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Hysterectomy
For removal of the uterus

More than 500,000 women have a hysterectomy in the United States. The procedure is performed for a variety of diseases, and particularly for cancer of the uterus or ovary.

Anatomy and Physiology

The uterus or womb is a pear shaped organ that is found in the female pelvis at the top of the vagina. It varies in size and shape depending on the hormonal and childbearing status of the woman. It has a cavity, which is essentially closed when the woman is not pregnant. The inside lining of the uterus, called the endometrium, separates from the uterine wall each month. The vaginal bleeding that occurs is called the menses or period. The menses do not occur during pregnancy and normally continues until the menopause. (Figures 1,2, and 3).

Figure 1 - Anatomy of the uterus and surrounding organs as seen in a section through the middle of the body. © C. ScaliciFigure 2 - Uterus as seen from in front. © C. Scalici
Figure 3 - View of the uterus, ovaries, Fallopian tubes, and round ligament through a laproscope. (Courtesy O. Kadry, M.D.)
  • The lowest portion of the uterus at the point that it connects to the vagina contains the neck of the uterus or cervix. The opening in the center of the cervix is the entrance to the to the uterine cavity. The inside of the uterus is lined with a layer of special cells, the endometrium
  • The Fallopian tubes are found at the upper end of the uterus. There is one Fallopian tube on each side of the uterus. These are hollow tubes through which the fertilized egg travels to reach the uterus
  • The ovaries lie just beneath the other end of the Fallopian tubes and contain the female's eggs. The Fallopian tubes hang over the ovaries like a hood
  • When an egg leaves the ovaries, it is directed by the hood into the Fallopian tubes and then through the tubes into the uterus where the egg may implant into the uterine wall
  • There are a series of ligaments that attach the uterus and Fallopian tubes to the pelvic wall. The blood vessels to the uterus and ovaries are contained within these ligaments
  • Lymph nodes are found near the uterus and along the blood vessels of the uterus. Lymph nodes are small glands about the size of a small nut that are part of the lymphatic system. The lymphatic system is found throughout the body and is composed of the nodes connected by thin channels (lymphatics) filled with a colorless fluid called lymph. This system is important since it acts as one of the first defenses against disease
  • In some patients there may occur congenital abnormalities of the uterus including a completely double uterus or a doubling of only parts of the uterus. Sometimes there is only one Fallopian tube

Pathology

Various conditions found in women may be corrected by removal of the uterus, Fallopian tubes or ovaries.

  • Cancer of the uterus, cervix, ovaries, or Fallopian tubes
    1. Cancer of the uterus forms in the endometrium and is the most common female malignancy in the pelvis. It occurs primarily in postmenopausal women. Two to three percent of women develop this type of cancer in their lifetime
    • Women who use oral contraceptives appear to have a reduced risk of uterine cancer. In contrast, women past menopause who take estrogen (female hormone) containing medication for a long period may have a slightly greater risk of cancer, but not if the estrogen is combined with progesterone (another female hormone)
    • A breast cancer fighting medication called tamoxifen, which is also a hormone, may slightly increase the risk of uterine cancer
    1. Cervical cancer is the third most common gynecological malignancy of the pelvis. It occurs most frequently between the ages of 35-39 and 60-64 years (Figure 4)
    1. Ovarian cancer is the second most common gynecological malignancy of the pelvis, but more women die from ovarian cancer than from uterine or cervical cancer. This is because there is not a good screening test for this cancer and women usually do not have any symptoms until the cancer is large or has spread to other organs
    2. Cancer of the Fallopian tube is very rare
  • Fibroids (leiomyomas) are benign uterine tumors. They are the most common pelvic tumor in the female, found in 20-30% of women. This is the most common reason for a hysterectomy. (Figure 5)

    Figure 4 - Lymphatic drainage of the uterus in the presence of carcinoma of the cervix. Figure 5 - Large uterine fibroid as seen through the laproscope. (Courtesy O. Kadry, M.D.)
  • Endometriosis is a disease in which the tissue that normally lines the cavity of the uterus is found implanted (stuck) to the tissues of the pelvis outside of the uterus. These implants are hormonally active and may cause severe pelvic pain and/ or scar formation. (Figure 6a&b)
    Figure 6a - Small area of endometriosis on the pelvic wall as seen through the laproscope. (Courtesy O. Kadry, M.D.) Figure 6b - Laproscopic view of a large endometrial implant in an ovary (Courtesy O. Kadry, M.D.)
  • Pelvic inflammatory disease is an infection of the uterus and Fallopian tubes. This is frequently caused by sexually transmitted diseases such as gonorrhea. A hysterectomy is indicated in these patients only if they have not responded to antibiotics
  • Genital prolapse occurs when the supporting ligaments of the uterus are weak leading to a dropping of the uterus into the vagina. These patients may have partial or total prolapse of the uterus out of the vagina (Figure 7)
    Figure 7 - Prolapse of the uterus into the vagina.
  • Benign ovarian tumor may be an indication for surgery if persistent or symptomatic. At the time of surgical removal of the ovaries some patients may request removal of the uterus

History

The symptoms and signs of the various conditions affecting the uterus and ovaries depend on the disease.

  • Cancer of the uterus usually presents with bleeding. This may be an increase in the amount of bleeding or in the number of days of bleeding at the time of the menses or the presence of bleeding after the menopause ยท Cervical cancer may cause bleeding after intercourse
  • Ovarian cancer in its earlier stages may only cause a feeling of pressure in the pelvis. Later there may be pelvic pain and an increase in abdominal girth
  • Leiomyomas or fibroids may cause pelvic pressure or pain, or heavy vaginal bleeding
  • Endometriosis usually causes pain in the pelvis frequently aggravated by intercourse. It also is a relatively common cause of infertility
  • Pelvic inflammatory disease is an infection of the uterus and Fallopian tubes. This is frequently caused by sexually transmitted diseases such as gonorrhea and chlamydia. A hysterectomy is indicated in these patients only if they have not responded to antibiotics
  • Genital prolapse causes a feeling of pressure in the pelvis. As it becomes more severe the cervix of the uterus begins to protrude to or outside of vagina. Urinary problems may also occur, particularly dribbling of urine (incontinence)
  • Benign ovarian tumors may produce pelvic pain
  • A few ovarian cancers have an abnormal gene that is suggested by the following:
    1. close relatives with ovarian cancer
    2. a close relative with ovarian cancer and a close relative with breast cancer under the age of 50
    3. ovarian cancer and two close relatives with breast cancer under the age of 60

Diagnostic Tests

  • X-rays of the abdomen and pelvis may show a tumor or fluid (called ascites)
  • CT or MRI scans of the pelvis may show the uterus and whether it is enlarged or contains cancer. These tests may also show if there is a spread of cancer to the surrounding tissues such as the bladder and bowel
  • Abdominal ultrasound uses a small instrument that is passed over the skin of the abdomen. The sound waves produce a picture of the inside of the abdomen
  • Vaginal ultrasound is a device that is placed in the vagina and uses sound waves to produce a picture of the inside of the uterus
  • Laparoscopy uses a small fiber optic scope attached to a video camera to examine the inside of the abdomen. The scope is inserted through a large needle (trocar)
  • Dilatation and curettage (D & C) is a procedure that is carried out under anesthesia. The opening in the cervix is stretched (dilated) and an instrument is inserted that allows the endometrium of the uterus to be scraped. The tissue (biopsy) is sent for examination under a microscope
  • Endometrial (suction biopsy) is similar to a D & C except it does not require an anesthetic. A small tube is passed through the cervix into the uterus. Gentle suction is then used to obtain a biopsy of the endometrium.
  • Hysteroscopy uses a small fiber optic scope attached to a video camera to look inside the uterus. The instrument aids in selecting tissue for biopsy
  • Pap smear is a test in which the surface of the cervix is scraped and placed on a glass slide. The slide is processed and the cells reviewed under a microscope to see if the cells are cancerous
  • Certain tests are particularly helpful in the diagnosis of the various diseases of the uterus and ovaries
    1. Uterine cancer - endometrial biopsy
    2. Cervical cancer - pap smear, cervical biopsy
    3. Ovarian cancer - ultrasound
    4. CT scan Fibroid uterus - ultrasound, CT scan, MRI scan Endometriosis - laparoscopy
    5. Pelvic inflammatory disease - laparoscopy Genital prolapse - physical exam
    6. Benign ovarian tumor - abdominal ultrasound

     

Indications for Hysterectomy

Hysterectomy may be performed for the following of diseases of the uterus

  • Fibroids
  • Endometriosis
  • Cancer or premalignant disease
  • Genital prolapse
  • Stress incontinence (involuntary loss of urine)
  • Chronic pelvic pain
  • Abnormal uterine bleeding
  • Severe pelvic infection
  • Emergency hysterectomy such as may be necessary for severe bleeding from the uterus after delivery or during surgery

Alternatives to Hysterectomy

  • Uterine artery embolization may be used instead of hysterectomy for the treatment of fibroids. A catheter is inserted into the uterus through which small particles are injected into the blood vessels supplying the fibroid. By cutting off its blood supply the fibroid will shrink
  • Endometrial ablation and resection involves removal of the endometrium. It can be carried out under local anesthesia and may be used for excessive bleeding, fibroids and polyps
  • Myomectomy is removal of a large fibroid while preserving the uterus
  • Laser ablation of the endometrium has been used in cases of excessive bleeding

Procedure

A hysterectomy is the treatment of choice for the various diseases noted above, most particularly, for cancer of the uterus. In cancer surgery the surgeon usually removes not only the uterus but also both ovaries and the Fallopian tubes so as to remove as much of the cancer as possible. The tissues are then given to a pathologist who examines the tissues to determine if all the cancer was removed. If the entire tumor has been removed, no further therapy may be necessary.

Abdominal hysterectomy

  • The uterus is removed through the abdomen (Figures 8 & 9)
Figure 8 - Abdominal hysterectomy. The Fallopian tubes and the ligaments that suspend the ligaments and run with the blood vessels have been clamped and tied. Figure 9 - Cross-section view showing the separation of the uterus from the bladder and the line through which the vagina is cut to separate the uterus from the vagina. The upper end of the vagina is then sutured closed.
  • The surgery is carried out under general anesthesia. A small tube is placed in the airway so that the anesthesiologist can control breathing. A catheter is placed in the bladder
  • In some cases small catheters are also placed in the ureters (the long thin tubes that carry urine from the kidneys to the bladder) so that the surgeon can easily identify the ureters, particularly in the presence of cancer or adhesions
  • Usually an antibiotic is given before the operation begins to minimize infection
  • In some cases, particularly with cancer, the patient may be placed on a low residue diet 2-3 days before surgery. This reduces the chance of contaminating the surgery should the bowel be injured
  • The incision for removal of the uterus may be made horizontally (from side to side) about one inch above the pubic bone or may be made in the midline from just below the umbilicus (belly button) to just above the pubic bone
  • The incision is carried into the abdominal cavity and pelvis
  • The ligaments that attach the uterus to the pelvic wall are separated and surgical clamps are placed across the ligaments and the blood vessels that run along with the ligaments. These structures are cut and the ends tied with suture
  • The ovaries may or may not be removed depending on the disease
  • Care is taken to identify and preserve the ureters. The bladder is separated from the front lower aspect of the uterus and cervix
  • The upper end of the vagina is entered and separated from the uterus leaving a deep opening in the vagina, which is then closed with sutures
  • The tissues of the abdominal wall are then closed in layers with sutures and the skin closed with suture or staples

Laparoscopic Hysterectomy

In certain circumstances a hysterectomy may be carried out using a laproscope. Instead of a large incision, several small incisions are made through which the laproscope and specially designed surgical instruments are passed into the abdominal cavity and pelvis. The surgeon while viewing a monitor carrying the image from the laproscope manipulates the surgical instruments. Except for the technical aspects of the procedure, removal of the uterus is essentially the same as described above,

Vaginal hysterectomy

  • The uterus is removed through the vagina
  • The surgery is carried out under general anesthesia
  • A catheter is placed in the bladder
  • An incision is made in the upper end of the vagina
  • The cervix is separated from the bladder in front
  • The ligaments containing the blood vessel to the uterus are clamped with a surgical clamp, cut and tied with sutures
  • The uterus is brought out through the vagina and the cut end of the vagina sutured

Complications

There is no surgical procedure that is free of the possibility of complications.

  • As with any surgical procedure there may be a complication of the anesthetic
  • Injury to the bowel or rectum
  • Injury to the bladder or ureters
  • Hemorrhage that may require a blood transfusion
  • Wound Infection
  • Urinary tract infection
  • Incontinence
  • Urinary retention requiring continued use of a catheter
  • Bowel obstruction
  • Vaginal pain
  • Fistula (abnormal communication) between the vagina and bladder or rectum

After Surgery

Recovery in the hospital is generally 3 days for uncomplicated cases. A longer stay may occur if there has been a complication.

  • The catheter in the bladder is usually removed the first day after surgery
  • You will also have intravenous fluids and pain medication
  • In uncomplicated cases, the patient is usually given clear liquids on the first day after surgery, and usually tolerates solid food by the second day
  • Sutures are usually removed from the skin incision on the third day just before the patient is sent home. You are given a prescription for pain medication and instructions for follow up in the doctors office
  • Following removal of the uterus you will no longer have your monthly periods or be able to become pregnant
  • Sexual intercourse should be avoided as directed by your surgeon, usually about six weeks. This allows the wound to heal properly. If you have any questions about when to resume intercourse, be sure to discuss this with your surgeon

Other Therapy for Treatment of Cancer

Radiation therapy is used when the cancer cannot be completely removed. It destroys the cancer cells by directing high energy X-rays to the involved tissues.

    1. Your doctors may determine that the cancer cannot be removed surgically and may treat with radiation only
    2. Radiation therapy may also be used if the cancer comes back later
    3. Radiation therapy can be given from the inside using a source of radiation that travels only a short distance or from the outside

Hormonal therapy

    1. Cancer of the uterus may be sensitive to hormones such as progesterone, which occurs naturally
    2. Chemically engineered medications similar to progesterone but more potent are used such as medroxyprogesterone acetate (Provera)
    3. Hormonal therapy is generally used when it is believed the cancer has recurred or has spread to other parts of the body (metastasized)

Chemotherapy

    1. Chemotherapy, like hormonal therapy, is used when the cancer has recurred or metastasized
    2. These drugs are very potent and while they are primarily directed to the cancer cells, normal cells, particularly blood cells may be affected. This may produce a loss of the white cells that protect against infection.
    3. Other side effects include
      • nausea
      • vomiting
      • loss of hair
      • mouth ulcer