Hysterectomy: Purpose, Procedure, and Risks

Overview

With over three decades of experience in the field of GYN surgery, the Seckin Endometriosis Center is one of the pioneers in laparoscopic hysterectomy surgery while ensuring minimal invasion. We have been at the forefront of not only providing the proper technique for hysterectomies but also warning doctors and patients alike that the removal of the uterus should be performed with extreme diligence and only when absolutely necessary. They 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]. With endometriosis, a hysterectomy is necessary if the uterus is heavily involved with the disease, a condition called diffuse adenomyosis. However, it is common to see patients treated with an unnecessary hysterectomy by prior surgeons, only to experience persistent symptoms as lesions are left behind in the peritoneum, bowels, etc. It should be considered only by 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 if absolutely necessary and unavoidable. Regardless of whether a hysterectomy is necessary, it is imperative to also perform laparoscopic excision in order to examine and remove all other adhesions outside of the uterus. Laparoscopic excision of endometriosis lesions outside the uterus is the gold standard treatment and ensures patients their highest chance of symptom relief and recovery.

It is the surgical removal of the uterus (womb). A total hysterectomy includes the removal of the cervix. A supracervical hysterectomy preserves the cervix. Either way, it is a definitive surgical option and causes menstruation to cease.

What is the function of the uterus and ovaries?

The uterus, the source of monthly menstruation, also houses a developing fetus. In the absence of pregnancy, a typical woman has about 400 menstrual cycles during her reproductive life. The ovaries are the sites where egg development and subsequent ovulation take place, along with the production of estrogen and progesterone. Whereas estrogen prepares the lining of the uterus for pregnancy in the first 14 days of the cycle, progesterone then matures and prepares the endometrium between days 14 to 28 of a cycle 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. Then, the pregnancy continues to develop and is housed in the uterus for an average of nine months and ten days.

It is a commonly believed misconception that key reproductive hormones are made in the uterus. This is not true. The uterus is not responsible for the production of estrogen, progesterone, or any other hormones. The ovaries produce estrogen and progesterone and then feed these hormones into the uterus.

Side effects

The removal of a uterus eliminates the function it serves, which is to host pregnancy development. Without the uterus, a woman will no longer have menstrual periods nor bear children.

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 performed each year. In fact, approximately 300 out of every 100,000 women will undergo a hysterectomy at some point in their lives [4].

Why are they so common?

While a hysterectomy rate of 0.3% may not seem like such a large number, it is the second most common surgery performed on women in the United States after a C-section. Some of the most experienced surgeons in the world argue that hysterectomies are amongst some of the most overperformed surgeries in women’s health. A great number of hysterectomies are performed in order to ensure a patient will no longer suffer from disorders such as endometriosis. However, in most cases, a hysterectomy will not treat a patient's endometriosis. An endometriosis patient should always pursue laparoscopic excision surgery should first, and should only consider a hysterectomy if absolutely necessary. However, many doctors lack the experience, skill, and knowledge to perform laparoscopic excision surgery and thus settle on performing a hysterectomy. This is not a testament to how “good” or “bad” the doctor is, as they may not even be aware of this form of treatment. Nevertheless, this lack of knowledge is one of the primary reasons why hysterectomies are so common. If you decide to have a hysterectomy, it is crucial for you to make sure you have exhausted all other surgical methods and that there are no remaining endometriosis lesions in your body.

When is it necessary?

A hysterectomy should have justifiable indications. Pelvic pain, after all, may have multiple causes. In the absence of uterine disease, doctors and patients should be cautious in proceeding with a hysterectomy. In addition, pre-operative tests like MRIs do have false sensitivity in detecting uterine pathologies such as endometriosis or adenomyosis, thus any believed need for a hysterectomy based on such disorders should be confirmed with laparoscopic surgery. Nevertheless, there are several conditions where a hysterectomy is 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 these conditions?

Types

The first laparoscopic hysterectomy was performed by Harry Reich in 1988 [5]. Since then, the technique has evolved to ensure minimal invasion. Hysterectomies are performed via either the vagina or abdomen. An abdominal hysterectomy (with a surgery route through the abdomen) requires varying lengths of visible incisional scarring. A vaginal hysterectomy (with a surgery route through the vagina), provides almost no abdominal scarring and is today considered the best surgery route for a hysterectomy. However, not all uteruses can be removed via vaginal hysterectomy as the uterus may be too large, or the status of the ovaries and peritoneal disease may be unknown. There are limitations to vaginal hysterectomies. Nevertheless, in hysterectomy surgery, a laparoscope is used to visualize the uterus, ovaries, and pelvic cavity via very small incisions made through the abdomen. These incisions allow for the uterus to be removed from the vagina. The laparoscopy gives a surgeon complete visualization of the pelvic anatomy, allowing them to remove any believed abnormal pathology outside the uterus involving the ovaries and fallopian tubes that would not have been visualized if 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 called laparoscopically assisted vaginal hysterectomy (LAVH).

What are the different classifications?

Many patients are surprised to hear that there are several different forms of hysterectomies. The uterus can be removed via the abdomen or vagina. However, aside from 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 should remember that you always have a choice. A hysterectomy is a very personal and emotionally-taxing surgery, and you should feel comfortable discussing your best option. Here are a few options that your surgeon may suggest if a hysterectomy is the right procedure for you.

• Supracervical hysterectomy ("partial"): 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’ outcomes in sexual function and pelvic support. Nevertheless, patients risk ongoing cyclic bleeding from the cervix or reoperation to remove the cervix in the future[6].

  

• Hysterectomy ("total"): This form of hysterectomy removes the uterus and the cervix but preserves the ovaries. Patients often think that ovary removal is standard in a hysterectomy procedure, but in reality, ovaries will only be removed if specified. Although the ovaries are preserved, the uterus is nonetheless removed, and as a result, surgical “menopause” will occur. This means that periods will cease due to uterus removal. However, since the ovaries are preserved, key hormones such as progesterone and estrogen continue to produce. Menopause symptoms such as hot flashes, mood swings, and fatigue will not occur, as these key reproductive hormones are still present.

  

• Hysterectomy with bilateral salpingo-oophorectomy: This procedure moves the uterus, fallopian tubes, and ovaries in their entirety. The word “salpingo” is the Latin word for tubes, while "oophor" stands for ovaries, hence the 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 (the removal of the fallopian tubes and ovaries). Only when the term salpingo-oophorectomy is accompanied by a hysterectomy should patients be aware that the fallopian tubes and ovaries will be removed. With this procedure, the body goes through menopause. Estrogen and progesterone are no longer produced and menopause symptoms such as hot flashes, mood swings, and fatigue occur. This form of hysterectomy can be a very personal and emotionally-taxing issue, and it is very important to note that it should only be conducted if a patient chooses to have their ovaries removed.

  

What is a partial vs. total?

A common misconception among patients concerns the difference between a partial and total hysterectomy. It is commonly 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 (the removal of the fallopian tubes and uterus). In other words, the removal of the ovaries is not part of a hysterectomy procedure, unless specified. When patients hear the term hysterectomy, they should not be concerned about losing their ovaries unless bilateral salpingo-oophorectomy is specified. Nonetheless, doctors still use the term partial hysterectomy, but it refers to the removal of the upper half of the uterus, with the cervix preserved. To surgeons, a total hysterectomy 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 opposed to the public misperception of whether or not the ovaries are removed. In both partial and total hysterectomies, the ovaries are preserved unless specified.

Will menopause occur following a hysterectomy?

One of the side effects of a hysterectomy is that a woman will no longer menstruate. However, this end to 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. A woman’s period stops due to the removal of the uterus, but menopause symptoms such as hot flashes, vaginal dryness, and mood swings do not occur as the ovaries remain. Because of the ovaries, female reproductive hormone levels are normal, and menopause symptoms do not surface. This is not the case in hysterectomies with bilateral salpingo-oophorectomies, where the ovaries are not preserved. Removing the ovaries means the loss of estrogen and progesterone levels, thus normal hormonal menopause begins. Strong consideration should be given to conserving normal ovaries when possible, so it is imperative to carefully consider whether to seek an oophorectomy with your hysterectomy.

How will my hysterectomy type 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 maybe. 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 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 a laparoscopic total hysterectomy (LTH) and laparoscopic supracervical hysterectomy (LSCH).
• Vaginal hysterectomy: Maximum of three incisions that are each 10-12cm, which guarantees one day overnight at the hospital and one to two weeks of recovery time.
• Robotic hysterectomy: Five incisions that are each 8-12mm, which guarantees one to two days overnight at the hospital and two to four weeks of recovery time.
• Open abdominal hysterectomy: One large incision that is 10-12inches, which guarantees three to five days overnight at the hospital and six to eight weeks of recovery time.

Hysterectomy as treatment for endometriosis

Is it necessary to treat endometriosis?

adenomyosis, is a hysterectomy truly needed." />

No. A hysterectomy is not always necessary to achieve a comprehensive treatment for endometriosis. This is a common misconception among 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 a 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. In cases of endometriosis requiring a hysterectomy, it is crucial that all extrauterine superficial and deep endometriosis is excised before a hysterectomy is conducted. This ensures that all possible causes of a patient's symptoms are treated.

When is it needed in cases of endometriosis?

The surgical choice for treatment of endometriosis with a hysterectomy depends on many factors, including the patient’s age, the 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 made for a total hysterectomy with bilateral oophorectomy. But even in these cases, it is still crucial that their excision surgery is performed for all visually recognized and suspected endometriosis tissues along with the hysterectomy. Depending on the excision expertise of the surgeon, ovarian conservation may also be considered.

FAQ

Our Approach

How does our the treatment ensure minimal invasion?

As one of the pioneers in the field of proper hysterectomy use, and with over three decades of experience, 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, in great part due to our world-renowned expertise in the field. We do not resort to invasive techniques such 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 over abdominal hysterectomy?

Another component of 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. We do this by first excising all endometriosis lesions we can find throughout the pelvic and abdominal cavity. 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 a simple vaginal hysterectomy. Using this technique, we evaluate the peritoneum, cul-de-sac, and the uterus’s relationship with ovaries and bowels. Additionally, by removing the uterus through the vagina, we are ensuring minimal invasion. When an abdominal hysterectomy is performed, a greater number of incisions that are larger in size must be made in order to remove the uterus through the abdomen. We have worked tirelessly to master the technique of vaginal hysterectomy so we can ensure minimal invasion.

How do we ensure that a patient is relieved of symptoms?

We firmly believe that whenever a hysterectomy is needed in cases of endometriosis, thorough laparoscopic excision surgery should precede this hysterectomy. If a patient is found to have believed endometriosis adhesions upon laparoscopic examination, 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. 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 to not only remove the uterus but also ensure we are not doing so in vain. Our primary focus is always ensuring our patients their highest chance of symptom relief, and laparoscopic deep excision of endometriosis is the best way to do so, with a hysterectomy conducted only if needed.

Why is a hysterectomy our last resort for treatment?

The final aspect that makes our expertise in hysterectomy so unique is our strong belief that hysterectomies 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. Not only do we recognize the futility of such procedures, but we also understand the emotional tax 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 practice determines what specific type of hysterectomy we determine is right for you. We always look to preserve the ovaries if possible. There is a potential increased risk of cardiovascular issues and bone loss in premenopausal patients with prophylactic bilateral salpingo-oophorectomy [8]. As a result, hysterectomy and bilateral salpingo-oophorectomy is our last option. Nevertheless, this procedure can sometimes be needed. But even in those rare instances, we always have our patients' approval, understanding, and consent. We always want our patients to know that they have a choice when it comes to the sensitive field of 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 mindset. 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 at Seckin Endometriosis Center.

Our goal is to always ensure that all endometriosis is excised out of the body. We want our patients to have the highest chance of symptom relief and recovery, both physically and mentally. We are extremely cautious in performing hysterectomies. No patient wants to hear that a hysterectomy is the only option for them. They want to be reassured that a hysterectomy is deemed necessary only after all other options have been considered. 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 is through communication[9].

Patient Story

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 underwent successful supracervical hysterectomy treatment at Seckin Endometriosis Center. 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. Women's Health (Lond), 2009. 5(5): p. 565-76.
9. Seckin, T., The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016.