Hysterectomy

Topic Overview

What is a hysterectomy?

A hysterectomy is surgery to take out a woman's uterus, the organ in a woman's belly where a baby grows during pregnancy. After a hysterectomy, you will not be able to get pregnant.

Other organs might also be removed if you have severe problems such as endometriosis or cancer. These organs include the cervix (the lower part of the uterus that opens into the vagina), the ovaries (glands on both sides of the uterus that release eggs for pregnancy), and the fallopian tubes (the passageway between the uterus and the ovaries).

Whether or not the ovaries are removed will depend on your age and risk for certain types of cancer. For example, removing the ovaries lowers the risk of ovarian cancer and some types of breast cancer. But if you have your ovaries removed before the age of menopause, you will go into early menopause, and you may be more likely to get heart disease or osteoporosis. Be sure to discuss with your doctor all the benefits and risks of removing your ovaries.

See a picture of the female reproductive system.

What problems does this surgery treat?

Most often, hysterectomy is done to treat problems with the uterus, such as pain and heavy bleeding caused by endometriosis or fibroid tumors. The surgery may also be needed if there is cancer in the uterus, cervix, or ovaries. Some women may have the surgery during childbirth to save their lives if there is heavy bleeding that cannot be stopped.

Before you choose to have a hysterectomy, consider all of your treatment options. In many cases, this surgery is a last resort after trying other treatments for the problem.

For more information, see:

• Abnormal Uterine Bleeding.
• Endometriosis.
• Uterine Fibroids.

How is the surgery done?

There are many different ways to do hysterectomy surgery. The type of surgery you have depends on three main things: the reason for the surgery, the size of the uterus and its position in the belly, and your overall health. The most common types are:

• Abdominal hysterectomy. In this type, the doctor makes a cut in the belly, either across the bikini line or straight up and down. The doctor takes out the uterus and the cervix. This type is most often done when cancer might be present or when severe endometriosis, a lot of scar tissue (adhesions), or a very large uterus makes the uterus hard to remove.
• Vaginal hysterectomy. With this type, the doctor takes out the uterus through the vagina. He or she makes a small cut in the vagina instead of the belly. Your doctor will not use this method when there is a chance that cancer may be in the uterus, cervix, or ovaries. Doctors use this type of surgery only in cases where the uterus is small and easy to remove.
• Laparoscopic hysterectomy. In this type of surgery, the doctor puts a lighted tube (laparoscope) through small cuts in your belly. The doctor can see your organs with the scope and insert surgical tools to cut the tissue that holds your uterus in place.

How long will it take to recover from surgery?

Feeling better after surgery takes time. You might go home the day of surgery or stay in the hospital 1 to 2 days after. Some women stay up to 4 days.

When you get home, make sure you move around, but also be sure you don't do too much. You can walk around the house and up and down stairs, but take it slow. During the first 2 weeks, it's important to get plenty of rest. Even after you start to feel stronger, you should not lift heavy things (anything over 20 pounds). Also, you should not have sex until your doctor says it's okay. It usually takes 4 to 6 weeks to get back to a normal routine.

Why It Is Done

In most cases, hysterectomy is an elective surgery used to treat noncancerous female reproductive system (gynecologic) conditions that haven't improved with medical treatment. For women who have no plans for pregnancy and have considered and tried other treatment options without success, a hysterectomy may be a reasonable treatment choice.

Hysterectomy is also a potentially lifesaving measure when used to stop severe bleeding after childbirth or to remove cervical cancer or endometrial (uterine) cancer.

Reasons for hysterectomy include:

• Severe bleeding after childbirth.
• Heavy menstrual bleeding.
• Uterine fibroids.
• Pelvic organ prolapse.
• Endometriosis and adenomyosis.
• Chronic pelvic pain (only when caused by a diagnosed condition that can be corrected with hysterectomy).
• Cancer of the cervix, uterus, or ovaries.

Hysterectomy Types

Hysterectomy is the surgical removal of a woman's uterus. In some cases, the ovaries and fallopian tubes are also removed during a hysterectomy procedure. This is called a salpingo-oophorectomy.

There are three major types of hysterectomy:

• Total hysterectomy is the surgical removal of the uterus and the cervix, which is the lower "neck" of the uterus that opens into the vagina.
• Subtotal hysterectomy is the removal of the uterus, leaving the cervix in place. It is also known as "supracervical" or "partial" hysterectomy.
• Radical hysterectomy is the removal of the uterus, cervix, ovaries, structures that support the uterus, and sometimes the lymph nodes. A radical hysterectomy may be done to treat endometriosis or cancer of the uterus, ovaries, or cervix.

Deciding whether to have a total or subtotal hysterectomy can be difficult. This is because research that compares the two is limited and shows only small differences. In the past, experts believed that a subtotal hysterectomy reduced problems after surgery and prevented problems with urinary incontinence and/or sexual dysfunction. But research has shown that for certain conditions, a subtotal hysterectomy does not prevent these problems better than a total hysterectomy does.^{footnote 1}

When considering a hysterectomy, ask your doctor what other treatments can be used for your condition, what hysterectomy options are available to you, and how well hysterectomy is likely to work for you. If you have a hysterectomy, the type of procedure you have will depend on the medical reason for the hysterectomy, the size and position of your uterus, and your general state of health.

Hysterectomy procedures (how the uterus is removed) include:

• Abdominal hysterectomy.
• Vaginal hysterectomy.
• Laparoscopically assisted vaginal hysterectomy (LAVH).
• Laparoscopic supracervical hysterectomy (LSH).
• Total laparoscopic hysterectomy (TLH).

Comparison of Hysterectomy Procedures

There are several different hysterectomy procedures, each with advantages and disadvantages. Depending on your reason for considering a hysterectomy, you may have a choice between two or more procedures. For complicated or cancer-related conditions that require maximum access and careful examination, your doctor will likely recommend an abdominal hysterectomy.

Vaginal hysterectomy

This type of hysterectomy is done through an incision (cut) in the vagina, rather than through an abdominal incision. The ovaries and other organs may also be removed. Vaginal hysterectomy tends to cause less pain, and takes less healing time than abdominal hysterectomy. A vaginal hysterectomy can be done:

• To remove small uterine fibroids.
• When the uterus is of normal size or slightly enlarged.
• When endometriosis growths (implants) are not present.
• When there is no significant scarring in the pelvis from previous surgeries.

Vaginal hysterectomy requires more specialized surgical skill than an abdominal hysterectomy. It can pose a higher risk of injury to other organs. Vaginal hysterectomy is not used when there is a question about possible cancer in the uterus, cervix, or ovaries.

Abdominal hysterectomy

This type of hysterectomy is done through a larger abdominal incision, giving the surgeon the best possible access to the pelvic organs. The cervix may be removed with the uterus (total hysterectomy) or left in place (subtotal hysterectomy). The ovaries and other organs may also be removed. An abdominal hysterectomy is typically done when:

• The uterus is very large.
• Uterine fibroids are larger than8 in. (20 cm) across or located around blood vessels.
• Cancer of the uterus, ovaries, or cervix is possible.
• An ovarian growth (mass) is suspected but can't be diagnosed on ultrasound.
• There is significant scarring or severe endometriosis in the pelvic area.

If a hysterectomy is chosen to treat endometriosis, an abdominal hysterectomy is usually required. One example is when endometriosis growths (implants) or scar tissue (adhesions) must be removed to restore the function of other organs.

Laparoscopically assisted vaginal hysterectomy (LAVH)

Laparoscopic hysterectomy is done with a lighted tube and scope (laparoscope) and surgical instruments inserted through a vaginal incision and one or more small abdominal incisions. The ovaries and other organs may also be removed. The uterus is removed through the vagina. It is done:

• When uterine fibroids are small to moderate in size.
• When the uterus is slightly larger than normal.
• To remove endometriosis and scar tissue (adhesions) confined to the uterus, fallopian tubes, and ovaries.
• To assess or remove ovaries at the same time as a vaginal hysterectomy.

LAVH requires the surgeon to have specialized training.

Laparoscopic supracervical hysterectomy (LSH)

Laparoscopic supracervical hysterectomy is done by inserting a laparoscope and surgical instruments through several small abdominal incisions. The uterus is removed in small pieces through one of the incisions and the cervix is left intact. This is also known as subtotal or partial hysterectomy. This type of procedure usually causes minimal blood loss and pain. The hospital stay is shorter than for total abdominal surgery. Most women can return to normal activity a week or two afterward. LSH can be done:

• To remove uterine fibroids of any size.
• To remove a uterus of any size.

LSH usually takes longer to do than abdominal or vaginal hysterectomy. LSH is not available in some areas.

Total laparoscopic hysterectomy (TLH)

The total laparoscopic hysterectomy is done by inserting a laparoscope and surgical instruments through several small incisions in the abdomen. The uterus and the cervix are removed in small pieces through one of the incisions. TLH can be done:

• To remove uterine fibroids that are small to moderate in size.
• When there is not a lot of scar tissue in the pelvic area.
• When there is not a worry about cancer in the ovaries.

TLH requires the surgeon to have special training. It usually takes longer to do than abdominal or vaginal hysterectomy. But recovery and hospital stay are shorter than for total abdominal hysterectomy. TLH is not available in many parts of the country.

There are a number of ways that laparoscopic hysterectomies are done. Sometimes a tool called a morcellator is used to remove the uterus in small pieces. This procedure is not done if there is a risk of uterine cancer because the tool could cause the cancer to spread to other parts of your body. Talk to your doctor about your risks with a laparoscopic procedure.

Some laparoscopic surgery is done using only one incision. This is called laparoendoscopic single-site surgery (LESS) or single-port surgery.

Some doctors offer robot-assisted surgery for hysterectomy. For this method, the surgeon controls robotic arms that hold the surgery scope and tools. Robotic surgery for hysterectomy may be an option for women who have certain conditions. But it usually costs more money, and studies have not shown that it is better than other hysterectomy procedures.^{footnote 1}

Risks of Hysterectomy

Hysterectomy poses some risks of major and minor complications. But most women do not have complications after a hysterectomy. Studies show that vaginal hysterectomies have fewer problems and a shorter recovery time than abdominal or laparoscopic hysterectomies.^{footnote 1}

Your risk of problems after surgery may be higher or lower than average. This may depend in part on how experienced the surgeon is.

Complications

Complications after a hysterectomy include:

• Heavy blood loss.
• Bladder or bowel injury.
• Blood clot to the lung.
• Infection.

Infection risk is lowest when your doctor gives you antibiotic medicine at the time of surgery.^{footnote 2}

Other ongoing complications of hysterectomy include:

• Difficulty urinating. This is more common after removal of lymph nodes, ovaries, and structures that support the uterus (radical hysterectomy).
• Weakness of the pelvic muscles and ligaments that support the vagina, bladder, and rectum. Kegel exercises may help strengthen the pelvic muscles and ligaments. But some women need other treatments, including additional surgery.
• Continued heavy bleeding. Some vaginal bleeding within 4 to 6 weeks following a hysterectomy is expected. But call your doctor if bleeding continues to be heavy.
• Some women may experience early menopause.
• The formation of scar tissue (adhesions) in the pelvic area.

Preparing for a Hysterectomy

Before a hysterectomy, you may have:

• A physical exam, during which your doctor will ask you questions about your medical history.
• A pelvic examination.
• Blood tests.
• An electrocardiogram (ECG or EKG), which measures the electrical signals that control the rhythm of your heartbeat, if you are over the age of 40 or have diabetes or high blood pressure.
• A meeting with the doctor who will do the hysterectomy. During this meeting, the doctor will explain how the surgery will be done, where the surgical incisions will be made, and the risks and expected outcomes of the surgery. You will probably receive written instructions about how to prepare for surgery at this time.
• A meeting with an anesthesiologist or nurse anesthetist. During this meeting, you will discuss the types of anesthetic recommended for use during the surgery. You may not meet with this person until the day of your surgery.

Your doctor may order additional tests based on your physical exam and medical history. These tests may include:

• A pregnancy test if you have not reached menopause.
• Urine tests, such as urinalysis, to check for any signs of urinary tract infection.
• A chest X-ray, for a general evaluation before using general anesthesia.
• Blood typing, in case you should need a blood transfusion (which is rare).
• Blood clotting studies, if you tend to have excessive bleeding or a history of deep vein thrombosis.

See a list of questions to ask your doctor when you are considering hysterectomy.

When to Call a Doctor

After a hysterectomy, call your doctor or go to the emergency room if:

• You have bright red vaginal bleeding that soaks one or more pads in an hour, or you have large clots.
• You have foul-smelling discharge from your vagina.
• You are sick to your stomach or cannot keep fluids down.
• You have signs of infection, such as:
  • Increased pain, swelling, warmth, or redness.
  • Red streaks leading from the incision.
  • Pus draining from the incision.
  • Swollen lymph nodes in your neck, armpits, or groin.
  • A fever.
• You have pain that does not get better after you take pain medicine.
• You have loose stitches, or your incision comes open.
• You have signs of a blood clot, such as:
  • Pain in your calf, back of knee, thigh, or groin.
  • Redness and swelling in your leg or groin.
• You have trouble passing urine or stool, especially if you have pain or swelling in your lower belly.
• You have hot flashes, sweating, flushing, or a fast or pounding heartbeat.

Your doctor will give you specific instructions after your hysterectomy. Be sure to follow them. Usually, getting some rest and following those instructions will help postoperative problems diminish over time.

Recovery

Recovering from a hysterectomy takes time. You may go home the same day or you may stay in the hospital for 1 to 2 days for postsurgery care. Some women stay in the hospital up to 4 days.

Abdominal hysterectomy. As soon as you feel strong enough, get up and around as much as you can. This helps prevent problems after surgery like blood clots, pneumonia, and gas pains. During the first 2 to 3 weeks, it is important to also get plenty of rest. Hold a pillow over your incision when you cough or take deep breaths. This will support your belly and decrease your pain.

You will gradually be able to increase your activities. To help you heal well, avoid lifting more than 20 pounds during the first 4 to 6 weeks after surgery. For the same reason, this is also an important time to avoid vaginal intercourse.

As soon as you can move easily without pain or without using narcotic pain medicine, you can drive. Complete recovery usually takes 4 to 6 weeks. Your return to a work routine will depend not only on how quickly you get back your energy and strength but also on how demanding your work is.

Vaginal or laparoscopic hysterectomy. As soon as you feel strong enough, get up and around as much as you can. This helps prevent problems after surgery like blood clots, pneumonia, and gas pains. When you can move easily without pain, you can drive. To help you heal well, avoid lifting more than 20 pounds during the first 4 to 6 weeks after surgery. For the same reason, this is also an important time to avoid vaginal intercourse.

Recovery from a vaginal or laparoscopic hysterectomy takes much less time than from an abdominal surgery. After a routine laparoscopic surgery removing the uterus but not the cervix (laparoscopic supracervical hysterectomy, or LSH), most women are able to return to normal activity in 1 to 2 weeks. About 4 to 6 weeks after the hysterectomy, see your doctor for a follow-up examination.

What are possible long-term problems after hysterectomy?

Pelvic weakness. After a hysterectomy, some women develop other physical problems that are related to weakness of the pelvic muscles and ligaments that support the vagina, bladder, and rectum. Kegel exercises may help strengthen the pelvic muscles and ligaments. But some women need other treatments, including additional surgery.

Vaginal dryness from low estrogen levels may develop if your ovaries were removed (oophorectomy). This can also develop gradually after a hysterectomy. If sexual intercourse is painful because of vaginal dryness:

• Use a vaginal lubricant, such as K-Y Jelly or Astroglide, or a polyunsaturated vegetable oil that does not contain preservatives. If you are using condoms, use a water-based lubricant, rather than an oil-based lubricant. Oil can weaken the condom so that it breaks. Avoid petroleum jelly (for example, Vaseline) as a lubricant, because it increases the risk of vaginal irritation and infection.
• Use a low-dose vaginal estrogen cream, ring, or tablet, which will reverse vaginal dryness and irritation by affecting only the vaginal area. If you are having other menopausal symptoms, talk to your doctor about systemic estrogen therapy (ET) and other treatment options. For more treatment information, see the topic Menopause and Perimenopause.

• Hysterectomy and Oophorectomy: Should I Use Estrogen Therapy (ET)?

Pain during intercourse may occur if your vagina was shortened during your hysterectomy. Changing positions may help make intercourse less painful. Talk with your doctor if you have any difficulty during intercourse after a hysterectomy.

How will I feel emotionally after my hysterectomy?

It is normal to have various concerns when faced with the possibility of having a hysterectomy. A woman's emotions are often based on her beliefs about the importance of her uterus, her fears about her health or personal relationships after a hysterectomy, and concerns about her enjoyment of sexual activities after surgery. If you are considering a hysterectomy, talk with your doctor about your specific fears and anxieties concerning the surgery.

What to Think About

Your doctor may suggest other treatments before recommending a hysterectomy. If you are considering a hysterectomy and would like more information about other treatments or surgeries, talk with your doctor. Ask about the risks and benefits of each option. Consider both the immediate and long-term risks and benefits of all treatments.

Hysterectomy is a necessary and effective treatment for cancer of the pelvic organs, a severe infection of the uterus, or uncontrollable bleeding.

Following hysterectomy, you will not be able to become pregnant. If you have plans for a future pregnancy, hysterectomy is not an appropriate treatment option for conditions such as uterine fibroids, endometriosis, or pelvic organ prolapse. Talk with your doctor about other treatments.

Hysterectomy is not used to prevent pregnancy. There are many methods of birth control that are safe and effective. If you are not sure which method is best for you, talk with your doctor about your options.

Estrogen therapy (ET)

Women who have early, sudden menopause after hysterectomy are usually advised to use estrogen therapy (ET) to protect against bone loss. The low estrogen levels of menopause cause bone thinning. Compared with women who are not taking hormone therapy, women taking ET have fewer hip fractures (a sign of estrogen's bone-protecting effect).^{footnote 3}

For more information, see:

• Hysterectomy and Oophorectomy: Should I Use Estrogen Therapy (ET)?