hysterectomy

A hysterectomy is the surgical removal of the uterus, usually done by a gynecologist. Hysterectomy may be total (removing the body and cervix of the uterus) or partial (also called supra-cervical). In many cases, surgical removal of the ovaries (oophorectomy) is performed concurrent with a hysterectomy. The surgery is then called "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (sometimes abbreviated TAH-BSO). However, the term "hysterectomy" is often used colloquially yet incorrectly to refer to removal of any parts of the female reproductive system.

Women who have total abdominal hysterectomy with bilateral salpingo-oophorectomy surgeries lose most of their ability to produce the hormones estrogen and progesterone, and lose about half of their ability to produce testosterone, and subsequently enter what is known as "surgical menopause" (as opposed to normal menopause, which occurs naturally in women as part of the aging process). In women under the age of 50, hormone supplements (usually estrogen) are often prescribed as part of hormone replacement therapy (HRT) to offset the negative effects of sudden hormonal loss (most notably an increased risk for early-onset osteoporosis) as well as menopausal problems like hot flashes that are usually more severe than those experienced by women undergoing natural menopause. Cardiovascular problems are also associated with early surgical menopause, but the exact causation is unknown. Hormone replacement treatment is somewhat controversial due to the known carcinogenic and coagulative properties of estrogen; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality of life issues as a consequence of early surgical menopause. The ovarian hormones of estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions.

Technique

Although many hysterectomies are performed via a full abdominal laparotomy with a lengthy incision, two common surgical approaches that are less invasive are laparoscopic or vaginal procedures. Surgery with ovarian conservation is an option for younger patients with benign diseases (non-cancerous).

Indications

Indications for hysterectomy include uterine fibroids, certain kinds of pelvic pain (including endometriosis and adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer or pre-cancerous diseases. Hysterectomy is also a surgical resort used in cases of uncontrollable postpartum obstetrical haemorrhage. Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some women. Many treatments are possible: Pharmaceutical (the use of NSAIDs for the pain or hormones to suppress the menstrual cycle), uterine artery embolization, or surgery. The surgical treatment varies depending on the location of the fibroids. If the fibroids are inside the lining of the uterus, hysteroscopic removal might be an option.

Transsexuals undergoing sex reassignment surgery as part of a female-to-male (FTM) transition commonly have hysterectomies and oophorectomies to remove the primary sources of female hormone production. For health reasons, some FTM have these organs removed prior to full sex reassignment surgery, as it reduces risk for developing Polycystic ovary syndrome and other ovarian and uterine problems due to the higher doses of testosterone being administered as part of the process; some, however, wait to have a hysterectomy and oophorectomy as part of the full sex reassignment surgery procedure to avoid having multiple surgeries over the course of their transitions.^[1]

Alternatives

New treatment options have begun to decrease the number of hysterectomies performed in the United States, Canada, and Britain^{citation needed]}. Despite the availability of alternative treatments to hysterectomy, many women still have traditional hysterectomy^{citation needed]}. For some patients, these alternatives are not appropriate, or may have been previously tried and been found unsuccessful^specify]. All patients should be counselled on alternative therapies and offered them if appropriate^specify].

Menorrhagia (heavy or abnormal menstrual bleeding) may be treated with the less invasive endometrial ablation.

Potential risks

Several studies have found that increased bone loss or fracture risk is associated with hysterectomy. ^{[2] [3] [4] [5] [6] [7]} It has also been demonstrated that women who have had a hysterectomy (with both ovaries conserved, and with pre-operative FSH levels <10 IU/L) reach hormonal menopause an average of 3.7 years earlier than women who have had no hysterectomy.^[8]

As compared to intact women (who were treated with endometrial ablation for dysfunctional uterine bleeding) reduced sexual wellbeing was found in women who had been given a hysterectomy with preservation of one or both ovaries. An even greater reduction in sexual wellbeing was reported in women who had been given a hysterectomy with both ovaries removed.^[9]

Women who have had a hysterectomy with both ovaries conserved typically have reduced testosterone levels as compared to intact women.^[10] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,^[11] while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire.^[12] Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.^[13]

Other studies have examined these risks and found no correlation between them and hysterectomy.^{[14] [15] [16] [17]} In the case of sexual function after hysterectomy, studies which find a favorable outcome (i.e., improved sexual wellbeing after hysterectomy) have compared women's sexual function after hysterectomy to the same women's sexual experience before surgery, when they were still dealing with serious uterine problems and may have been stressed about their upcoming surgery.^{[18] [19]} In contrast, the study which found hysterectomy was associated with a reduction in sexual wellbeing, compared women treated with hysterectomy to those whose uterine problems were resolved without removing their uteruses.^[9] Collectively, these studies suggest that women experience the greatest sexual wellbeing when they have a healthy uterus (including those whose uteruses have become healthy after treatment)^[9] -- yet sexual experience may improve after hysterectomy, once the problems requiring treatment have been resolved and the stress leading up to surgery has passed.^{[18] [19]}

In short, the research suggessts that retaining both the uterus and the ovaries aids in sexual function,^[9] and in bone health,^[6] and delays the onset of hormonal menopause.^[8] In addition, retention of the ovaries at the time of hysterectomy, when performed for benign disease, is associated with greater longevity.^[20]

Alternatives

Many alternatives to hysterectomy exist. For example, women with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically.^[21] Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.^[22]

Each treatment option requires skills specific to it. It is unlikely that any one health care practitioner will offer all available therapies.

Notes

1. ^ Hudson's FTM Guide: FTM Hysterectomy and Oophorectomy, "Why have a hysterectomy/oophorectomy?" (Retrieved 21 January 2006)
2. ^ Kelsey JL, et al. "Risk factors for pelvis fracture in older persons." Am J Epidemiol. 2005 Nov 1;162(9):879-86.
3. ^ van der Voort DJ, et al. "Risk factors for osteoporosis related to their outcome: fractures." Osteoporos Int. 2001;12(8):630-8.
4. ^ Watson NR, et al. "Bone loss after hysterectomy with ovarian conservation." Obstet Gynecol. 1995 Jul;86(1):72-7.
5. ^ Duraes Simoes R, et al. "Effects of simple hysterectomy on bone loss." Sao Paulo Med J. 1995 Nov-Dec;113(6):1012-5.
6. ^ ^a b Hreshchyshyn MM, et al. "Effects of natural menopause, hysterectomy, and oophorectomy on lumbar spine and femoral neck bone densities." Obstet Gynecol. 1988 Oct;72(4):631-8.
7. ^ Menon RK, et al. "Endocrine and metabolic effects of simple hysterectomy." Int J Gynaecol Obstet. 1987 Dec;25(6):459-63.
8. ^ ^a b Farquhar CM, et al. "The association of hysterectomy and menopause: a prospective cohort study." BJOG. 2005 Jul;112(7):956-62.
9. ^ ^a b c d McPherson K, et al. "Psychosexual health 5 years after hysterectomy: population-based comparison with endometrial ablation for dysfunctional uterine bleeding." Health Expect. 2005 Sep;8(3):234-43.
10. ^ Laughlin GA, et al. "Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: the Rancho Bernardo Study." J Clin Endocrinol Metab. 2000 Feb;85(2):645-51.
11. ^ Jassal SK, et al. "Low bioavailable testosterone levels predict future height loss in postmenopausal women." J Bone Miner Res. 1995 Apr;10(4):650-4.
12. ^ Segraves R, Woodard T. "Female hypoactive sexual desire disorder: History and current status." J Sex Med. 2006 May;3(3):408-18.
13. ^ McPherson K, et al. "Self-reported bladder function five years post-hysterectomy." J Obstet Gynaecol. 2005 Jul;25(5):469-75.
14. ^ Shilbayeh S. "Prevalence of osteoporosis and its reproductive risk factors among Jordanian women: a cross-sectional study." Osteoporos Int. 2003 Nov;14(11):929-40. Epub 2003 Oct 7.
15. ^ Larcos G. "Hysterectomy with ovarian conservation: effect on bone mineral density." Aust N Z J Obstet Gynaecol. 1998 Nov;38(4):452-4.
16. ^ Ravn P, et al. "Lack of influence of simple premenopausal hysterectomy on bone mass and bone metabolism." Am J Obstet Gynecol. 1995 Mar;172(3):891-5.
17. ^ Bhattacharya S, et al. "A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation." Br J Obstet Gynaecol. 1996 Sep;103(9):898-903.
18. ^ ^a b Roovers JP, et al. "Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy." BMJ. 2003 Oct 4;327(7418):774-8.
19. ^ ^a b Rhodes JC, et al. "Hysterectomy and sexual functioning." JAMA. 1999 Nov 24;282(20):1934-41.
20. ^ Parker WH, et al. "Ovarian conservation at the time of hysterectomy for benign disease." Obstet Gynecol. 2005 Aug;106(2):219-26.
21. ^ William H. Parker, Rachel L. Parker, "A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health," 2002, Plume; Rev ed., 89-92, 105-150.
22. ^ Frederick R. Jelovsek, "Having Prolapse, Cystocele and Rectocele Fixed Without Hysterectomy"Hysterectomy"

External links

• A.D.A.M Medical Encyclopedia Article on Hysterectomy
• A Survivor's Guide to Surgical Menopause: Collected information on managing post-hysterectomy conditions
• HysterSisters: Hysterectomy support, information, resources, community
• Encyclopedia of Surgery Article on Hysterectomy
• Hudson's FTM Guide article on hysterectomy as part of the overall female-to-male transition
• Laparoscopic Supracervical Hysterectomy, live internet broadcast from McLeod Health in Florence, South Carolina, November 29, 2005.
• Hysterectomy at h2g2