Hysterectomy

Hysterectomy is the most common non–pregnancy-related major surgery performed on women in the United States. This surgical procedure involves removal of the uterus and cervix, and for some conditions, the fallopian tubes and ovaries.

Reasons for choosing this operation are treatment of uterine cancer and various common noncancerous uterine conditions such as fibroids, endometriosis, prolapse, etc., that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Although this procedure is highly successful in curing the disease of concern, it is a surgical alternative with the accompanying risks, morbidity, and mortality that an operative procedure carries and it leads to sterility in women who are premenopausal. The patient may be hospitalized for several days and may require 6-12 weeks of convalescence. Complications, such as excessive bleeding, infection, and injury to adjacent organs, also may occur.

For related information, see Medscape's Women's Sexual Health Resource Center.

In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. In 1929, Richardson, MD, performed the first total abdominal hysterectomy (TAH), in which the entire uterus and cervix were removed. ^[1]

Epidemiology of fibroids

Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of gynecological visits, and they create an annual cost of $1.2 billion. ^{[2, 3]} They are benign uterine tumors that increase in size and frequency as women age but revert in size postmenopausally. ^{[4, 5]} Factors that have proven to contribute to fibroid growth include estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and transforming growth factor-beta. ^[6]

The frequency of fibroid appearance in African American women is 2-3 times higher than in white women. Women who are obese or experience menarche when younger than 12 years are at increased risk of fibroid development due to prolonged exposure to estrogen. Women who have had children are at a lesser risk for fibroid development than women who have never been pregnant. ^[7]

Each fibroid arises from a single monoclonal cell line from the smooth-muscle cells of the myometrium. ^[8] Most (60%) fibroids are chromosomally normal. The rest have nonrandom chromosomal abnormalities that can be separated into 6 cytogenic subgroups, which are trisomy 12, translocation between chromosome 12 and 14, rearrangements of the short arm of chromosome 6 and the long arm of chromosome 10, and deletions of chromosomes 3 and 7. ^[9]

Asymptomatic fibroids are relatively slow growing and characterize most of the tumors found in patients. Previously, uterine size (consisting of asymptomatic fibroids) equivalent to 12 weeks' gestation (280 g) had been the standard threshold for recommending a hysterectomy. Thus, asymptomatic fibroids of smaller size were handled via observation, with an annual pelvic examination and/or transvaginal ultrasonography.

Currently, surgical procedures are not recommended for fibroids based on uterine size alone in the absence of symptoms. According to Reiter et al, no increased incidence in perioperative morbidity existed posthysterectomy in those women with a fibroid uterus larger than 12 weeks' gestational size compared to those women with a fibroid uterus smaller than 12 weeks' gestational size. ^[10] They concluded that hysterectomy for a large asymptomatic fibroid uterus may not be needed as a means of preventing increased operative morbidity associated with future growth, unless a sarcomatous change is observed.

In patients who experience symptoms with fibroids, the symptoms are related to the size, location, and number of fibroids within the uterus. As many as one third of patients with symptomatic uterine fibroids experience abnormal bleeding, cramping, and prolonged and heavy menstrual periods, which can result in anemia. The growth of fibroids to large sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic pain or pressure, pain during sexual intercourse, reduced urinary capacity due to increased bladder pressure, constipation due to increased colon pressure, and infertility or late miscarriages. ^[6]

Epidemiology of endometriosis

Endometriosis is responsible for approximately one fifth of hysterectomies, and it affects women during their reproductive years. ^[11] It is a disease in which tissue similar to the endometrium is present outside the endometrial cavity (in other areas of the body). Such sites include all the reproductive organs, bladder, intestines, bowel, colon, and rectum. Other sites may include uterosacral ligaments, the cul-de-sac, pelvic sidewalls, and surgical scars. This ectopic endometrial tissue responds to monthly hormonal stimulation and, thus, breaks down and bleeds into the peritoneal cavity when located there, causing internal bleeding, inflammation of the surrounding areas, and formation of scar tissue. Scar tissue then can become bands of adhesions that are capable of distorting internal anatomy. Patients also may experience symptoms of pelvic pain; pain during bowel movements, urination, and sexual intercourse; and infertility or miscarriages. ^[12]

Currently, no cure exists for endometriosis. Although many women seek hysterectomy for pain relief, it does not provide a definite cure because some women in whom one or both ovaries are preserved may continue to experience problems with endometriosis that was left behind.

Epidemiology of pelvic relaxation

Genital prolapse is the indication for approximately 15% of hysterectomies. Various stresses on the pelvic muscles and ligaments can cause significant weakening and, thus, uterine prolapse. The prime cause of insult to the pelvic support structures is childbirth. Therefore, multiple pregnancies and vaginal deliveries increase the risk for uterine prolapse. A few less dramatic causes of increased pelvic pressure include straining during bowel movements, chronic coughing, and obesity. Also, significant pelvic structure weakening occurs postmenopause because estrogen, which pelvic tissues need to maintain their tonicity, is not present in significant amounts after menopause.

Women with mild pelvic relaxation may be free of symptoms. However, patients with moderate-to-severe relaxation may experience symptoms that include heaviness and pressure in the vaginal area; low back pain, leakage of urine, which can worsen during heavy lifting, coughing, laughing, or sneezing; urinary tract infections; retention of urine; and problems with sexual intercourse. ^[11] Although several techniques that provide temporary improvement and control of pelvic relaxation exist, in moderate-to-severe situations, hysterectomy may provide a more functional and longer-lasting results.

Epidemiology of cancer of reproductive organs

Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in the United States, with an estimated 36,100 new cases in 2000. ^[13] It affects women aged 35-90 years, with a mean age of 62 years. Cancer begins in the lining of the endometrium and can spread to other reproductive organs and to the rest of the body.

Stage 1 endometrial cancer is confined to the corpus, or body, of the uterus. Symptoms may include bleeding between periods or, as is in most cases, spotting in patients after menopause. Stage 1 endometrial cancer is very slow growing and highly curable. A hysterectomy is the preferred method of treatment. Not only is the uterus removed, but the ovaries and fallopian tubes also are removed because ovaries are a possible site for more cancer, or they may secrete hormones that play a synergistic role in the growth of the cancer. Surgical menopause due to bilateral oophorectomy compared to natural menopause does not increase all-cause, cardiovascular, or cancer mortality. ^[14] Only in cases of early endometrial cancers in women who are in their second or early part of the third decade of life are attempts made to preserve the ovaries.

In stage 2 endometrial cancer, the cancer has spread to the cervix. Approximately 12,800 new cases of cervical cancer diagnoses occur annually in the United States. ^[15] Symptoms of cervical cancer include bleeding between periods, bleeding postmenopause, or bleeding after sexual intercourse. In some cases, radical hysterectomy (removal of the uterus, cervix, top portion of vagina, ovaries, fallopian tubes, and tissues in the pelvic cavity surrounding cervix) may be the treatment of choice, along with chemotherapy or radiotherapy if needed.

In stage 3A endometrial cancer, the cancer has spread to the ovaries and fallopian tubes. This may be treated with a TAH and bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries), along with chemotherapy or radiotherapy if needed. In stage 3B, the cancer has spread to the vagina. In this case, a vaginectomy or radical hysterectomy must be performed, along with chemotherapy or radiotherapy if needed. By stage 3C, the cancer has entered the lymph nodes. In this case, lymph node dissection and hysterectomy is the treatment of choice, along with chemotherapy or radiotherapy if needed.

Frequency

Approximately 600,000 hysterectomies are performed annually in the United States, with a cost of approximately $5 billion per year.

The US Centers for Disease Control and Prevention (CDC) estimated 3.1 million US women had a hysterectomy from 2000-2004.

• The hysterectomy rate decreased slightly from 5.4/1000 in 2000 to 5.1/1000 in 2004.

• From 2000-2004, rates of hysterectomy differed by age. Overall rates were highest among women aged 40-44 years and lowest among women aged 15-24 years. Hysterectomy rates among women aged 50-54 years decreased significantly from 8.9/1000 in 2000 to 6.7/1000 in 2004.

• Hysterectomy rates also differed by geographic region. The overall rate was highest for women living in the South (6.3/1000) and lowest for those in the Northeast (4.3/1000). Hysterectomy rates in the Northeast decreased from 4.9/1000 in 2000 to 3.7/1000 in 2004.

• From 2000-2004, the most common medical reasons for undergoing a hysterectomy included benign fibroid tumors, endometriosis, and uterine prolapse. Uterine cancer was not as common but is an important reason for undergoing a hysterectomy.

• The proportion of hysterectomies with an indication of uterine leiomyoma decreased from 44.2% in 2003 to 38.7% in 2004.

The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13% in 1995 and then steadily declined to 3.9% in 2003 (p for trend < 0.001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (p for trend < 0.001).

Preoperative evaluation includes the following:

• Complete history and physical: Evaluate, in detail, any comorbid conditions such as diabetes mellitus, hypertension, cardiac disease, or asthma.Previous abdominal surgeries and failed medical treatments should be taken into account.

• Medication history such as use of aspirin, oral hypoglycemics, heparin, or warfarin, also any herbs or over the counter medications .

• PAP smear, endometrial sampling, ultrasonography, CBC count, blood type and cross match, and, depending upon age and risk factors, ECG and chest radiograph.

• In case of malignancy, preoperative staging can be determined with the help of biopsies, CAT scans, IVP, cystoscopy, barium enema, etc.

Reasons for choosing hysterectomy are treatment of uterine cancer, ovarian cancer, some cases of cervical cancer, and various common noncancerous uterine conditions like fibroids, endometriosis, uterine prolapse, or adenomyosis; that lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Various hysterectomy procedures are available, including the following:

• Total abdominal hysterectomy involves removal of the uterus and cervix through an abdominal incision.

• Supracervical or subtotal hysterectomy is removal of the uterus through an abdominal incision, while sparing the cervix.

• Radical hysterectomy is extensive surgery that, in addition to removal of the uterus and cervix, might include removal of lymph nodes, loose areolar tissue near major blood vessels, upper vagina, and omentum.

• Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical removal of the ovary and salpingo-oophorectomy is the removal of the ovary and the fallopian tube.

• Vaginal hysterectomy is removal of the uterus and the cervix through the vagina.

• Laparoscopy-assisted vaginal hysterectomy is vaginal hysterectomy with the help of laparoscopy.

• Total Laproscopic Hysterectomy- where the uterus and cervix are removed completely with the help of laproscope & laproscopic instruments. The specimen is either removed vaginally or through laproscopic port. The vaginal vault is then closed laproscopically.

The uterus is the inverted pear-shaped female reproductive organ that lies in the midline of the body, within the pelvis between the bladder and the rectum. It is a dynamic female reproductive organ that is responsible for several reproductive functions, including menses, implantation, gestation, labor, and delivery. It is responsive to the hormonal milieu within the body, which allows adaptation to the different stages of a woman’s reproductive life. The uterus adjusts to reflect changes in ovarian steroid production during the menstrual cycle and displays rapid growth and specialized contractile activity during pregnancy and childbirth. It can also remain in a relatively quiescent state during the prepubertal and postmenopausal years.

The ovaries are small, oval-shaped, and grayish in color, with an uneven surface. The actual size of an ovary depends on a woman’s age and hormonal status; the ovaries, covered by a modified peritoneum, are approximately 3-5 cm in length during childbearing years and become much smaller and then atrophic once menopause occurs. A cross-section of the ovary reveals many cystic structures that vary in size. These structures represent ovarian follicles at different stages of development and degeneration.

For more information about the relevant anatomy, see Female Reproductive Organ Anatomy, Uterus Anatomy, and Ovary Anatomy.

Vaginal hysterectomy is contraindicated in only 10-20% of cases, eg, uterine size greater than 280 g ^[16] , previous multiple abdominal or pelvic surgeries, advanced uterine or cervical malignancies, and ovarian malignancies.

A study by Mahnert et al that included 10,274 women who underwent hysterectomy for benign disease reported that approximately 1 in 11 women present to the emergency department within 30 days of hysterectomy for benign disease, most commonly for pain (29.5%), gastrointestinal (12.8%), and genitourinary (10.7%) complaints. The study concluded that these visits can be reduced with expanded perioperative education and improved communication pathways for high-risk patients. ^[17]