Everything you need to know about hysterectomies
Hysterectomies are common in the UK and are most likely to be performed on women aged between 40 and 50. Most are for “benign” reasons – about 30,000-40,000 hysterectomies take place each year in England and Wales to treat non-life-threatening conditions. While the advent of keyhole surgery has made the procedure faster and minimally invasive, the decision to have one should not be taken lightly.
“By the time women have got to the point of thinking seriously about a hysterectomy, it’s because nothing else has worked for them, and their quality of life has been severely impacted by pain and bleeding,” says Prof Justin Clark, a consultant gynaecologist and the spokesperson for the Royal College of Obstetricians and Gynaecologists.
“For many it can be life-changing,” says Prof Clark, “but thorough counselling beforehand is so important.” So what sort of hysterectomies are available – and what are the risks?
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What is a hysterectomy?
A hysterectomy is an operation to remove the womb (uterus). Anyone who has a hysterectomy will no longer be able to get pregnant or have periods.
Common reasons for hysterectomies, says Martin Hirsch, a consultant gynaecologist, are conditions such as:
Fibroids
Adenomyosis
Very heavy periods that have become very challenging to manage
A randomised controlled trial of 660 women with heavy menstrual bleeding treated in 31 UK hospitals found that 97 per cent who’d undergone a hysterectomy were satisfied with their operation 15 months later.
Different kinds of hysterectomy
A total hysterectomy is the removal of the womb and cervix (the neck of the womb)
A subtotal hysterectomy involves removing only the main body of the womb and retaining the cervix.
A radical hysterectomy – which involves removing the womb, the cervix and also greater margins including part of the vagina – is more common in cases of cancer.
A hysterectomy with “bilateral salpingo-oophorectomy” is one where fallopian tubes and ovaries have been removed too.
“A bilateral salpingo-oophorectomy requires a very careful, patient-centred discussion,” Hirsch explains. “In cancer cases, the tubes and ovaries are routinely removed – but even if it’s for non-cancerous reasons, removing tubes but leaving the ovaries intact can significantly reduce the chance of developing ovarian cancer in the future.”
Which type of surgery is right for you?
“If all smear tests have been normal, and the patient is having the hysterectomy because of bleeding problems, then keeping the cervix may be a less risky procedure,” explains Hirsch. “However, if someone is there because of pain, then removing the cervix is recommended because pain can also come from the cervix.
“If the hysterectomy is for non-cancerous reasons, you want to take away as little as possible,” Hirsch adds.
What the final decision rests on
“The decision will depend on many factors, including age, family history and also the condition that brought them there,” says Hirsch. “If the condition is endometriosis, then ovaries can continue to secrete hormones that will stimulate it. In those cases, the removal of ovaries with carefully managed hormone replacement therapy (HRT) might be the best option. These decisions require very careful, nuanced discussion.”
What does a hysterectomy operation involve?
Vaginal hysterectomies: A vaginal hysterectomy involves removing the womb through a cut in the top of the vagina, sometimes with only a spinal or local anaesthetic, and is most common for cases of uterine prolapse. “Research suggests it’s the least painful and has the quickest recovery,” says Hirsch. “However, it isn’t suitable in all cases, for example, if the womb is too enlarged or ovaries are also being removed.”
Prof Clark says that with the advent of keyhole and robotic surgery, which afford surgeons excellent views inside the body, vaginal hysterectomies have become something of a “lost art”. Many gynaecologists don’t perform them and they now account for only about 10 per cent of surgeries, according to Prof Clark. Both alternatives require a general anaesthetic.
Keyhole surgery: “Keyhole surgery is less invasive than open surgery, and you can be out of hospital on the same day,” Prof Clark explains. It typically involves three or four small incisions around the belly button.
Open surgery: Open surgery, which is more common in cancer cases or where the uterus is grossly enlarged, involves a horizontal incision along the bikini line or in a vertical line from the belly button to the bikini line. This may involve a hospital stay of two to four nights.
What are the risks of having a hysterectomy?
Pain, bleeding and infection: “There is some pain, though it should be well controlled with painkillers,” advises Hirsch. Women often describe the pain as similar to menstrual cramping. Vaginal hysterectomies should be the least painful – with some pain lasting up to about two weeks. Open surgery may cause pain for six to 12 weeks. There is also a 1–10 per cent risk of excess bleeding (requiring blood transfusion) and infection, most commonly at the site of the womb, as with any surgery. Most women will be given antibiotics to minimise infection risk.
Damage to bladder, bowel and urethra: The risk of damage to surrounding organs is generally low – about 0.5-1 per cent – but certain factors increase this risk.
“If there is lots of scar tissue from a condition like endometriosis or extensive infection, or if there have been lots of previous surgeries, then the hysterectomy becomes more complex and should be discussed first,” Prof Clark explains. There is also a 10 per cent long-term risk of hernias at any time of life after surgery.
Failure of the procedure: “If the hysterectomy was meant to cure pain, especially in cases of adenomyosis or endometriosis, there is a chance of up to10 per cent that pain will persist,” says Hirsch.
How can that be when the source of pain has been removed? “Pain is related to the nervous system. If a hammer hits your finger hard enough, you’ll continue to feel pain after the hammer stops because the pain has become centralised and fired by the nerve fibres. If pain isn’t addressed properly and quickly enough, then pain can become centralised. That can be harder to manage.”
Recovery from a hysterectomy
“If a vaginal hysterectomy is done in the morning, the patient can be walking around by the afternoon,” says Hirsch. “If it was open surgery and involved a big cut, a patient may just be able to sit up in a chair 12 to 24 hours later.”
Discharge from hospital can typically range between the same day and five days, and once home, patients are advised to keep as minimally active as possible. “If you take to your bed, you increase your risk of blot clots,” says Hirsch.
“Make small goals – walk around at home on the first day, and the next day walk outside the house. Make your own tea, put on your own wash. You should be feeling a little bit better each day.”
How long does it take to recover?
Many women are able to return to work and even have sex after four to six weeks. Full recovery is usually within eight weeks. Returning to driving may depend on your insurance and revolves around your ability to do an emergency stop. This can be between two to six weeks.
Hysterectomy side effects
Immediate menopause: Women whose ovaries are removed before menopause will become postmenopausal immediately. In contrast to a natural menopause, which is gradual, a surgical menopause can be dramatic and intense.
Symptoms can include:
Hot flushes
Night sweats
Mood swings
Vaginal dryness and loss of libido
To partially offset this crash, many consultants now recommend inducing a temporary menopause several months before surgery through a hormone-blocking injection. “This allows someone to find the HRT that works well for them so it is already well established,” says Hirsch. Research suggests that some women who have had a hysterectomy and retained their ovaries go into earlier menopause – although this might also be down to the underlying condition that led to surgery.
Other risks: A hysterectomy may contribute to pelvic floor weakness by changing anatomy and nerve supply. It may also increase a woman’s lifetime risk of pelvic organ prolapse (POP).
Effects of a hysterectomy on your sex life
There really is no general rule, as women’s experiences vary so greatly. Some report a loss of libido, decreased sexual responsiveness and less intense orgasms, particularly if the cervix, which contracts during orgasm, has been removed.
Others find their sex life enhanced, especially when freed of the pain and bleeding that led them to the operation. “Sexual function, enjoyment and desire is complex,” notes Prof Clark. “The clitoris and labia, which drive arousal and enjoyment, are still intact after a hysterectomy. Most patients I see tell me their sex life has improved as it’s hard to feel sexy when you’re bleeding and in pain.”
Emotional impacts of hysterectomy
There is evidence that a hysterectomy can increase the long-term risk of depression, especially when performed in younger women. This might be triggered by the inability to have children, or a perceived loss of womanhood or femininity. Good patient support and psychological care post-hysterectomy can do much to mitigate depressive symptoms, anxiety and body image issues.
‘I don’t regret having the hysterectomy because my PMDD was so bad, but I do think that the full impact wasn’t discussed and the follow-up support wasn’t there’
Cheryl Bagshaw had a hysterectomy at 41 and looking back at the operation itself, the recovery time and the lasting impact, there has been much that she hadn’t anticipated.
The procedure was a last resort to rid Cheryl of crippling premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome. “For three weeks each month, I was in chronic pain, angry and anxious,” says Cheryl, a housing officer and mother of four from Sheffield. “It came to the point where the only way to stop it would be to permanently stop my body from ovulating.” For this reason, Cheryl had a total hysterectomy with bilateral salpingo oophorectomy (BSO) – that’s the removal of her womb, cervix, ovaries and fallopian tubes.
In some ways, Cheryl was surprised by how easy it was. “I found the operation a bit of a breeze,” she says. “I was able to get up and walk within hours and there wasn’t much sitting around when I got home as I have four children.”
Far harder was the chemical menopause that was triggered instantly by the loss of her ovaries. “I literally woke up after the operation to a hot flush. I remember saying, ‘I need a fan’,” says Cheryl.
“I was told I had to wait eight weeks for an HRT consultation. By then, I was full of anxiety and had brain fog and restless leg syndrome, and the sweating was unbearable.” It took many months of HRT trial and error, and ultimately paying a private specialist, before Cheryl found the HRT implants that work for her. “I don’t regret having the hysterectomy because my PMDD was so bad, but I do think that the full impact wasn’t discussed and the follow-up support wasn’t there.”
