Considering a Hysterectomy

A hysterectomy is an operation to remove the uterus (womb). It is one of the most frequently performed operations by gynaecologists and is most commonly performed for heavy periods, period pain and prolapse.

Whilst hysterectomy is a common gynaecological procedure – with 1 in 3 women in 2006 having had a hysterectomy – the need for hysterectomy in Australian women has almost halved since the 1980s. This is largely due to the development and use of medications and day procedures such as the Mirena intra-uterine device and endometrial ablation.

For most women the decision to proceed with a hysterectomy is not easy. It can be quite an emotional journey and supporting our patients through this decision-making process is a priority for myself and my colleagues at Eve Health.

For many women, periods are a marker of womanhood and for most it allows us the option to have children so taking this away can be quite confronting. In my practice some are worried that their hormones will change, and that sex will be different. They worry that they will be less of a woman and that the recovery will be long. However, depending on the reason for considering this procedure, it may in fact allow you to claim back your life and sexuality!

These questions and worries are all very common and they are asked of us every day. This blog is important for women considering a hysterectomy so please read on.

Not all hysterectomies are the same, and the way in which it is performed depends on the reason for having a hysterectomy as well as patient and surgeon preference.

I’ve heard there are a few different ways hysterectomies can be done. What would I require?

1. Laparoscopic hysterectomy – 4 small incisions, 1cm or less, are made on the abdomen to allow the passage of surgical instruments. The uterus is “disconnected” then essentially “delivered” through the vagina before the top of the vagina is sutured. The large majority of hysterectomies can now be performed this way, meaning that pain, time in hospital and the time to return back to usual activities is much better than previously.
2. Abdominal hysterectomy – a 10 – 15cm incision is made on the bikini line (like a Caesarean Section), or occasionally for those with a very enlarged uterus, vertically from the pubic bone toward the belly-button.
3. Vaginal hysterectomy – there are no surgical incisions on the abdomen and the uterus is removed entirely through the vagina. Usually performed for women who have some degree of pelvic organ prolapse and require a vaginal repair procedure at the same time.

What exactly is removed during a hysterectomy?

1. The uterus, including the cervix – there is no benefit to leaving the cervix behind. Old studies suggested that it may be useful to leave it in place for sexual satisfaction or reduction of future prolapse however this is now known to be false. Also, removing the cervix for most women means that you can say goodbye to having pap smears!
2. Usually also the fallopian tubes – the only purpose of the fallopian tubes (although it is an exceptionally important purpose!) is to help an egg meet sperm to make a baby. Some ovarian cancers are thought to arise from the ends of the fallopian tubes and many studies have shown that removal of these at the time of hysterectomy can halve a woman’s chance of future ovarian cancer, even if she still has her ovaries.
3. Sometimes, the ovaries – in a woman under the age of 69, with no increased risk of ovarian cancer, it is usually advised to leave the ovaries in place. Removal of the ovaries in a woman prior to menopause may bring on sudden menopausal symptoms such as hot flashes and insomnia due to the abrupt withdrawal of the hormones that the ovaries produce. Even after the menopause and almost into the 70s, the ovaries provide a small amount of woman hormones that are important for bone, heart and brain health, and also sex drive. Women who have cancer, are at high risk of cancer, have severe endometriosis or are in their 70s are usually advised to have removal of their ovaries at the same time as their hysterectomy.

What can I expect before I go to hospital?

You will have a discussion with your gynaecologist regarding the surgery. Useful questions to ask your surgeon include – are there any alternatives to hysterectomy? Will I retain my ovaries? Which surgical approach will be required? Your surgeon will discuss possible risks and benefits of surgery and ask you to sign a consent form and in some cases ask you to have some preoperative blood tests. Prior to the surgery, you will be contacted by your anaesthetist who will ask you questions regarding your general health, any medications you are taking and any allergies you have. You will be asked to refrain from eating for at least 6 hours prior to the procedure, however usually encouraged to continue drinking clear fluids until closer to the procedure.

What can I expect in hospital?

You will be met by your surgeon and anaesthetist. You will require a general anaesthetic, and depending on the complexity of the procedure, it may last anywhere between 1.5 – 2.5 hours. Most women will return to the ward once they are awake and will be encouraged to sip fluids or have a small meal the same day. A urinary catheter that empties the bladder during the procedure will usually be removed within the first 6 – 24 hours depending on how well you are able to move around.

Possible complications that can occur include bleeding requiring a blood transfusion, infection (in the wounds, at the top of the vagina or in the bladder), and in up to 1 in 100 women – damage to the bowel, bladder or the urinary tract.

In hospital, most women are given a combination of paracetamol and anti-inflammatories as well as occasional use of stronger pain medications like Tramadol or Endone. It is often recommended to start on some bowel softeners whilst in hospital – like Movicol or Coloxyl – to avoid constipation which can contribute to discomfort after a procedure.

How long you stay in hospital is largely dependent on how the hysterectomy is performed. A laparoscopic hysterectomy may only require an overnight hospital stay, whereas a vaginal or abdominal hysterectomy may require a 3 – 4 day stay.

What can I expect after I go home from hospital?

It is advised to continue regular paracetamol and/or anti-inflammatories and bowel softeners initially when you return home. These are gradually reduced as you no longer require them.

Physical Activity: You will need to rest at home for the first week. After this you can commence gentle activity. To minimise the chances of a later hernia through the incision sites, heavy lifting, straining and strenuous exercise (running, weights), is advised to be avoided for the first 4 – 6 weeks. Swimming is not advised for the first 6 weeks until wound healing is complete.

Driving: can be resumed once you are no longer taking any strong pain relief (like Endone or Targin) and you feel physically able to use the foot pedals in your car without being in pain. This may take 2 weeks after a laparoscopic or vaginal procedure, however may take up to 4 weeks after an abdominal procedure. It is pertinent to also check with your car insurance company that they will cover you during this time if you were to be involved in an accident.

Work: Laparoscopic surgery allows most women to return to work after 2 – 4 weeks. It is advisable to have 4 – 6 weeks off of work after an abdominal or vaginal procedure. If it is possible to work from home, this may be possible from 2 weeks post-surgery, allowing for periods of rest when required.

Sex: Again, this depends on the type of procedure and surgeon preference. Most women are advised to avoid vaginal intercourse for 8 – 10 weeks until the scar at the top of vagina has reached full strength and there are no longer any sutures present. Your surgeon will discuss this with you at your post-operative check-up.

Whilst a hysterectomy is not a light undertaking, once you have recovered and are relieved from the troublesome symptoms that led you to surgery, you are likely to be emotionally and physically in a better place.

I would recommend finding a qualified surgeon that you feel comfortable discussing the anticipated benefits of hysterectomy with, and one that is happy to answer any questions you have prior to proceeding with surgery. Here at Eve Health our gynaecologists are highly qualified in performing these procedures. When needed, we work alongside our wonderful physiotherapists, nurse, dietician and psychologist to make this decision and the journey through this with you as smooth as possible so you can get back to better health quicker.