Hysterectomy: when is it necessary?

by Stephanie Slon

An hour after the birth of Jan Cole's second child, the midwife was just about to make her exit, leaving Jan to bond with her new daughter. One final check of her uterus, however, revealed a problem: the postpartum bleeding hadn't stopped. To Jan's shock and dismay, she was immediately rushed into the operating room. Five hours of surgery later, she emerged without her uterus.

Jan is just one of the approximately 570,000 women in the United States who undergo hysterectomies each year. Although this figure is down from a peak of 724,000 in 1985, hysterectomy is still the second most commonly performed major surgery in the U.S. This statistic becomes all the more astounding when you realize that half the population (men) never have this operation at all.

Historically, women had their reproductive organs removed for every conceivable complaint ranging from headaches to liver trouble. Nineteenth century physicians firmly believed that removing the ovaries could modify a woman's personality, making her a "generally more agreeable creature." Even textbooks written as recently as the mid-1970s proclaimed the uterus worthless once childbearing was completed.

Fortunately, the modern medical community has become a little more enlightened in the intervening decades. The extent of the role of the uterus in a woman's body is still not completely understood. However, there is mounting evidence in favor of saving it whenever possible. The American Heart Association cites research indicating that the hormone prostaglandin secreted from the uterus may offer protection from heart disease. In addition, a 1995 study in Obstetrics and Gynecology looked at the loss of bone density in women who had a hysterectomy before menopause compared with those who didn't. The women whose uteruses were removed showed a significant loss of bone even though their ovaries had not been touched.

Problems leading to hysterectomy

The reasons for hysterectomy can seem as individual as each woman's personal story. They do, however, fall into a few broad categories. Hysterectomies that are prompted by severe pelvic pain and abnormal bleeding, a diagnosis of cancer, or performed as an emergency measure to save a woman's life.

Far and away, the most common ailment initiating a hysterectomy is the overgrowth of fibroid tumors in the uterus. If the tumors are small and aren't causing any distress, you and your doctor can comfortably adopt a watchful waiting strategy. Large or rapidly expanding fibroids are often a source of significant pain and anemia due to excessive bleeding. If you want to bear children or feel strongly about not giving up your uterus, you can opt for a surgery called myomectomy. This operation excises the tumors but leaves the uterus intact. The drawbacks are that it is a slightly riskier procedure and offers no guarantee that the fibroids won't come back. In fact, 15 to 20 percent of women see the tumors return within the next five years.

There is another procedure now available called uterine artery embolization, which is sometimes considered as an alternative to hysterectomy. The uterine artery is embolized (obstructed), which results in decreased blood flow to the uterus and shrinkage of the fibroids.

Another diagnosis that sometimes leads to hysterectomy is endometriosis, a condition in which clumps of tissue from the uterine lining grow outside their natural site. The result is severe pain and unmanageable menstrual flow. Thanks to new hormone therapies and laser surgery, hysterectomy is now rarely indicated in women with endometriosis. More often, doctors remove the uterus only to solve abnormal pelvic bleeding of undefined origin that doesn't respond to treatments such as hormone regimens or dilation and curettage.

Thirty-three percent of hysterectomies in postmenopausal women are due to a prolapsed uterus. Years of childbearing and the hormonal changes that accompany menopause can weaken the pelvic floor muscles. Deprived of support, the uterus sinks so that it rests against the bladder and bowels. A hysterectomy can remedy the resulting incontinence, constipation, and pelvic pressure. Alternatively, a device worn in the vagina called a pessary may give the sagging uterus the boost it needs.

Cancer of the cervix, uterus, or ovaries prompts about 17 percent of hysterectomies. Cervical cancer, if caught in its early stages by a routine Pap smear, can be successfully treated by less drastic measures. In the rest of the cases, a hysterectomy often means the difference between life and death.

Occasionally, doctors must perform an emergency hysterectomy to save a patient's life. This rare situation occurs when bleeding cannot be stopped after childbirth or in the case of an infection in the reproductive organs.

Types of hysterectomies

The term hysterectomy refers only to the removal of the uterus. In cases of cancer, serious infection, or endometriosis, the ovaries may be removed at the same time. This procedure is called an oophorectomy.

There are three surgical approaches to hysterectomy. Currently, three out of four hysterectomies are performed abdominally, referred to as a transabdominal hysterectomy, a statistic that has not changed over the last 20 years. Research shows, however, that the risk of post surgical complications from this procedure is 1.7 times that of the vaginal approach, which is called a transvaginal hysterectomy. Since recovery with vaginal hysterectomies is faster than those performed through the abdomen, a third surgical approach, laparoscopy, is sometimes used. With this method, a small scope, called a laparoscope, is inserted into the abdomen through the belly button for viewing purposes and surgery is performed through small incisions in the abdomen. Surgeons are able to perform part of the hysterectomy in this manner, allowing it to be completed through the vagina. At present, there are no clear cut guidelines dictating when a particular method should be used. If you are considering a hysterectomy, you should ask your doctor to describe the pros and cons of each procedure for your individual circumstances.

In most instances, the entire uterus including the cervix is removed. A variation, known as a subtotal or partial hysterectomy, leaves the cervix in place. Some women fear that removing the cervix will interfere with sexual pleasure. There is no definitive scientific evidence to support this belief, however.

What to expect as you recover

What to expect as you recoverPhysical changes following a hysterectomy will be most dramatic if you've not gone through menopause: menstrual periods will cease and childbearing will no longer be possible. If the ovaries are removed at the same time, your body suddenly will be deprived of estrogen as well. In this event, doctors almost always recommend hormone replacement therapy (HRT) to prevent the premature onset of menopause. In addition to staving off hot flashes and vaginal dryness, estrogen is a key factor in lowering a woman's risk of heart disease and helping maintain bone mass.

Women are barraged with a wide variety of emotions in the wake of a hysterectomy. You may experience everything from a sense of well-being to feelings of anger, grief, and loss. Women who were planning future pregnancies are the hardest hit emotionally. Even if their families are complete, many women mourn the loss of their reproductive capacity. On the other end of the spectrum, women battling cancer can feel intense relief following the operation. A few studies done in the 1960s and 1970s indicated that women are more prone to clinical depression after a hysterectomy. However, more recent research refutes that claim.

The question of how a hysterectomy affects your sexuality is a complicated one. A number of women have reported sexual function changes, which include loss of libido, decreased sexual arousal, and difficulty achieving orgasm, but a 1999 study in the Journal of the American Medical Association reported just the opposite, citing increases in overall sexual function after hysterectomy. However, since the patients were only followed for four to six months prior to hysterectomy, the authors could not conclude that sexual function returned to levels equivalent to those prior to the symptoms that lead to the surgery.

More research is needed on this issue, in particular a better-defined relationship between sexual function and the anatomy of a woman. It may be that by sparing the nerves and blood vessels vital to normal sexual function, as is routinely done in men for prostate operations, will help to preserve sexual function. In addition though, your feelings about yourself, your partner's view, your sexual organs, and your hormone levels are all factors in determining your libido and your sexual response. Although it may take some adjustment, the majority of women who enjoyed a satisfying sex life before a hysterectomy are able to resume it after the operation.

No woman wants a hysterectomy she doesn't need. It's important, therefore, to be as informed as possible before going into the operation. Most hysterectomies are not performed on an emergency basis, affording time to consider all the options and to seek a second opinion if necessary. You can minimize your risk of emotional problems following the operation by discussing your feelings and concerns openly with your doctor. Scheduling the surgery with adequate time to get used to the idea (at least several weeks) can also help you feel comfortable with your decision.