Hysterectomy

Hysterectomy is the second most common surgical procedure in the United States; almost half a million are performed each year. There is much controversy about the appropriateness of hysterectomies and their effect on women’s lives. Dramatic stories about women’s experiences with hysterectomies are reported both in print and on television talk shows. What is the truth about hysterectomies?

Hysterectomy refers to the surgical removal of the uterus and cervix. Removal of the ovaries and fallopian tubes is a separate procedure (although may be performed at the same time as a hysterectomy) called a bilateral salpingoophorectomy (BSO). A supracervical hysterectomy refers to removal of the uterus but not the cervix. Hysterectomies may be performed through an abdominal incision or through the vagina. It is important to understand that the reproductive hormones (estrogen, progesterone and testosterone) are mainly produced in the ovaries and not in the uterus.

Unless performed for life threatening hemorrhage or cancer, a hysterectomy is considered an elective procedure. Some indications for elective hysterectomy include uterine prolapse, heavy or irregular uterine bleeding, symptomatic uterine fibroids, disabling menstrual cramps, severe endometriosis and pelvic pain unresponsive to medical therapy. Before embarking on a major surgery it is important to have excluded non-uterine causes for pain, have had appropriate testing and have thoroughly reviewed medical treatments for the particular condition. For example, abnormal uterine bleeding may be treated with medication or with less invasive surgery such as endometrial ablation (where only the uterine lining is removed).

There have been several studies looking at the effectiveness of hysterectomy on improving quality of life. A study published earlier this year, from the University of Maryland, followed 1300 women for two years after their hysterectomy. The researchers found that the majority of women reported substantial improvement in symptoms, quality of life and psychological function. This confirmed previous findings from the Maine Women’s Health Study. Of interest is that both groups of researchers found that women who were significantly depressed or had other severe emotional problems were less likely to be satisfied. Certainly there were women in both studies who had problems after their surgery or whose symptoms were not significantly improved. Other women developed physical or emotional problems that were unrelated to the surgery. These studies both emphasize the need for a comprehensive preoperative evaluation and trial of non-surgical management before resorting to hysterectomy. However, performed for appropriate medical conditions hysterectomy will improve quality of life for the majority of women in whom it is necessary.

Other concerns have been raised about sexual function after hysterectomy. A decrease in painful intercourse and an increase in libido were noted by the researchers at the University of Maryland in their group of women who required hysterectomy. Again, women with depression did not note as much improvement. This is not to imply that removal of a healthy uterus and ovaries will improve sexual function, only that women who need a hysterectomy because of disease can generally expect improvement in sexual function.

I have noted that women I have seen who were unhappy after hysterectomy were either unsure why they had the surgery or did not receive adequate estrogen replacement therapy if their ovaries were removed. Ovaries produce the majority of female hormones. Removal of ovaries will immediately place a woman in menopause. The decision to remove ovaries should be considered separately from the decision to perform a hysterectomy. If they are removed, attention to adequate hormone replacement is very important.

If a hysterectomy is needed women should explore other options and ask questions of their physician. However, they should be reassured that overall quality of life is improved when hysterectomy is performed for significant gynecologic pathology.