Hysterectomy: Ask the Expert
Juan Jose Diaz Quinones, M.D., is a gynecologist and obstetrician at the University of Miami Health System. In this Q&A, Dr. Diaz discusses the pros and cons of hysterectomies.
What is a hysterectomy?
Dr. Diaz: A hysterectomy is the surgical removal of the uterus or portions of it. In some cases, the hysterectomy is done with the simultaneous removal of other female reproductive organs. There are three types of these procedures.
- What the general population calls “partial hysterectomy” is the removal of the uterus while sparing the ovaries.
- A total hysterectomy removes the uterus and cervix.
- A radical hysterectomy removes the uterus, cervix, and part of the vagina.
In some cases, the ovaries, fallopian tubes, and nearby lymph nodes might also be removed. Approximately 600,000 hysterectomies are performed in the U.S. every year.
In what situations would a woman need a hysterectomy?
Dr. Diaz: The reasons for having a hysterectomy are varied. Certain conditions, with either benign or malignant causes, can necessitate this procedure. Benign conditions include symptomatic fibroids and pelvic organ prolapse. Hysterectomies are also commonly used to treat abnormal uterine bleeding, endometriosis, chronic pelvic pain, and pre-malignancies. In some patients, a radical hysterectomy may be necessary if they have endometrial or cervical cancer.
What common misconceptions are associated with this surgery? For instance, some people think that every hysterectomy procedure results in the immediate onset of menopause. Others believe it can cure endometriosis.
Dr. Diaz: Patients who undergo a hysterectomy and removal of the ovaries do experience immediate menopause. Usually, the ovaries are only removed in particular situations, such as the suspected or known presence of a gynecologic malignancy. A surgeon might also remove the ovaries if the patient suffers from severe pelvic infections, endometriosis, severe adhesions, or for some post-menopausal patients for whom the ovaries are no longer beneficial. All of this should be thoroughly discussed with the patient prior to having a procedure.
Some studies have shown that menopause may occur a little earlier in patients who underwent a hysterectomy compared to those who never had a hysterectomy. This might be caused by the disruption of blood flow to the ovaries.
In patients with endometriosis, a hysterectomy might be beneficial in treating their pain. However, patients who have a hysterectomy while keeping their ovaries have a 62% likelihood of their symptoms returning. Patients who undergo removal of both ovaries and fallopian tubes have only a 10% chance of their symptoms recurring. So yes, a hysterectomy could be helpful but is not always effective in all cases.
In what instances would you discourage a patient from having a hysterectomy?
Dr. Diaz: A hysterectomy is usually the last resort method that could be performed only after exhausting other less invasive medical treatments or surgical interventions. The alternative treatments depend on the type of problem the patient faces. For instance, a doctor may prescribe birth control pills to control irregular bleeding or treat the irregular bleeding with a procedure called endometrial ablation, depending on the individual patient’s characteristics. Once other treatments have failed, it is reasonable to consider a hysterectomy.
I would discourage a patient from having a hysterectomy if she desires to get pregnant in the future or if there is a less invasive treatment option available.
Are most hysterectomies performed laparoscopically or with robot-assisted minimally invasive surgery?
Dr. Diaz: Hysterectomies can be performed using minimally invasive techniques (including vaginal, laparoscopic, and robotic hysterectomies) or through an abdominal route (open hysterectomies). Most hysterectomies are performed through an abdominal route, but this can vary from one surgeon to another.
A minimally invasive approach should be performed whenever feasible instead of an open hysterectomy. Minimally invasive procedures offer patients many benefits, including a reduced risk of complications, minimal scarring, less pain (which minimizes the use of narcotics to control pain), and faster recovery. All of this means a quicker return to daily activities.
Do you recommend one surgical option over another, depending on the patient’s situation?
Dr. Diaz: Among minimally invasive hysterectomy options, the vaginal approach is usually preferred. The doctor selects the approach or surgical route based on the size and shape of the vagina and uterus, abdominal adhesions, the need for a concurrent procedure, the surgeon’s experience, and the patient’s preference.
What steps should a woman take before getting a hysterectomy?
Dr. Diaz: If the hysterectomy is elective and the patient has the time and the ability to lose weight if she is overweight, that is highly recommended. Obesity is a major risk factor in developing complications during and after surgery. Obese patients are more likely to develop infections and blood clots, among other complications. In addition, patients with chronic diseases such as anemia, diabetes, and heart disease must strictly control their medical issues to avoid potential complications that could be prevented. Patients with those conditions must be evaluated by their medical providers before surgery. Smokers and heavy drinkers must stop drinking at least two to four weeks before surgery to avoid complications.
How do different types of hysterectomy procedures affect sexual health?
Dr. Diaz: Like all surgical procedures, the body needs time to heal afterward. Generally, women should refrain from sexual relations for four to six weeks after a hysterectomy. The effect on sexual health depends on many factors, including the patient’s health before surgery and the type of procedure performed.
If the ovaries are removed, this will trigger menopause, which can affect sexual health. However, in some cases, symptoms subside with time and can be treated with over-the-counter and prescription medications. Some women report reduced sexual sensation, vaginal dryness, or lower libido after a hysterectomy. Others report better sexual health because the procedure alleviated their pain and/or irregular bleeding. Many of the surgical side effects can be addressed with pelvic floor exercises, medication, and following a healthy lifestyle.
If a woman is considering this procedure, what questions should she ask her doctor?
Dr. Diaz: Women should be counseled on the risks and benefits, as well as alternative treatments. It’s important to discuss the patient’s expectations and understanding of the procedure. If she is having a hysterectomy to treat a benign condition, her physician must rule out cancer with a Pap smear and possibly a biopsy of the uterus.
The physician/patient conversation should address the recovery period and type of care or help the patient may require immediately after surgery and after being discharged home. The physician should discuss the patient’s expectations regarding pain control, the importance of decreasing narcotic use, and they should encourage the use of NSAIDs (ibuprofen) and acetaminophen (Tylenol). The moderate use of narcotics allows faster recovery, decreases the length of the hospital stay, and decreases the risk of becoming dependent on opioids.
It’s important that patients understand the importance of becoming mobile as soon as safely possible after surgery to prevent blood clots. They should also be taught how to care for the surgical incision area and how to recognize an infected wound.
From a health care consumer standpoint, the patient should ask the surgeon how many hysterectomies they have performed, the type of procedures (minimally invasive or open) they typically perform, and how long they have been performing these procedures.
Every patient is different, so every case should be approached individually. Ultimately, the patient must always be included in the decision-making.
Q&A was compiled by Nancy Moreland, a contributing writer for UMiami Health News. She has written for several major health care systems and the Centers for Disease Control and Prevention. You can also find her writings in the Chicago Tribune.
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