Hysterectomy Definition, Types and Surgery

Overview

With over three decades of experience in the field of GYN surgery, the Seckin Endometriosis Center is one of the pioneers in laparoscopic surgery ensuring minimal invasion. We have been on the forefronts of proper technique and use of hysterectomies, ensuring patients and warning doctors worldwide, that the removal of the uterus should be performed with extreme diligence. Hysterectomies are performed in cases of multiple fibroids (40.7%), dysfunctional uterine bleeding (20%), uterine prolapse (14.5%), uncontrollable painful periods (10%), uterine cancer (9.2%), abnormal thickening of the endometrium, termed endometrial hyperplasia (2.7%), etc.[1]. When it comes to endometriosis, a hysterectomy is necessary if the uterus is heavily involved with the disease, a condition called diffuse adenomyosis. Laparoscopic excision of endometriosis lesions outside the uterus is the gold standard for a successful outcome if hysterectomy surgery is required. However, it is not uncommon to see patients aggressively treated with an unnecessary hysterectomy by prior surgeons, only to have persistent symptoms as lesions are left behind in the peritoneum, bowels, etc. It is hard not to shed tears when we see these patients. A hysterectomy is only an option for patients who do not respond to conservative surgical therapy (such as excision of endometriosis implants) and do not want to preserve fertility [2,3]. In other words, a hysterectomy should be a last resort and only performed unless it is necessary and unavoidable. But whether a hysterectomy is required or not, laparoscopic excision is needed in order to examine and remove all other adhesions outside of the uterus. This is the way to eliminate all endometriosis tissue from the body, ensuring patients their highest chance of symptom relief and recovery.

What is a Hysterectomy?

A hysterectomy is the surgical removal of the uterus (womb). A total hysterectomy includes the removal of the cervix, however, if the cervix is preserved it is called supracervical hysterectomy. Either way, hysterectomy is a definitive surgical option, and after it, menstruation will cease to occur.

What is the function of the uterus and ovaries?

The uterus, the source of monthly menstruation, also allows the growth of pregnancy to take place as the developing child is housed in the womb. In the absence of pregnancy, a typical female has about 400 menstrual cycles during her reproductive life.The ovaries are the sites where egg development with subsequent ovulation takes place, along with the production of key hormones, estrogen, and progesterone. Whereas estrogen prepares the lining of the uterus for pregnancy in the first 14 days of the cycle, progesterone then matures the endometrium between 14 to 28 days of the cycle, so that it can be ready for the first step of pregnancy, implantation. When an egg is fertilized by a sperm, the newly develop embryo travels down the fallopian tube and implants into the mature uterine lining. When this occurs, the pregnancy continues to develop and is housed in the uterus for an average of nine months and ten days until it is time for delivery.

It is also important to note, that a common misconception is that the uterus is where key reproductive hormones are made. This is false. The uterus is not responsible for the production of estrogen, progesterone or any other hormones. But rather it is the ovaries that produce estrogen and progesterone and then feed into the uterus.

What are the side effects?

By removing the uterus, you are eliminating the function it serves, which is to host pregnancy development. Without the uterus, a woman will no longer have menstrual periods. Therefore, after a hysterectomy is performed a woman will not be able to bear children.

How common is it for a hysterectomy to be performed in the US?

According to the Center for Disease Control and Prevention (CDC), the United States has the highest rate of hysterectomy surgeries in the world, with more than 600,000 hysterectomies performed each year. In fact, approximately 300 out of every 100,000 women will receive a hysterectomy at some point in their life[4].

Why are so common?

While a hysterectomy rate of 0.3% may not seem like such a large number, it is when considering that hysterectomies are the second most common surgery performed amongst women in the United States (C-section being the first). On top of this, some of the most experienced surgeons in the world would argue that hysterectomies are amongst some of the most overperformed surgeries in women’s health. This is because there are a great number of hysterectomies that are performed in order to ensure a patient will no longer suffer from such disorders as endometriosis. Make no mistake, a hysterectomy will not fix the problem for most endometriosis cases. Laparoscopic excision surgery should always be used as the primary option, with a hysterectomy performed only if necessary. However, the reason this does not happen as commonly as it should is because many doctors lack the experience, skill, and knowledge to perform laparoscopic excision surgery. Thus they settle to performing a hysterectomy. This is not a testament to how “good” or “bad” the doctor is, as they may not have ever been trained or made aware of this form of treatment. Nevertheless, it is one of the main reasons why hysterectomies are as common as they are. Thus it is crucial if you decide to have a hysterectomy, be certain that it is a last resort and that there is no endometriosis anywhere else.

When is it necessary?

Removal of the uterus should have justifiable indications. Pelvic pain, after all, may have multiple causes. Therefore, in the absence of uterine disease, doctors and patients should be cautious in proceeding with hysterectomy. In addition, pre-operative tests like MRIs do have false sensitivity in detecting uterine pathology such as endometriosis or adenomyosis, thus any believed need for a hysterectomy based on such disorders should be confirmed upon laparoscopic surgery. Nevertheless, here are several conditions in which a hysterectomy will be unavoidable.

• Multiple uterine fibroids
• Recurrent fibroids (previous myomectomies performed)
• Diffuse adenomyosis and extensive endometriosis
• Cervical dysplasia (pre-inclination of cervical cancer)
• Cervical cancer
• Uterine cancer

What diagnostic tests do I need to confirm?

 

Diagnostic Test	Purpose
Endovaginal and abdominal sonogram	Intravaginal and abdominal ultrasound imaging will help confirm the presence and location of adenomyosis and fibroids, as well help to determine the condition of the ovaries.
MRI and contrast	An MRI uses magnetic resonance imaging to produce high-quality photos of the body, which can give confirmation for a presumptive diagnosis of endometriosis, adenomyosis, fibroids, etc. This study allows your surgeon to visualize the status of the ureters, which serves as the kidney outlet to the bladder.
Hysteroscopy w/dilation and curettage (D&C)	While in the operating room, a surgeon will look inside your uterus with a video camera in order to rule out cervical or uterine cancer, diffuse adenomyosis, submucosal fibroids or any other findings that call for a hysterectomy.

Types

What are the different routes of hysterectomy treatment?

The first laparoscopic hysterectomy was performed by Harry Reich in 1988 [5]. Since then its technique has evolved into many different names but similar stages and forms, as surgeons have been looking for the best way to perform a successful surgery while ensuring minimal invasion. Hysterectomies are performed either from the vaginal route with absolutely no scar from the abdomen, also called vaginal Hysterectomy.When the surgery route is through the abdomen, this is known as abdominal hysterectomy,  which requires varying lengths of visible incisional scarring. Today the best hysterectomy surgery route is via the vagina, with next to no abdominal scarring. However, not all uteruses can be removed via vaginal hysterectomy as the uterus may be too large, the status of the ovaries and peritoneal disease may be unknown, etc. Thus because there are limitations to vaginal hysterectomies, mostly due to inexperience in medical training programs, the procedure that many surgeons perform is an abdominal hysterectomy. Nevertheless, amongst surgeons with great skill and experience in hysterectomy surgery, a laparoscope is used to visualize the uterus, ovaries and pelvic cavity from above the anatomical structures via very small incisions made through the abdomen, which ultimately allows a hysterectomy to be completed vaginally as the uterus is removed from the vagina. The laparoscopy gives a complete visualization of the pelvic anatomy, allowing the surgeon to remove any believed abnormal pathology outside the uterus involving the ovaries and fallopian tubes that would not have been seen if just a normal vaginal hysterectomy was performed. Proper pelvic floor suspension techniques are also performed during this time in order to lower the chance of prolapse. This technique is termed laparoscopically assisted vaginal hysterectomy (LAVH). Using it many more vaginal hysterectomies, whether it is a supracervical hysterectomy (LSCH), total hysterectomy (LTH) or a total hysterectomy with fallopian tubes and ovaries included, can be performed with both success and minimal invasion.

What are the different classifications of hysterectomies?

Many patients are surprised to hear that there are several different forms of hysterectomies. Remember, the uterus can be removed via the abdomen or vagina. However, aside from just the route through which the hysterectomy is performed, there are specific techniques as to how the uterus is removed. While your doctor should always provide the best recommendation for your particular case, you as the patient should remember, you always have a choice. A hysterectomy is a very personal and emotionally taxing surgery, therefore you should feel free and comfortable discussing what is the best option for you. But here are just a few options that your surgeon may suggest if a hysterectomy is the right procedure for you.

• Supracervical hysterectomy ("partial hysterectomy"): This procedure involves the removal of the uterus above the cervix. Surgeons refer to this as a “partial hysterectomy,” as the cervix is preserved. Retention of the cervix is thought to improve patients’ outcome including sexual function and pelvic support. Nevertheless, patients will have a potential risk for ongoing cyclic bleeding from the cervix or reoperation to remove the cervix in the future[6].

  

• Hysterectomy ("total hysterectomy"): This form of hysterectomy removes the uterus, including the cervix, in its entirety. Though the common public often misconstrues this procedure as a “partial hysterectomy,” surgeons consider this a “total hysterectomy,” as the cervix is removed. Patients often construe this to be a partial hysterectomy as they think that ovary removal is apartofastandardhysterectomyprocedure, when in reality this will only be done if specified. Because the ovaries are preserved, but the uterus is being removed surgical “menopause” will occur. This means that periods will cease due to uterus removal. However since the ovaries remain, key hormones such as progesterone and estrogen are preserved. Thus menopausesymptomssuchashotflashes,mood-swings and fatigue will not occur, as these key reproductive hormoneswhosedeclinecancausesuchsymptoms, are still present.

  

• Hysterectomy with bilateral salpingo-oophorectomy: Thisprocedureremovestheuterus,fallopiantubes and ovaries in their entirety. The word “salpingo” is the latin word for tubes, while "oophor" stands for ovaries, hence removal of the fallopian tubes and ovaries. When patients mistakenly think that this is just a total hysterectomy, it is really a total hysterectomy along with salpingo-oophorectomy, removal of the fallopian tubes and ovaries. Thus only when the term salpingo-oophorectomy is accompanied with a hysterectomy, should patients be aware that the fallopian tubes and ovaries will be removed. When this occurs the body goes through menopause as the ovaries are removed and thus their function ceases. Estrogen and progesterone are no longer made and menopausesymptomssuchashotflashes,mood-swings and fatigue occur. This form of hysterectomy can be a very personable issue, and thus it is very important to note that it should only be conducted unless a patient chooses to have their ovaries removed.

  

What is a partial vs. total hysterectomy?

A common misconception amongst patients is the difference between a partial and total hysterectomy. Amongst the common public, it is believed that a partial hysterectomy involves the removal of the uterus, while preserving the ovaries. A total hysterectomy is then believed to be complete removal of the uterus, along with the ovaries. However, what patients refer to as a total hysterectomy is what surgeons call a total hysterectomy with bilateral salpingo-oophorectomy, removal of the fallopian tubes and uterus. In other words, removal of the ovaries is not part of a hysterectomy procedure, unless specified. Thus when patients hear the term hysterectomy, they should not be concerned about losing their ovaries, unless bilateral salpingo-oophorectomy is specified along with it. Nevertheless doctors still use the term partial hysterectomy, but it refers to the removal of the upper half of the uterus, with the cervix being preserved. A total hysterectomy to surgeons means the removal of the uterus in its entirety, which includes the cervix. Therefore when a surgeon uses the terms “partial” vs. “total” hysterectomy it is to identify whether or not the cervix will be preserved, as oppose to the public misperception of whether or not the ovaries are removed. In both partial and total hysterectomy the ovaries are preserved, unless specified.

Will menopause occur following hysterectomy surgery?

One of the side effects following a hysterectomy is the that a woman will no longer go through her menstrual period and thus menopause. However, this ceasing of menstruation can bring on different symptoms depending on the form of hysterectomy surgery. When a partial or total hysterectomy is performed and the ovaries are preserved, estrogen and progesterone levels remain the same, and in turn “surgical menopause” takes place. This is when a woman’s period stops due to removal of the uterus, but menopause symptoms such as hot flashes, vaginal dryness and mood-swings are not felt, as the ovaries are retained. In other words, because the ovaries remain and there is normal female reproductive hormone levels, menopause symptoms do not surface. This is not the case in hysterectomies with bilateral salpingo-oophorectomies, wherein the ovaries are not preserved. Removing the ovaries means the loss of estrogen and progesterone levels, thus normal hormonal menopause takes place, including the signs and side effects that go with it. Thus choosing whether or not an oophorectomy to go along with your hysterectomy is right for you is imperative, as strong consideration should be given to conserving normal ovaries when possible.

Depending on the type of hysterectomy, how will this affect the day of surgery?

The hysterectomy technique that is performed the day of your surgery, can have consequential effects on the amount of scarring left behind and how long your hospital stay and recovery time may be. Taking these factors into account, here is a list of the most successful hysterectomy surgeries arranged from most preferred to least:

• Laparoscopically assisted vaginal hysterectomy (LAVH): Maximum of three incisions made that are each 3-5mm, which guarantees no stay overnight at the hospital and a one week recovery time. This also includes such procedures as laparoscopic total hysterectomy (LTH) and laparoscopic supracervical hysterectomy (LSCH).
• Vaginal hysterectomy: Maximum of three incisions made that are each 10-12cm, which guarantees one day overnight at the hospital and one to two weeks recovery time.
• Robotic hysterectomy: Five incisions made that are each 8-12mm, which guarantees one to two days overnight at the hospital and two to four weeks recovery time.
• Open abdominal hysterectomy: One large incision made that is 10-12inches, which guarantees three to five days overnight at the hospital and six to eight weeks recovery time.

Hysterectomy as a treatment for Endometriosis

Is hysterectomy always necessary to treat endometriosis?

No. A hysterectomy is not always necessary to achieve a comprehensive treatment for endometriosis.This is a common misconception amongst many physicians and we cannot stress it enough. First and foremost, the primary treatment of endometriosis should always be laparoscopic excision of all endometriotic lesions. Only in cases of endometriosis with diffuse adenomyosis, multiple fibroids with recurrence even after a myomectomy, and/or cervical or uterine cancer, is a hysterectomy needed. For definitive treatment of endometriosis when hysterectomy is indicated, the operation should be tailored to relieve all symptoms, and not just symptoms of suspected uterine origin. In other words, many surgeons misguidedly conduct hysterectomies in order to ensure the patient no longer suffers from further spreading of endometriotic tissue. However, the endometriotic lesions that have already spread throughout the body, will go unremoved and therefore untreated. Thus in cases of endometriosis requiring hysterectomy, it is crucial that all extrauterine superficial and deep endometriosis is excised out first before a hysterectomy is conducted. This ensures all possible causes of a patient's symptoms are treated.

When is a hysterectomy needed in cases of endometriosis?

The surgical choice for treatment of endometriosis with a hysterectomy depends on many factors, including the patient’s age, severity of her symptoms, and whether she wants to have children. These are all key factors in decision-making. A thorough history and physical exam is warranted for determining many of these factors, as well as gauging the areas that may be affected in the pelvis. Diagnostic testing, such as ultrasound imaging and MRI are also useful tools in determining if a hysterectomy is required, which is strictly in instances of diffuse adenomyosis with anterior and posterior cul-de-sac obliteration. Nevertheless, a hysterectomy alone will not definitively cure endometriosis if the tissues with endometriosis in the pelvis are not also removed. Only in cases where women with endometriosis no longer wish to have children and conservative laparoscopic surgery has already been performed, is the definitive option for recurrent symptoms, total hysterectomy with bilateral oophorectomy. But even in these cases, it is still crucial that along with the hysterectomy, there should be excision surgery performed for all visually recognized and suspected endometriosis tissues. Depending on the excision expertise of the surgeon, ovarian conservation may also be considered.

Frequently Asked Questions?

What to expect on the day of your surgery?

Once you and your physician have come to an agreement that a hysterectomy is the right surgery for you, you must prepare for the day of surgery. Any trip to the operating room can be a bit intimidating, therefore we like to offer inform our patients of what to expect before coming in for your hysterectomy.

• Light bowel preparation is required the day before surgery, which entails taking stool softner in the form of magnesium citrate in order to empty the bowels. The purpose of this is when full, the bowels have a tendency of sticking to the uterus, especially in cases of extensive endometriosis such as in stage four endometriosis and frozen pelvis. Thus light bowel preparation the night before surgery can make the bowels much more accessible for your surgeon while you are in the operating room.
• A light dinner that is predominantly liquid based is also advised the night before surgery, with no oral intake after midnight.
• Expect to be in the hospital overnight or go home the same day.
• Near scarless surgery to the abdomen with three to four incisions made, each less than ⅕ of an inch (5mm). Our technique for post surgery suturing models that of plastic surgery.
• No sutures requiring a follow-up appointment are made, as we use “surgical band-aids” that can be removed two to three days following surgery.

Can I have sex after?

Certainly! It usually takes a maximum of 6-8 weeks for a patient to heal following hysterectomy surgery, whether it is a supracervical or total hysterectomy. Actually, evidence has consistently shown that the majority of women have unchanged or improved sexual function 1 to 2 years after hysterectomy [7]. Either way, your surgeon should always go over proper postoperative care measurements in order to ensure you have a successful and time efficient recovery period.

What are common complications that can arise immediately after hysterectomy surgery?

 

Infection	Internal bleeding	Nerve Injury Causing Leg Pain
Pneumonia	Ureter Obstruction Fistula (abnormal passageway between uterus and another organ or exterior of the body)	Colostomy Complications (complications in medical device that collects waste)
Hematoma (blood clot within tissue)	Wound Dehiscence (surgical wound rupture)	Bowel Obstruction

What are common complications that can arise late after hysterectomy surgery?

 

What are key surgical aspects to avoid when choosing a hysterectomy surgeon?

Improper procedure It is crucial to pick a hysterectomy procedure that suits your particular case. It is key to find a doctor who will have the patience and personability to have this type of discussion with you, while at the same time give you choices.

Many Large incisions The best surgeons can perform a hysterectomy, while at the same time ensure minimal invasion. This means that less is more. Having small and few incisions is always more preferred over large and many as it gives a lower chance of post-surgical scarring.

Avoid Robotics! Never get sucked into the “new” and “innovative” treatments, simply because of the appeal. Choose the best surgery: one that has the highest chance of success, while guaranteeing minimal invasion and a high quality of care. In the case of “cutting-edge” technological treatments such as robotic surgery, there is a lower rate of success with more and larger incisions made when compared to excision surgery performed in the hands of an experienced laparoscopic surgeon. Don’t choose cool, choose correct.

Inexperienced surgeon The final and perhaps most important aspect of any surgery, is picking the right surgeon. Your surgeon should have great experience in hysterectomies. This means that they take all of the above components, such as proper procedure and minimal invasion, into consideration. Any experienced surgeon will not only be able to perform the right hysterectomy procedure for you, but they will also make you feel comfortable while doing so.

Our Approach

How does our hysterectomy treatment ensure minimal invasion?

Having been one of the pioneers in the field of proper hysterectomy use, and with over three decades of experience to go along with it, we have mastered our technique in order to ensure minimal invasion. We have found that the laparoscopic visualization required in proper uterus removal, can be done without large or many incisions to the abdomen. Our technique ensures minimal invasion thanks in great part to our world-renowned expertise in the field, which allows us not to resort to such invasive techniques as robotic surgery. By not using robotics we are able to perform quicker, less risky and overall more productive surgery. Our results are nearly scarless.

Why do we prefer vaginal hysterectomy over abdominal hysterectomy?

Another component to our hysterectomy technique that makes our approach so unique is our expertise in performing laparoscopically assisted vaginal hysterectomies (LAVH). Most surgeons are not able to do this, especially when it comes to cases of endometriosis, due to the great skill and experience it requires to be done successfully and without complications. Before the uterus can be removed, a vaginal hysterectomy requires a surgeon to separately detach the uterus from the ovaries, fallopian tubes, upper vagina, as well as all the blood vessels and connective tissue that support it. Even in cases of endometriosis and diffuse adenomyosis, we perform all hysterectomies vaginally if possible. This is done by first excising all endometriosis lesions we can find throughout the pelvic and abdominal cavity. Overall by performing laparoscopically assisted vaginal hysterectomies, we are able to see above the uterus anatomically, giving us the ability to identify endometriosis lesions that would not normally be seen through simple vaginal hysterectomy. Using this technique, we evaluate the status of the peritoneum, cul-de-sac and the uterus’s relationship with ovaries and bowels. Also by removing the uterus through the vagina, we are once again are ensuring minimal invasion. When an abdominal hysterectomy is performed, larger and even more incisions must be made in order to remove the uterus through the abdomen. Thus we have worked tirelessly to master the technique of vaginal hysterectomy, so that we can ensure all of our patients minimal invasion.

How do we ensure endometriosis cases requiring hysterectomy, are relieved of symptoms?

We firmly believe that whenever a hysterectomy is needed in cases of endometriosis, thorough laparoscopic excision surgery should go along with it. If a patient is found to have believed endometriosis adhesions upon laparoscopic examination, then all lesions should be excised out completely before the hysterectomy is conducted. We cannot tell you how many patients come in after having hysterectomies, only to find that their symptoms and pain have not been treated. If a patient has endometriosis, simply removing the uterus does not address the many other regions where endometriosis may remain. In fact, the patient will most likely continue to experience their symptoms, as the disease spreads and pain worsens, and thus nothing is accomplished. This is why we take the time in the operating room to ensure that all lesions and signs of endometriosis are excised, even before we begin to remove the uterus. When we go into surgery our primary goal is not to just to remove the uterus, but rather it is to ensure the reason for doing so is not in vain. Working to give our patients their highest chance of symptom relief is always our primary focus, and laparoscopic deep excision of endometriosis is the best way to do so, with a hysterectomy conducted only if needed.

Why a hysterectomy is our last resort for treatment?

The final aspect that makes our expertise in hysterectomy so unique, is in the strong belief that they should only be performed when necessary. As stated before, so many surgeons perform hysterectomies without treating or even recognizing the multitude of areas where endometriosis lesions can still exist, grow and spread. In turn, this makes the procedure pretty much pointless. Not only do we recognize the futility in such procedures, but we also understand the emotional taxing this can have on both the body and mind. Once the uterus is taken out, it cannot be put back in, and a woman can longer have children. This is why it can be such an emotionally difficult surgery to undergo and is why we use it as an absolute last resort. This same conservative method of thinking goes towards how we decide our recommendation for the specific type of hysterectomy that is right for you. Meaning, we always look to preserve the ovaries if possible.There has been a potential increase risk of cardiovascular risk and bone loss in premenopausal patients with prophylactic bilateral salpingo-oophrectomy [8].This makes a hysterectomy and bilateral salpingo-oophorectomy our last option. Nevertheless, this procedure can sometimes be needed. But even in these rare instances, we always have our patients approval, understanding and consent. We always want our patients to know that they have a choice and understand our reasoning, especially when it comes to the sensitive field that is hysterectomies.

Unfortunately, many surgeons who are not well versed in endometriosis, especially those with no experience or even awareness of deep-excision surgery, do not have this mind set. They simply tell their patients that the only solution to their ailment is to remove the uterus, which in many cases is either not true or not the full story. While these may seem like small nuanced details to the average physician, to an experienced laparoscopic excision surgeon they mark the difference of a pointless hysterectomy procedure versus a highly successful excision surgery, with the possibility of preserving the uterus. This meticulous attention to detail makes a monumental difference in not only patient symptom relief following surgery, but also in the fact that a patient can be reassured if they are told a hysterectomy is required, as this decision is made after thorough examination and removal of all endometriosis lesions in the pelvic and abdominal cavity. To put it simply, there are no pointless hysterectomy procedures performed here at Seckin Endometriosis Center.

Our goal is to always ensure that all endometriosis is excised out of the body as much as humanly possible. We want our patients to have the highest chance of symptom relief and recovery, which means both physically and mentally. This is why we are so cautious in performing hysterectomies. No patient wants to hear that a hysterectomy is the only option for them. They want to be reassured that if a hysterectomy is necessary, it is only after all other options have been considered. We assure our patients that their concerns, are ours as well. We want to work with you to obtain a comprehensive and thorough understanding of your particular case in order to see if a hysterectomy is truly the right option for you, and the first step to this is through communication[9].

Patient Testimonial:
Hysterectomy for Advanced Endometriosis (Stage 4)

E.L was a patient in her early 40’s who quietly struggled with adenomyosis for nearly two years. After consulting with two other physicians, she came to us where she underwent successful supracervical hysterectomy treatment. Learn about E.L’s story here.

You can read more stories of patients who received hysterectomies, at varying stages, in our testimonial section.

References

1. Whiteman, M.K., et al., Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol, 2008. 198(1): p. 34 e1-7.

2. Novak, E., Berek & Novak's gynecology. J. S. Berek (Ed.). Lippincott Williams & Wilkins. 2012.

3. Endometriosis Foundation of America. https://www.endofound.org/video/medical-conference-2012-antonio-setubal-md-2/281.

4. Center for Disease Control. https://www.cdc.gov/reproductivehealth/data_stats/.

5. Kadar, N., Laparoscopic management of gynecological malignancies. Curr Opin Obstet Gynecol, 1997. 9(4): p. 247-55.

6. Ghomi, A., J. Hantes, and E.C. Lotze, Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol, 2005. 12(3): p. 201-5.

7. Hartmann, K.E., et al., Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol, 2004. 104(4): p. 701-9.

8. Parker, W.H., et al., Effect of bilateral oophorectomy on women's long-term health. Womens Health (Lond), 2009. 5(5): p. 565-76.

9. Seckin, T., The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016.

 

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