The modern trend after a hysterectomy is to be discharged as soon as possible.

The advice varies according to the type of hysterectomy.

The shortest length of stay in hospital is after a laparoscopic hysterectomy. The modern approach to this operation is as a day case procedure meaning you stay in hospital for less than 24 hours. Most women will be discharged in 1-2 days.  You may feel tired for the first few days after surgery and find yourself napping a lot. This is because your body is concentrating on healing itself.

The advice after hysterectomy is to rest, this does not mean complete bed rest. Women can expect to potter about the house but still need to take things easy and in most cases should have someone around for the first few days. Most women at this stage will still need to take some painkillers. Depending on the strength of this medication they will be advised not to operate machinery and if the medication contains “opiates” strong painkillers they may be advised not to use a hot kettle. Recovery after a laparoscopic hysterectomy will take about 1-2 weeks for the majority of women and return to work can take as little as 2-4 weeks. Of course this depends on the type of job you do.

If you work from home it is possible to undertake some work within the first week.

By the end of the week it should be possible to negotiate stairs and even visit the “corner shop” to by the newspaper. It may be best to be accompanied on the first venture out doors.

Lifting: it is important not to lift heavy objects immediately after major surgery. This includes lifting children as is often tempting. Hovering also works the muscles of the abdomen and pelvic floor it is important not to under take this activity for the first 4 weeks

Driving may take up to 2 weeks after a laparoscopic hysterectomy; you need to be free from the effects of painkillers. The advice is that if you are able to sit in a car that does an emergency stop without any discomfort. Other things you should be able to do before you drive are:

 Be able to sit in the car comfortably and work the controls

Be able to wear the seatbelt comfortably

Be able to make an emergency stop

Be able to comfortably look over your shoulder to manoeuvre.

For the vaginal hysterectomy hospital stay is usually 2-3 days and return to normal activity 2-4 weeks.

For the traditional abdominal open hysterectomy recovery can somewhat be delayed as because as well as internal healing the outside scar also needs time to heal. Hospital stay is longer and can take up to 4-5 days and recovery takes about 6 weeks

Outcomes of hysterectomy

The decision to have a hysterectomy is not to be taken lightly. It is important to have explored alternative, less invasive therapies before making the final decision.

The majority of women do well after a hysterectomy, their symptoms are resolved and they return to normal activity. Satisfaction with the outcome will often depend on what the symptoms were and how well women were counseled regarding the process and what their expectations were.

From the social point of view, it is a procedure that is surrounded by a lot of controversy.

Hysterectomy has long been regarded as an operation performed by hyster-happy often male surgeons.

In fact the medical historian Roy potter saw the rising tide in the number of hysterectomies as a manifestation of the abuse of gynaecological surgery to control women in the 19th century.

Natalie Angier in her book: Woman an intimate geography, goes on to state: Despite this major operation being routine despite the numerous indications for hysterectomy, it would be nice to find someone a doctor to blame for being hyster-happy. Unfortunately no such monster can be found and the explanation for the frequency of hysterectomy lies within the organ (the womb) itself.

Her views and those of others are backed up in some very large studies (the 1994 Maine women’s health study and the Maryland study), and in fact women are no more likely to have a hysterectomy if their surgeon is male or female.

1.     Quality of life

Large studies that have looked at this issue have found that hysterectomy is associated with

•  An increased health related quality of life
  

•  Improved sex life
  

• Increase in general health
  

•  Improved psychological outcomes
  

• Three quarters of women who had anxiety or depression before hysterectomy no longer had 12- 24 months follow up
  

•  3-10% of women who previously had no such symptoms went on to develop them 
  

2. Bladder function

Most studies demonstrate improvement or no difference in incontinence symptoms post hysterectomy

Miller et al AMJOG 2008 identical twin study

•  Hysterectomy did not predispose to incontinence
  

• Most women with urinary incontinence prior to hysterectomy will have significant improvement
  

• 10% will have new or worsening symptoms. 
  

• Most women will have improvement of symptoms at 12 months post hysterectomy
  

3.     Bowel function

There is usually no deterioration of bowel function after hysterectomy for the majority of women however about 3% may notice some sluggishness

4.     Prolapse

Hysterectomy does increase the risk of prolapse. A study by the Oxford family planning unit (Mant 1997 BJOG),followed 17,032 women from 25-39 for an average of 17 years

•  Annual incidence of surgery for prolapse was 0.16% per year
  

• For women with hysterectomy for reasons other than prolapse 0.29% per year
  

• The incidence of surgery rose from 1% at 3 years and 5% at 15 years
  

4.     Effect of hysterectomy on the ovaries

• Women who have a hysterectomy can expect that their ovaries will stop full function about 3-5 years before they would have been expected to without a hysterectomy
  

below is a video of the "ideal Hysterectomy'. A "keyhole" hysterectomy leaving the ovaries and cervix, removing the womb and the fallopian tubes

Why take your Fallopian tubes out when having a hysterectomy?

The question really is why leave them in?

After a hysterectomy the "tubes" are redundant in fact the "post reproductive” have no known benefit in fact they may be a future health hazard.

The only argument for leaving them used to be the fear of compromising the blood supply to the ovary, however this has been shown not to be true.

Researchers comparing women who had their tubes removed and those who had them left behind after hysterectomy found no difference in hormone levels. And the timing of the menopause has not been found to be different

These are the things that can go wrong with the Fallopian tube after hysterectomy:

Infection

A number of women after hysterectomy may develop infection in the remnant fallopian tube

Hydrosalpinx where the tube becomes filled with fluid this can happen in up to 30% of women after hysterectomy however only a minority of women require reoperation for this reason

Benign cysts of the Fallopian tube:

These sometimes can grow to a very large size and can be confused with ovarian cysts. They can be responsible for pain after a hysterectomy

Ectopic pregnancy:

The first case of ectopic pregnancy after hysterectomy was reported in 1895 since then there have been 56 reports in medical literature with the number of reports on the increase. It can happen after any type of hysterectomy as long as tubes and ovaries have been left.  The diagnosis of ectopic pregnancy after hysterectomy is often quite because most women and health professionals would not put ectopic pregnancy at the top of their list of diagnosis particularly after a hysterectomy. But it should be considered in every woman who has tubes and ovaries that presents with abdominal pain.

Prolapse of the Fallopian tube through the vagina

This sometimes happens after hysterectomy and can be responsible for vaginal discharge after hysterectomy

Ovarian cancer risk

There are some women who are known to be genetically at risk of ovarian cancer. These women are routinely advised to have their ovaries and tubes removed once they have completed their families.

Scientists examining the removed tubes of these women found a certain type of ovarian cancer (serous) at the end of the Fallopian tubes. Taking this research further they found that the Fallopian tube was the origin of certain types of ovarian cancer and tubal cancer even in women who did not process the gene that put them at increased risk.

For these reasons most women who are undergoing hysterectomy should ask their doctor about what will happen to their fallopian tubes

Weighing up the risk of ovarian cancer before deciding on whether to have ovaries removed at hysterectomy is always difficult. 
In a way this is because of how the medical profession has presented the risk of developing ovarian cancer. Everyone is scared of developing cancer but is the risk that great considering other illnesses that may also happen for example 20 in 100 women will die of lung cancer, and 33 in 100 will die of heart disease (figures are greater than the mortality from ovarian cancer

Ovarian cancer though relatively rare, is more common in women who have continued to produce eggs without interruption through their reproductive life. Factors that decrease ovulation help decrease the risk of ovarian cancer

What is the risk?

The lifetime risk of developing ovarian cancer in the general population is 1:70, put another way if a woman were to live to 90 the risk of developing ovarian cancer would be 1.4%.

About 1:100 women will develop ovarian cancer.

•  If a first-degree relative e.g. sister has ovarian cancer that risk increases to about 5:100.
  

• If ones grandmother or aunt has or developed ovarian cancer the risk is about 3:100
  

•  With 2 or more relatives with ovarian cancer the risk increases to 14:100
  

Factors that decrease the risk of ovarian cancer include:

1.     Taking the oral contraceptive pill for more than a year decreases the lifetime risk to 1:140, decreasing the risk by about 10%. Taken for 5years or more it can decrease the risk by 50-70%

2.     Late onset of periods decreases the risk to about 1:80

3.     Menopause before the age of 45 years decreases the risk to about 1:85

4.     Having one or more children decreases the risk to about 1:140

5.     Breast feeding decreases the risk

6.     Tubal sterilization decreases the risk by about 30%

7.     Hysterectomy decreases the risk by 50%

A family history of ovarian cancer increases the risk, however this again needs to be taken in context as less than 10% of ovarian cancers are in women who are susceptible due to genetics. In women with the gene implicated in ovarian cancer may have up to a 50% chance of developing ovarian cancer and are sometimes advised to have their ovaries removed once they have completed their families.

The risk of ovarian cancer needs to be weighed against the risk of other things that can occur once the ovaries are removed. Therefore in the absence of a strong family history or in some cases severe endometriosis with pelvic pain, it is always better to keep ovaries.

Should ovaries be routinely removed at hysterectomy?

The decision whether to remove or keep ovaries at the time of hysterectomy should not be taken lightly

The balance between keeping and removing ovaries at the time of hysterectomy is centered on the potential risk and fear of the development of ovarian cancer and the risks of going into the menopause once the ovaries are removed.

The ovaries do not “die” after the menopause, they continue to produce hormones for many years after the change and these hormones continue to be beneficial for well being.

Another issue is with the use of hormone replacement therapy. HRT used to be the “panacea” for all illnesses in women over the age of 45. But with the much-publicized HRT scare in the mid 1990s (even though the risks of HRT were overstated), many women are reluctant to take HRT and many doctors are reluctant to prescribe them. Even in women who had their ovaries removed during hysterectomy, one study suggests that only 30% of women who were prescribed HRT continued to use it.

There was a time when nearly all women over the age of 45 were advised to have their ovaries removed when having a hysterectomy this was to prevent ovarian cancer.  For this reason in 1999 nearly 80% of women having a hysterectomy had their ovaries removed compared to just 25% in 1965. But this risk should be looked at in perspective and in relation to the individual patient. The risk of developing ovarian cancer has probably been overstated in medical literature.

In women who do not have a first degree relative with ovarian cancer the lifetime risk is 1:70. This risk is halved if a hysterectomy is performed and ovaries left behind, and decreased by a third in women who have been sterilized.

In order to prevent one case of ovarian cancer about 100 pairs of ovaries would need to be removed.

So the benefit of removing ovaries at the time of hysterectomy needs to be weighed against.

The increased risk of heart disease

• Oophorectomy (removal of ovaries) after the age of 50 increases the risk of stroke by 40% in women who do not take HRT (Hormone replacement therapy.
• There is a 2.2 fold increase in ischaemic heart disease in oophorectomised

women not on HRT

The increased risk of osteoporosis and the increased risk of fracture

• Women who have had their ovaries removed over the age of 60 have a two fold increase in mortality after low impact hip fractures
• Women also have a 54% more osteoporotic fractures

There is also a decline in cognitive ability in women with their ovaries removed after the age of 60 this increases the risk of

• Dementia
• Parkinson’s disease

There is also a decline in sexual function after the ovaries have been removed related to the decrease in testosterone produced by the ovaries.

A medical study looking at the balance of risk after removal of ovaries at hysterectomy without the use of HRT suggests that:

If we take 10,000 women and remove their ovaries between the ages of 50-54 and follow them up till age 80

• ·      Removing their ovaries would have prevented 47 deaths from ovarian cancer 

                                 But resulted in

• ·      838 deaths from heart related illness 

                                  And

• ·      158 deaths from hip fracture.
  

For the above reasons I would not advocate the routine removal of ovaries at the time of hysterectomy.

It is very important to get into an individualized discussion with your doctor about your ovaries before having them removed at hysterectomy    

The video below shows a large fibroid uterus weighing 850g being removed laparoscopically the normal uterine size is between 60-90g. This video shows that even for large uteruses laparoscopic subtotal hysterectomy "LASH" is possible

The laparoscopic subtotal hysterectomy also known as the Laparoscopic supracervical hysterectomy or LASH for short is the ideal hysterectomy and here is why:The laparoscopic subtotal hysterectomy is least traumatic hysterectomy to recover from.

There should be no reason why a woman with a normal cervix, who has had normal smears should have her cervix removed, especially if she is having a hysterectomy for fibroids or for heavy periods.

The arguments for and against having a laparoscopic subtotal hysterectomy are:

1. Shorter recovery time: recovery from the procedure takes about 1-2 weeks with a full return to function for most women within 2-4 weeks
2. Better sex: the jury is still out on this, but what is known is that

• Women who have subtotal hysterectomy resume sex earlier than women who have had a total hysterectomy.
• Some believe that from some women orgasm originates from the cervix. If this is the case then if the cervix is left behind then the source of orgasm is not removed.
• The vagina is not entered when a subtotal hysterectomy is performed therefore the vagina is not shortened therefore theoretically sex life should not change

  3. Prolapse: theoretically the use of subtotal hysterectomy should prevent prolapse. 
     This is because the ”pericervical ring” tissue around the cervix that helps support the vagina is not interrupted   
      during the procedure. Scientific studies however have not been done to support or refute this.
 4. Bladder of bowel function: there is no difference in bowel or bladder function
 5. Decrease in complication rates:  
     the major injury that is reduced is injury to the ureters. Because the operation is above the ureters they are
    protected.
 6. Easier operation for the surgeon

Those that argue against leaving the cervix behind argue that it may be the source of future cancer. The risk of developing cervical cancer on the cervical stump after 3 negative smears is less than 0.4%.  This risk is much less than developing cancer of the vagina after total hysterectomy but no one removes the vagina because of future risk of that cancer.

As with all things the risks need to be balanced against the benefits.

In summary LASH is the ideal hysterectomy for heavy menstrual bleeding it is ideal because:

1. Hospital stay can be only 24 hours in fact it can be done as a day case procedure
2. It produces minimal scaring - Minimally invasive
3. It is the most cosmetic - no large abdominal incision
4. Causes the least stress to your body
5. There is no scar in vagina 
6. There is no shortening of the vagina
7. Fewer complications
8. It provides more satisfactory sex life after surgery

Before having your hysterectomy get into discussion with your surgeon. Ask whether there is any reason why your cervix should not be left behind.

 The reason for possible add on procedures at the time of hysterectomy is that the  practice of medicine is both an art and a science and it is forever evolving. One of the principles of the practice of medicine include

1. Curing illnesses

                      And where possible 
  2. Preventing future illness
Where the natural history of an illness is known preventative measures can be taken to prevent future illness. A good example of this is the cervical screening program for the prevention of cervical cancer, which has certainly successfully brought down the number of deaths from cervical cancer. Unfortunately the screening program for the prevention of ovarian cancer has not been as successful because the natural history of ovarian cancer is not as clear.

Where the natural history is not known in order to prevent future illness the doctor and patient come to an individualised agreement based on potential future risk of developing an illness.

For this reason whilst undergoing surgery for one illness your doctor may advise that you have another organ removed to prevent future illness 

A good example of this is when having a hysterectomy your doctor may advise that you

1. Have your ovaries removed

2. Have your cervix removed

3. Have your Fallopian tubes removed

This is usually irrespective of whether you are having your operation by traditional open surgery or by laparoscopic surgery.

 These "prophylactic" or "bolt on" procedures may not be necessary but may have implications for future health.

When deciding on the route of hysterectomy irrespective of patient preference and surgeon skill there are certain things the surgeon needs to take into consideration:

1.     The angle of the arch of the pelvis

2.     The descent of the uterus

3.     The size of the uterus

                                                                   4.     The disease process being treated

The medical teaching is that most hysterectomies should be vaginal. And for a vaginal hysterectomy the angle of the arch of the pelvis should be more than 90degrees, and there should be good uterine descent. These factors allow the surgeon access to the uterus via the vagina. The ideal size of uterus for a vaginal hysterectomy is below 280g (the normal uterus weighs between 60-90g), with uteri (wombs) bigger than this it is possible to perform vaginal hysterectomy but this again requires a very skilled surgeon.

Apart from size of the uterus the shape of the uterus also plays an important part in decision-making, the broader the uterus the more difficult the surgery and if the uterus is too broad even laparoscopic hysterectomy may not be possible.

If the uterus is immobile or there is added pelvic pathology in order to visualize the pelvis a laparoscopic hysterectomy may be required.

There should be few if any reason for open abdominal hysterectomy as it is possible to remove very large uteruses either vaginally or by means of laparoscopic surgery. There are reports of uteri up to 3kg being removed laparoscopically. I have published in medical literature of techniques that can simplify laparoscopic hysterectomy for the larger uterus with fibroids.

In medical literature when comparing types of hysterectomy

1.    Vaginal vs. abdominal hysterectomy

a.     Shorter hospital stay

b.     Faster return to normal activity

c.      Fewer post operative complications

2.    Vaginal vs. laparoscopic hysterectomy

a.     In experienced hands no increase in operative time and no additional complications

3.    Laparoscopic vs. abdominal

a.     Shorter post-operative recovery and return to normal activity

b.     Shorter hospital stay

c.      Lower operative blood loss

d.     Decreased fever

e.     Fewer infections

f.      Though literature suggests longer operating times and complications this was found not to be the case in expert hands. A recent study looking at 4000 women found the complication risk to be less than 1%

In the United Kingdom as in most countries the majority of hysterectomies are still performed by the open traditional method, mostly because of surgeon preference.

Before having a hysterectomy it is important to ask your doctor

1.     What their commonest method of hysterectomy is

                   a.     For normal sized uterus

                   b.     For the large uterus

2.     Are they able to carry out laparoscopic or vaginal surgery in order to avoid an open operation?

It is true that there are now many treatments available for the treatment of heavy or abnormal menstrual bleeding but despite this hysterectomy remains the commonest major gynaecological procedure. About 600,000 of these operations performed yearly in the USA. This means that one hysterectomy is performed every minute of every day of every year.

It is a big step for any woman to have her womb removed however there are women who need to have hysterectomy.

 For reasons other than cancer some indications for hysterectomy include:

• Heavy menstrual bleeding where other less invasive techniques have failed. Indeed a hysterectomy under these circumstances gives 100% guarantee that bleeding will stop.
• Fibroids. Hysterectomy is only used for the treatment of fibroids if family is complete and or  more conservative treatments have failed.
• Pelvic pain. Unfortunately hysterectomy will not always cure pelvic pain. The chances of cure will depend on the cause of the pain. The quoted figures range between 70-90%

Hysterectomy is a major operation and  can be associated with complications and as with all things, there has to be a balance of benefits against a background risk.

The morbidity and mortality from hysterectomy has dramatically decreased in modern times, and the method of performing hysterectomies has also changed.

Most early hysterectomies were subtotal hysterectomies where the neck of the womb "cervix" was left behind. This was because the risk in those days was from bleeding, infection and anaesthetic. But with improvements in antibiotic therapy and sterile techniques as well as reliable blood transfusion these risks were reduced. Moving forward it was noticed that as women who had subtotal hysterectomy were at risk of developing cervical cancer. Thus the wheel turned again and more women ended up having total abdominal hysterectomies.in the 1940s however the cervical screening program was introduced, this successfully reduced the morbidity and mortality from cervical cancer

Indeed if a woman has had 3 normal smears and is on a screening program the risk of developing cervical cancer is negligible.

The focus of the ideal hysterectomy for these reasons has thus once again shifted.The focus now is on the least traumatic, the least painful, early recovery, reduced hospital stay, early return to normal activity and family life and least complications

The choices for the modern woman who has decided to have a hysterectomy are:

Laparoscopic "keyhole" hysterectomy

Vaginal hysterectomy

Abdominal hysterectomy

For either type of hysterectomy consideration needs to be given to

• Taking out the ovaries at the same time or not
• Taking out the cervix at the same time or not
• Taking out the fallopian tubes at the same time or not

In the coming weeks I shall be comparing the risks and benefits of these procedures