Hysterectomy: everything you need to know about removal

of the uterus
What is a hysterectomy?

A hysterectomy is a surgical procedure in which the uterus (womb) is removed.

It’s a common gynaecological operation, with around 27,000 women undergoing
the procedure in the UK for benign conditions every year. Around 20 per cent of
women have had a hysterectomy by the age of 55.

During a hysterectomy:

 One or both fallopian tubes may also be removed (salpingectomy/bilateral salpingectomy).

 One or both ovaries may also be removed (oophorectomy/bilateral oophorectomy).

A bilateral salpingo-oophorectomy (BSO) is the term used if both tubes and both
ovaries are also removed.

There are medical reasons why it’s often in your best interest to leave your
ovaries in place when you have your hysterectomy. Removal of your ovaries is
likely to increase your cardiovascular risk over time. However, sometimes – for
example, if there has been a family history of ovarian cancer – it may be better
to remove them. Your surgeon will discuss these options with you.

Types of hysterectomy

There are several different methods a surgeon can use to remove the uterus:

• Laparoscopic hysterectomy

A traditional laparoscopic hysterectomy is performed using a laparoscope, which

is a narrow, flexible tube containing a camera. The laparoscope is inserted into
the pelvic cavity by making several small incisions, low down on
the abdominal wall.

In the past, a hysterectomy meant making one large incision across the lower
abdomen, but now with laparoscopic surgery, there is no need to do this. This is
also called ‘minimally invasive’ or ‘keyhole’ surgery.

Once the laparoscope is inserted, the surgeon can visualise all the pelvic organs
and tissues easily. Because there is less tissue damage, this results in a faster
recovery time.

A variation of this is a ‘robotic laparoscopic hysterectomy.’ This means a

computer robot assists the surgeon with the procedure. The robot does not
actually perform the surgery – it just provides the use of a 3D camera, and acts to
hold various instruments in its arms, allowing the surgeon to be very precise.
Some studies have shown robotic-assisted procedures have advantages, which
result in a quicker recovery and a shorter hospital stay.

A laparoscopic hysterectomy – with or without robotic assistance – is generally

the first choice of hysterectomy, if this is considered suitable for you.

Data suggest the number of laparoscopic hysterectomies across the UK has risen
in recent years, and the number of abdominal hysterectomies has fallen.

• Laparoscopic supracervical hysterectomy (LSH)

This is also a type of hysterectomy procedure which is undertaken using a

laparoscope. This operation specifically involves removing the body of the uterus
only – the cervix is left behind.

Leaving the cervix in place has advantages, as the cervix provides an anchor for
the vaginal walls, as well as various pelvic muscles and ligaments. This is
thought to reduce the future risk of prolapse.

Laparoscopic hysterectomies are generally done under a general anaesthetic,

meaning you are asleep for the procedure. The length of stay in hospital for these
procedures is generally 24 hours, but may be up to three days.

• Vaginal hysterectomy

When a hysterectomy is done vaginally, there is no incision in the abdomen. The

surgeon inserts a speculum as if you were having a smear or a swab taken, and
the uterus is removed through your vagina.

This is often a good option if the uterus is prolapsed (has dropped lower into the
pelvis).

A vaginal hysterectomy can be done under a general anaesthetic, meaning you

are asleep for the procedure. Sometimes, you may be offered a local anaesthetic,
meaning you’ll be awake, but won’t feel any pain. Alternatively, you may be
offered a spinal anaesthetic – an injection in your spine that effectively numbs
everything from the waist down.

A vaginal hysterectomy is often preferred, as it involves a shorter stay in hospital

– around three days – and recovery is usually quicker.

• Transabdominal hysterectomy (TAH)

This is performed by making an incision across your lower abdomen, above the
pubic bone. Most commonly, this is a horizontal incision along your bikini line,
but sometimes it has to done vertically from just below your belly button. It’s
usually done under a general anaesthetic, meaning you will be asleep for the
procedure.
A TAH is usually done if the uterus is too large to be removed through the vagina
– for example, if there are large fibroids. The usual length of stay in hospital is
five days.

Common reasons for a hysterectomy

The most common reasons for undergoing a hysterectomy operation are:

 Heavy periods – there are a range of treatments for heavy periods , which are recommended
to try before resorting to a hysterectomy. However, if no cause can be found and treatments are
unsuccessful, hysterectomy is an option.
 Fibroids – benign swellings in the uterine wall.
 Endometriosis/adenomyosis – often this condition causes very heavy, painful periods.
 Prolapse – where the uterus has dropped low into the pelvic cavity and is causing pressure
symptoms.
 Severe pelvic infections – chronic symptoms which have not responded to treatment.
 Cancer - of the cervix, endometrium, uterus, fallopian tubes or ovaries
 Emergency postpartum hysterectomy – in the case of severe, uncontrollable bleeding after
childbirth (rare)

Preparing for a hysterectomy

It’s common to feel anxious prior to a hysterectomy. Many women worry about
their body, their pelvic function and how it might affect their sex life in the
future. However, your feelings will vary depending on the reason for the surgery.
Women who are fed up with very heavy periods and pelvic pain will see their
hysterectomy as a great relief. Others may grieve for their loss of fertility, or
worry they will feel less feminine.

However, many research studies have concluded that hysterectomy greatly

improves quality of life. In fact, after hysterectomy, many women report
improvements in sexual desire and arousal, as well as reduced pain during sex,
orgasm and increased overall sexual satisfaction.

Hysterectomy: the risks

Although a hysterectomy is a safe procedure, there can be complications. A

hysterectomy is only offered when other medical treatment options have been
unsuitable, unsatisfactory or have failed. After a hysterectomy, around four in
100 women will experience a serious complication.

Frequent hysterectomy risks

Infections: these occur in around two per 100 women, for example, urinary tract
infection (UTI), bladder infection (cystitis), chest infection (pneumonia) or a
wound infection.

 Bleeding: this occurs in around four in 100 women. Bleeding can be from the wound site,
internally and/or from the vagina. Around 1 in 100 will need a blood transfusion.
 Wound problems: the wound can gape or appear bruised.
 Scarring: scars may be painful.
 Shoulder tip pain: this is common because, during the procedure, gas is pumped into the
abdominal cavity. This tends to travel upwards and irritate your diaphragm. It will gradually settle.

Serious hysterectomy risks

Damage to other structures: such as the bladder, ureters (the tubes that connect
the kidneys to the bladder), bowel, nerves or blood vessels – this occurs in two in
100 women. These sorts of complications are more common with laparoscopic
surgery. If they do happen, it may be necessary to do a laparotomy incision to
repair the damage.

Blood clots: deep vein thrombosis/pulmonary embolus. These occur in 1 in 100

women after surgery. Your risk is increased if you are diabetic,
overweight/obese, have had a blood clot before or have a family history of blood
clots, smoke, or are immobile. There are several ways to reduce the risk of a
blood clot:

 Wear venous compression stockings

 Mechanical leg compression in theatre
 Stop smoking
 Mobilise as soon as possible
 Possible use of blood thing agents, for example, enoxaparin

Further surgery following hysterectomy

Around one in 100 women need to go back to the operating theatre soon after
their initial operation if there is a complication. This may mean a laparotomy (a
10-12 cm vertical incision from under your rib cage to your pubic bone). This type
of incision is needed to perform most major abdominal surgery, because the
surgeon needs the best access to your pelvic/abdominal cavity to be able to deal
with the problem.

Longer-term risks following a hysterectomy

The following risks can occur following a hysterectomy operation:

• Bladder problems

It's common for women to develop bladder problems after a hysterectomy. This is
because the bladder can drop lower down into the pelvis, called a prolapse.
Symptoms include recurrent urinary infections, pressure symptoms, discomfort
during sex or stress incontinence.

• Hernias

These are small lumps on the abdominal wall, which occur when the tissues
under the skin have split apart and fat or muscle is bulging through.
• Premature menopause

If you have a hysterectomy and your ovaries are left behind, this is associated
with an increased risk of your ovaries failing earlier than they would have done,
without the hysterectomy. Also, by not having your uterus, you will no longer be
having periods, hence you will not know that your periods have stopped due
to menopause. It’s important to be aware of this.

Recovery after a hysterectomy

Following a hysterectomy, you will be given pain relief, such as paracetamol,

ibuprofen, codeine or morphine. You should also drink plenty of fluids and you
should be able to eat a small meal within 24 hours of surgery.

You will be encouraged to get out of bed as soon as possible, to move around.
This will be within 24 hours of surgery and regularly during your hospital stay. If
you stay in the hospital for two to three days, you will see the physiotherapist for
advice about mobilising, breathing and coughing.

Most women with a laparoscopic hysterectomy will be home after 24 hours. Most
other women will be home within three to five days.