Hysterectomy

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A hysterectomy is a surgical procedure to remove the womb (uterus). You'll no longer be able to get pregnant after the operation. 

 

If you haven't already gone through the menopause, you'll no longer have periods, regardless of your age. The menopause is when a woman's monthly periods stop, which usually occurs from the ages of to 45 to 55.

 

Around 30,500 hysterectomies were carried out in England in 2012 and 2013. It's more common for women aged 40-50 to have a hysterectomy.

 

 

Types of hysterectomy

 

There are various types of hysterectomy. The type you have depends on why you need the operation and how much of your womb and surrounding reproductive system can safely be left in place.

The main types of hysterectomy are:

 

• total hysterectomy – the womb and cervix (neck of the womb) are removed; this is the most commonly performed operation and the preferred option over a subtotal hysterectomy, because removing the cervix means there's no risk of you developing cervical cancer at a later date.

 

• subtotal hysterectomy – the main body of the womb is removed, leaving the cervix in place

 

 

There are three ways to carry out a hysterectomy:

 

• vaginal hysterectomy: where the womb is removed through a cut in the top of the vagina

 

• abdominal hysterectomy: During an abdominal hysterectomy, an incision will be made in your abdomen (tummy). It will either be made horizontally along your bikini line, or vertically from your belly button to your bikini line.  A vertical incision will usually be used if there are large fibroids (non-cancerous growths) in your womb, or for some types of cancer.

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• laparoscopic hysterectomy (keyhole surgery): Nowadays, a laparoscopic hysterectomy is the preferred treatment method for removing the organs and surrounding tissues of the reproductive system.  During the procedure, a small tube containing a telescope (laparoscope) and a tiny video camera will be inserted through a small incision in your abdomen. This allows the surgeon to see your internal organs. Instruments are then inserted through other small incisions in your abdomen to remove the womb, cervix and any other parts of the reproductive system.

 

 

Why do I need a hysterectomy?

 

Hysterectomies are carried out to treat conditions that affect the female reproductive system, including:

 

• Heavy periods.  Many women lose a large amount of blood during their monthly periods. They may also experience other symptoms, such as pain and stomach cramps.   For some women, the symptoms can have a significant impact on their quality of life.  Sometimes heavy periods can be caused by fibroids, but in many cases there's no obvious cause.  In some cases, removing the womb may be the only way of stopping persistent heavy menstrual bleeding when:

  • other treatments haven't worked

  • the bleeding has a significant impact on quality of life and it's preferable for periods to stop

  • the woman no longer wishes to have children

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• Endometriosis.  Endometriosis is a condition where cells that line the womb are found in other areas of the body and reproductive system, such as the ovaries, fallopian tubes, bladder and rectum.  A hysterectomy may remove the areas of endometrial tissue causing the pain. However, it will usually only be considered if other less invasive treatments haven't worked and the woman decides not to have any more children.

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• Fibroids.  Fibroids are non-cancerous tumours that grow in or around the womb (uterus). The growths are made up of muscle and fibrous tissue, and vary in size.  A hysterectomy may be recommended if you have large fibroids or severe bleeding and you don't want to have any more children.

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• Adenomyosis.  Adenomyosis is a common condition where the tissue that normally lines the womb starts to grow within the muscular wall of the womb. This extra tissue can make your periods particularly painful and cause pelvic pain.  A hysterectomy will cure adenomyosis, but will only be considered if all other treatments have failed and you don't want to have any more children.

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• Prolapse of the uterus.  A prolapsed uterus happens when the tissues and ligaments that support the womb become weak, causing it to drop down from its normal position.  A hysterectomy resolves the symptoms of a prolapse because it removes the entire womb. It may be recommended if the tissues and ligaments that support the womb are severely weakened and the woman doesn't want any more children.

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Deciding to have a hysterectomy

 

A hysterectomy is a major operation with a potentially long recovery time and is only considered after alternative, less invasive, treatments have been tried.  For benign (non cancerous conditions), it is a good idea to ask yourself before deciding to have the procedure.

 

• Are my symptoms seriously affecting my quality of life?

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• Have I explored all other alternative treatment options?

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• Am I prepared for the possibility of an early menopause?

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• Do I still want to have children?

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All of the above questions will be fully addressed during your appointment.  Other important things to consider are the following:

 

• If you have a hysterectomy, as well as having your womb removed, you may have to decide whether to have your cervix or ovaries removed. These decisions are usually made based on: 

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• ​your medical history​

• your doctor's recommendations​

• your personal feelings

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Removal of the cervix (total hysterectomy)

 

Removing the cervix means there is no risk of developing cervical cancer in the future.

 

Many women are concerned that removing the cervix will lead to a loss in sexual function, but there's no evidence to support this.

 

Some women are reluctant to have their cervix removed because they want to retain as much of their reproductive system as possible. If you feel this way, ask your surgeon whether there are any risks associated with keeping your cervix.

 

If you have your cervix removed, you'll no longer need to have cervical screening tests. If you don't have your cervix removed, you'll need to continue having regular screening for cervical cancer (cervical smears).

 

 

Removal of the ovaries (salpingo-oophorectomy)

 

The National Institute for Health and Care Excellence (NICE) recommends that a woman's ovaries should only be removed if there's a significant risk of associated disease, such as ovarian cancer.

 

If you have a family history of ovarian or breast cancer, removing your ovaries (an oophorectomy) may be recommended to prevent cancer occurring in the future.

 

Your surgeon can discuss the pros and cons of removing your ovaries with you. If your ovaries are removed, your fallopian tubes will also be removed.

 

If you've already gone through the menopause or you're close to it, removing your ovaries may be recommended regardless of the reason for having a hysterectomy. This is to protect against the possibility of ovarian cancer developing.

 

Some surgeons feel it's best to leave healthy ovaries in place if the risk of ovarian cancer is small – for example, if there's no family history of the condition. This is because the ovaries produce several female hormones that can help protect against conditions such as osteoporosis (weak and brittle bones). They also play a part in feelings of sexual desire and pleasure.

 

If you would prefer to keep your ovaries, make sure you've made this clear to your surgeon before your operation. You may still be asked to give consent to treatment in regards to having your ovaries removed if an abnormality is found during the operation.

 

Think carefully about this and discuss any fears or concerns that you have with your surgeon. 

 

 

Surgical menopause

 

If you have a total hysterectomy that removes your ovaries, you'll experience the menopause immediately after your operation, regardless of your age. This is known as a surgical menopause.

 

If a hysterectomy leaves one or both of your ovaries intact, there's a chance that you'll experience the menopause within five years of having the operation.

 

Although your hormone levels decrease after the menopause, your ovaries continue producing testosterone for up to 20 years. Testosterone is a hormone that plays an important part in stimulating sexual desire and sexual pleasure.

 

Your ovaries also continue to produce small amounts of the hormone oestrogen after the menopause. It's a lack of oestrogen that causes menopausal symptoms such as:

 

• hot flushes

 

• depression

 

• vaginal dryness

 

• insomnia (sleep problems)

 

• fatigue

 

• night sweats

 

Hormone replacement therapy (HRT) is usually used to help with menopausal symptoms that occur after a hysterectomy.

 

Hormone replacement therapy (HRT)

 

You may be offered HRT after having your ovaries removed. This replaces some of the hormones your ovaries used to produce and relieves any menopausal symptoms you may have.

 

It's unlikely that the HRT you're offered will exactly match the hormones your ovaries previously produced.

 

The amount of hormones a woman produces can vary greatly, and you may need to try different doses and brands of HRT before you find one that feels suitable.

 

Not everyone is suitable for HRT. For example, it's not recommended for women who have had a hormone-dependent type of breast cancer or liver disease. It's important to let your surgeon know about any such conditions that you've had.

 

If you're able to have HRT and both of your ovaries have been removed, it's important to continue with the treatment until you reach the normal age for the menopause (51 is the average age).

 

Cervical screening

 

If your cervix is removed during a hysterectomy, you'll no longer need to have cervical screening.

 

If your cervix is left in place after having a subtotal hysterectomy, you'll need to continue to go for regular cervical screening tests.

 

If you have a hysterectomy, as well as having your womb removed, you may have to decide whether to also have your cervix or ovaries removed.

 

Your decision will usually be based on your personal feelings, medical history and any recommendations your doctor may have.

 

You should research the different types of hysterectomy and their implications.

 

 

Getting ready

 

If you need to have a hysterectomy, it's important to be as fit and healthy as possible.

 

Good health before your operation will reduce your risk of developing complications and speed up your recovery.

 

As soon as you know you're going to have a hysterectomy, take the following steps:​

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• stop smoking

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• eat a healthy, balanced diet

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• exercise regularly

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• lose weight (if you are overweight)

 

You may need to have a pre-assessment appointment a few days before your operation. This may involve having some blood tests and a general health check to ensure you're fit for surgery. It's also a good opportunity to discuss any concerns and to ask questions.

 

 

Complications

 

As with all types of surgery, a hysterectomy can sometimes lead to complications. Some of the possible complications are:

 

General anaesthetic

 

It's very rare for serious complications to occur after having a general anaesthetic (1 in 10,000 anaesthetics given).

 

Serious complications can include nerve damage, allergic reaction and death. However, death is very rare – there's 1 in 100,000 to 1 in 200,000 chance of dying after having a general anaesthetic.

 

Being fit and healthy before you have an operation reduces your risk of developing complications.

 

Bleeding

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As with all major operations, there's a small risk of heavy bleeding (haemorrhage) after having a hysterectomy.

If you have a haemorrhage, you may need a blood transfusion.

 

Ureter damage

 

The ureter (the tube that urine is passed through) may be damaged during surgery, which happens in around 1% of cases. This is usually repaired during the hysterectomy.

 

Bladder or bowel damage

 

In rare cases, damage to abdominal organs such as the bladder or bowel can occur. This can cause problems such as:

 

• infection

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• incontinence

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• a frequent need to urinate

 

It may be possible to repair a damage during the hysterectomy. You may need a temporary catheter to drain your urine.

 

Infection

 

There's always a risk of an infection after an operation. This could be a wound infection or a urinary tract infection. These aren't usually serious and can be treated with antibiotics.

 

Thrombosis

 

A thrombosis is a blood clot that forms in a vein and interferes with blood circulation and the flow of oxygen around the body. The risk of developing blood clots increases after having operations and periods of immobility.

 

You'll be encouraged to start moving around as soon as possible after your operation. You may also be given an injection of a blood-thinning medication (anticoagulant) to reduce the risk of clots.

 

Vaginal problems

 

If you have a vaginal hysterectomy, there's a risk of problems at the top of your vagina where the cervix was removed. This could range from slow wound healing after the operation to prolapse in later years.

 

Ovarian failure

 

Even if one or both of your ovaries are left intact, they could fail within five years of having your hysterectomy. This is because your ovaries receive some of their blood supply through the womb, which is removed during the operation.

 

Early menopause

 

If you've had your ovaries removed, you'll usually have menopausal symptoms soon after the operation, such as:

 

• hot flushes

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• sweating

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• vaginal dryness

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• disturbed sleep

 

This is because the menopause is triggered once you stop producing eggs from your ovaries (ovulating).  This is an important consideration if you're under the age of 40, because early onset of the menopause can increase your risk of developing brittle bones (osteoporosis). This is because oestrogen levels decrease during the menopause.  Depending on your age and circumstances, you may need to take additional medication to prevent osteoporosis.

 

 

 

Recovering from a hysterectomy

 

A hysterectomy is a major operation. You can be in hospital for up to five days after surgery, and it takes about six to eight weeks to fully recover. Recovery times can also vary, depending on the type of hysterectomy. Return to normal activities is expected after two weeks following a laparoscopic hysterectomy.

 

Rest as much as possible during this time and don't lift anything heavy, such as bags of shopping. You need time for your abdominal muscles and tissues to heal.

 

After having a hysterectomy, you may wake up feeling tired and in some pain. This is normal after this type of surgery.

 

You'll be given painkillers to help reduce any pain and discomfort. If you feel sick after the anaesthetic, your nurse can give you medicine to help relieve this.

 

You may have:

• dressings placed over your wounds

• a drip in your arm

• a catheter – a small tube that drains urine from your bladder into a collection bag

• a drainage tube in your abdomen (if you've had an abdominal hysterectomy) to take away any blood from beneath your wound – these tubes usually stay in place for one to two days

• a gauze pack inserted into your vagina (if you've had a vaginal hysterectomy) to minimise the risk of bleeding – this usually stays in place for 24 hours

You may also be slightly uncomfortable and feel like you need to empty your bowels 

 

The day after your operation, you'll be encouraged to take a short walk. This helps your blood to flow normally, reducing the risk of complications developing, such as blood clots in your legs (deep vein thrombosis).

 

After the catheter has been removed, you should be able to pass urine normally. Any stitches that need to be removed will be taken out five to seven days after your operation.

 

Your recovery time

 

The length of time it will take before you're well enough to leave hospital depends on your age and your general level of health.

 

If you've had a vaginal or laparoscopic hysterectomy, you may be able to leave between one and four days later. If you've had an abdominal hysterectomy, it will usually be up to five days before you're discharged.

 

You may be asked to see your GP in four to six weeks, but follow-up appointments with the hospital aren't usually needed unless there are complications.

 

It takes about six to eight weeks to fully recover after having an abdominal hysterectomy. Recovery times are often shorter after a vaginal or laparoscopy hysterectomy.

 

During this time, you should rest as much as possible and not lift anything heavy, such as bags of shopping. Your abdominal muscles and the surrounding tissues need time to heal.

 

Side effects

 

After having a hysterectomy, you may experience some temporary side effects, as outlined below.

 

• Bowel and bladder disturbances.  After your operation, there may be some changes in your bowel and bladder functions when going to the toilet.  Some women develop urinary tract infections or constipation. Both can easily be treated. It's recommended that you drink plenty of fluids and increase the fruit and fibre in your diet to help with your bowel and bladder movements.  For the first few bowel movements after a hysterectomy, you may need laxatives to help you avoid straining. Some people find it more comfortable to hold their abdomen to provide support while passing a stool.

 

• Vaginal discharge.  After a hysterectomy, you'll experience some vaginal bleeding and discharge. This will be less discharge than during a period, but it may last up to six weeks.  Visit your GP if you experience heavy vaginal bleeding, start passing blood clots, or have a strong-smelling discharge.

 

• Menopausal symptoms.  If your ovaries are removed, you'll usually experience severe menopausal symptoms after your operation. These may include:

  • hot flushes

  • anxiety

  • weepiness

  • sweating

You may have hormone replacement therapy (HRT) after your operation. This can be given in the form of an implant, injections or tablets. It usually takes around a week before having an effect.

 

• Emotional effects.  You may feel a sense of loss and sadness after having a hysterectomy.   Some women who haven't yet experienced the menopause may feel a sense of loss because they're no longer able to have children. Others may feel less "womanly" than before.  In some cases, having a hysterectomy can be a trigger for depression. See your GP if you have feelings of depression that won't go away, as they can advise you about the available treatment options.  Talking to other women who have had a hysterectomy may help by providing emotional support and reassurance. Your GP or the hospital staff may be able to recommend a local support group.

 

 

Getting back to normal

 

Returning to work

How long it will take for you to return to work depends on how you feel and what sort of work you do.

If your job doesn't involve manual work or heavy lifting, it may be possible to return after two to six weeks.

 

Driving

Don't drive until you're comfortable wearing a seatbelt and can safely perform an emergency stop.

 

This can be anything from two to eight weeks after your operation. You may want to check with your GP that you are fit to drive before you start.

 

Some car insurance companies require a certificate from a GP stating that you're fit to drive. Check this with your car insurance company.

 

Exercise and lifting

After a hysterectomy, the hospital where you were treated should give you information and advice about suitable forms of exercise while you recover.

 

Walking is always recommended, and you can swim after your wounds have healed. Don't try to do too much, because you'll probably feel more tired than usual.

 

Don't lift any heavy objects during your recovery period. If you have to lift light objects, make sure your knees are bent and your back is straight.

 

Sex

After a hysterectomy, it's generally recommended that you don't have sex until your scars have healed and any vaginal discharge has stopped, which usually takes at least four to six weeks. As long as you're comfortable and relaxed, it's safe to have sex. 

 

You may experience some vaginal dryness, particularly if you've had your ovaries removed and you're not taking HRT.

 

Many women also experience an initial loss of sexual desire (libido) after the operation, but this usually returns once they've fully recovered.

 

At this point, studies show that pain during sex is reduced and that strength of orgasm, libido and sexual activity all improve after a hysterectomy.

 

Contraception

You no longer need to use contraception to prevent pregnancy after having a hysterectomy. However, you'll still need to use condoms to protect yourself against sexually transmitted infections (STIs).

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