality. This is to avoid disrupting the hormonal balance and prematurely inducing menopause.

 

 

How common is hysterectomy?

 

Hysterectomy is considered the most common surgical procedure in gynecology, second only to cesarean section. In the United States, approximately 600,000 hysterectomies are performed each year.

 

 

How is a hysterectomy performed and what are the methods?

 

Currently, there are three methods for performing a hysterectomy:

 

1.             Abdominal hysterectomy: An incision is made vertically or horizontally in the abdomen, approximately 10-15 centimeters long, to access the uterus, which is then removed.

 

2.             Vaginal hysterectomy: This involves making an incision at the top of the vagina, through which the uterus is removed. The vaginal incision is then stitched closed.

 

3.             Laparoscopic hysterectomy: This method involves making small incisions in the abdomen and inserting a small camera and surgical instruments to remove the uterus. The removed uterus can be extracted through the vagina or fragmented and removed through the abdominal incisions. This technique results in minimal pain, fewer complications, and faster recovery.

 

Diseases that require Hysterectomy for treatment

Fibroids are a condition that often requires more frequent removal of the uterus compared to other diseases. They are usually large fibrous growths that can cause pain or heavy menstrual bleeding. If fibroids are asymptomatic or nearing the end of the menstrual cycle, it may not be necessary to remove the uterus (as the fibroids tend to shrink when the menstrual cycle ends).

 

Endometriosis is a condition where the endometrial tissue grows outside the uterus, such as within the uterus itself or on the surrounding areas. If there are severe symptoms, excessive menstrual bleeding, or when medical treatment or other surgical methods fail to provide relief, removing the uterus may be necessary.

 

Uterine prolapse occurs when the uterus descends into the vaginal canal lower than it should and leads to complications such as pain, abnormal urination or bowel movements, or pressure sores on the cervix.

 

In cases of cancer, whether it is cervical, uterine, or ovarian cancer, if surgery is an option, the uterus is often removed as well.

 

Abnormal vaginal bleeding that is unresponsive to medical treatment (commonly caused by Adenomyosis or Fibroids) may require a hysterectomy.

 

Chronic, debilitating abdominal pain caused by structural abnormalities within the uterus or adhesions of the fallopian tubes may not improve without a hysterectomy.

 

What changes occur after a hysterectomy?

Once the uterus is removed, the most certain outcome is the absence of menstrual periods and the inability to conceive. However, if the ovaries are not removed and they are still functioning, you may experience normal sensations such as breast tenderness around the time when menstruation would have occurred, but there will be no vaginal bleeding.

 

If the ovaries are also removed, the experience is similar to menopause, which includes symptoms such as hot flashes, palpitations, and other changes. The recovery period after surgery varies depending on the type and method of the procedure.

 

For an abdominal hysterectomy, which involves an incision in the abdomen, the hospital stay is usually 2-4 days, and the recovery period ranges from 4-8 weeks.

 

For a vaginal hysterectomy or laparoscopic procedure, the hospital stay is usually 1-3 days, and the recovery period is approximately 2 weeks.

 

For both methods, it is advisable to avoid bathing in a tub or swimming for 6 weeks, as well as engaging in sexual intercourse.

 

If a subtotal hysterectomy is performed, where the cervix is left intact, the hospital stay is typically 1-2 days, and the recovery period is shorter, around 1-2 weeks. Bathing in a tub or swimming, as well as sexual intercourse, can resume after 2 weeks post-surgery.

 

What are the possible complications?

 

Complications that may arise from a hysterectomy include:

 

-               Excessive bleeding necessitating blood transfusion.

-               Injury to the intestines.

-               Injury to the bladder and ureter.

-               Infection and separate abdominal wound complications.

-               Complications resulting from anesthesia, such as lung inflammation or cardiac system issues.

 

However, due to advancements in surgical tools and techniques, these aforementioned complications are now significantly reduced.

 

Will there be a change in sexual sensation after the surgery?

 

For women who undergo a hysterectomy while retaining one or both ovaries, sexual sensation usually remains normal. Additionally, if there were preexisting sexual issues before the surgery, they often improve after the procedure. However, if both ovaries are removed, there may be problems with menopausal symptoms. It is advisable to consult with your physician regarding these matters.

 

Are there alternative options other than undergoing a hysterectomy?

 

If the reason for the hysterectomy is cancer, there are no other alternatives. However, if it is due to uterine fibroids or a displaced endometrial lining, there may be other options to explore before resorting to surgery. These options include:

 

-               Medication, such as prescribing drugs to control heavy or irregular menstrual bleeding or adjusting hormonal levels in the ovaries.

-               Destruction of the endometrial lining, which can be beneficial in cases of irregular or excessive menstrual bleeding.

-               Insertion of small objects through catheters into the blood vessels that supply the uterus to reduce excessive bleeding.

 

Selective removal of specific fibroids, which is often done when the patient desires to have children in the future. However, this method carries the risk of new fibroids developing.

Use of small rubber devices to push against the cervix (in cases of uterine prolapse) to prevent the uterus from descending. This method can be temporary or permanent and is commonly employed in older individuals.

 

For alternative methods other than surgery, it is recommended to consult with your treating physician, who can provide insights into the advantages and disadvantages specific to each patient.

 

What should a patient prepare for when undergoing a hysterectomy?

 

It is advisable to discuss with your physician about other options and the advantages and disadvantages, particularly in your specific case. Inquire about potential complications that may arise in your situation.

 

Each patient is unique in various aspects, so a surgery that may be beneficial for one person does not necessarily have to be the best choice for another. Consider seeking a second opinion from another physician if you are unsure. This is not an indication of mistrust or criticism towards anyone, as opinions and experiences can differ.

 

After a hysterectomy, should a Pap test be performed?

 

It is recommended to consult your doctor about whether you should undergo Pap tests in the future and how often. Generally, the following advice applies:

 

For individuals who have undergone a total hysterectomy (removal of the cervix) or have a cervix remaining, a Pap smear should be performed, similar to those who have not had a hysterectomy (assuming a history of normal Pap tests). The chance of developing cervical cancer within 30 years is 0.1% if previous Pap tests have been normal.

 

For individuals who have had a hysterectomy due to cervical cancer, are at risk of developing cervical cancer, or have abnormal Pap test results, Pap tests should be conducted throughout their lifetime, as even though the risk is low, cancer can still occur at the site of the surgical scar.

 

Regardless of whether it is necessary or recommended to have a Pap test after a hysterectomy, regular internal examinations are still advised as per the physician's recommendations, especially if any remaining ovarian tissue is present.

 

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