Why would any woman choose to have a hysterectomy today when so many alternatives are available? For a woman with fibroids, there are several reasons. The first is that hysterectomy provides a cure for uterine fibroids and eliminates the problem of recurrent fibroids. If a woman wants to eliminate her risk of fibroid symptoms in the future, hysterectomy is currently her only choice.
Second, hysterectomy also cures a number of other problems that can coexist with uterine fibroids. Conditions such as adenomyosis, endometriosis, and endometrial polyps can cause some of the symptoms being attributed to the fibroids. Other conditions that are not related to fibroids—such as cervical dysplasia (a precancerous condition detected by abnormal Pap smears)—may be best treated with hysterectomy, which simultaneously eliminates the fibroids and these unrelated problems.
Finally, studies show that hysterectomy improves the quality of life for most women with fibroids. There are sometimes good reasons for a woman to have a hysterectomy. However, hysterectomy is a major surgical procedure. It requires either a general anesthesia or a spinal or epidural anesthesia. It requires staying in the hospital at least a day and possibly several days. Depending on the size of the uterus, hysterectomy requires at least a vaginal incision and, usually for women with fibroids, one or more abdominal incisions, as well. There are also risks of post-operative anemia (sometimes requiring transfusion), infection, and other typical complications of surgery, although serious complications are rare. (Most reports of complications following hysterectomy include women undergoing this procedure for cancer as well women with fibroids. Women with cancer have higher rates of complications.)
Some data suggest that vaginal hysterectomies result in fewer complications than abdominal ones. However, a woman who has a very large uterus or who has had multiple prior surgeries, and who therefore would not be eligible for a vaginal hysterectomy, may be at risk for additional complications. The decreased risk of complications for a vaginal hysterectomy may be less related to the surgical approach per se and more related to the physiological characteristics of the woman who is eligible to undergo this procedure. Only a study in which women with similar uteruses are randomly assigned to the two types of hysterectomy would help us understand the different outcomes. Complications for abdominal hysterectomies appear to be increased in women with larger uteruses.
A total abdominal hysterectomy (TAH) removes both the fundus (top) of the uterus and the cervix. Leaving the cervix in place is termed a supracervical (above the cervix) hysterectomy (SCH) or subtotal hysterectomy. In a vaginal hysterectomy (VH), the cervix is generally removed because it is difficult to remove the uterus from a vaginal approach without first removing the cervix. Removing the ovaries is normally considered a second procedure, a bilateral salpingo-oophorectomy (BSO), meaning removal of both (bilateral) ovaries (oophorectomy) and fallopian tubes (salpingectomy).
Types of Hysterectomy
Several types of hysterectomy are available. The terminology can be somewhat confusing, and it is easiest to think about the options in the following way:
1. Will the ovaries be removed or left in place?
2. Will the cervix be removed with the rest of the uterus or left in place?
3. What type of incision(s) will need to be made to remove this uterus?
Will the ovaries be removed or left in place?
The ovaries generally are not removed when a hysterectomy is performed for uterine fibroids. Removing the uterus alone will cure the bleeding and the size-related symptoms caused by the fibroids. Removing the ovaries is thus not required in treating fibroids as it is for other diseases like endometriosis or gynecologic cancers.
Many physicians were taught that at a set age (which varies between 35 and 50) women should be told that removal of the ovaries is recommended as part of the surgery, in the mode of “while we are there, we may as well.” The general teaching had been that ovaries don’t have any function after menopause and the risk of ovarian cancer increases with increasing age, so removing the ovaries near the time of menopause was a no-lose proposition. This was especially true if hormone replacement therapy could be used to help younger women transition to the time when they would naturally go through menopause.
However, more recent research suggests that although after menopause the ovaries don’t make much estradiol (the major estrogen in premenopausal women), they make a tremendous amount of androgens (usually thought of as male hormones). It is thought that these androgens may be important in maintaining mood and sex drive. In addition, the risks of hormone replacement have become clearer, and many fewer women choose to use hormones following menopause. (Most women are aware that there has been research from the Women’s Health Initiative demonstrating significant complications with postmenopausal hormone replacement therapy. However, it is not widely known that the risks are lower for women without a uterus, who are able to take estrogen alone. Recently the role of prematurely losing the ovaries in increasing the risk of heart disease has also been explored.
Considering all these factors, there are good reasons to retain the ovaries if possible. The major reason to remove them at the time of fibroid surgery is if the woman has a high risk of ovarian cancer. There are several Internet-based sites that help women assess their risk of ovarian cancer—the Women’s Cancer Network (www.wcn.org), for example. There is also strong evidence that removing the uterus, even if the ovaries are left in place, reduces the risk of ovarian cancer. (A similar reduction in ovarian cancer risk is seen in women who have had a tubal ligation, suggesting that there is some kind of molecular communication between the uterus and ovaries.) Thus, unless they have a high risk of ovarian cancer, many women choose to keep their ovaries when undergoing a hysterectomy for fibroids.
Should the cervix be removed with the rest of the uterus?
Just as with the ovaries, the cervix does not need to be removed to remedy the symptoms caused by uterine fibroids. In fact, in the era before we had good antibiotics, the cervix was routinely not removed because removing it would entail entering the vagina, which leads to an increased risk of postoperative infection. (The vagina, just like the mouth, is filled with bacteria.) However, with better antibiotics, the trend became to remove the cervix to prevent cancer of the cervix from developing. Supracervical hysterectomy has only recently come back into practice.
The development of the Pap smear (named for its inventor, Dr. George Papanicolau) has made it less necessary to remove the cervix during hysterectomy. The Pap smear became one of the most important early detection and prevention tools for any cancer ever seen. A Pap smear involves using a small brush or spatula (or both) to gently collect cells on the surface of the cervix so they can be viewed under a microscope. Not only can cancerous cells be detected early, when treatment options are better, but precancerous cells can be detected and treated, so that cancer is prevented. These precancerous cells, called cervical dysplasia, can be frozen, burned, or surgically removed. Increasingly, tests for human papilloma virus (HPV), which is thought to cause cervical cancer, can also be used to predict who is most at risk for developing cervical cancer. (A vaccine to prevent HPV infection has been introduced and is likely to have a big impact on this disease in the future.)
The major reason for removing the cervix at the time of hysterectomy for fibroids continues to be eliminating the possibility of cancer of the cervix. This risk is very low, however, if the woman has never had an abnormal Pap smear and is in a mutually monogamous relationship (neither she nor her sex partner has additional partners, which eliminates new exposure to HPV). This risk is also low if women continue to get Pap smears or HPV testing (or both) as recommended following SCH. However, many women do not receive this routine preventive care and may be less motivated to get Pap smears once their fibroid problems are resolved with hysterectomy. It is also possible that new fibroids could develop in the cervix if it is left behind. This has never been reported but could occur.
An argument for retaining the cervix is that it may be important for sexual function and pelvic support. Clearly the cervix is stimulated during vaginal intercourse, and removing it changes the vagina and leaves some scar tissue where the cervix was removed. Early studies suggested that women had improved sexual function following SCH, but generally no comparison group was studied. However, a recent randomized clinical trial in which half the women were randomly assigned to SCH and the other half to TAH suggests that sexual function is the same, at least up to two years following surgery. Other studies suggest that preoperative sexual function and depression are important determinants of sexual function after hysterectomy. For most women without depression, sexual function improves following definitive resolution of symptoms.
Problems with pelvic support following hysterectomy cause the bladder, bowel, and vagina to bulge downward, or prolapse. To understand prolapse, it helps to visualize the uterus like an upside-down pear suspended in the middle of a large mixing bowl. The bowl represents the pelvic bones, and the pear represents the uterus with cervix. There are two pairs of tough fibrous bands that keep the uterus in place by connecting the bony pelvis and the cervix. The cardinal ligaments go out from either side of the cervix and attach to the sides of the pelvis. The uterosacral ligaments go out from the cervix, go around the bowel, and hold the cervix to the sacrum, the part of the pelvis analogous to the back of the bowl. These attachments provide the major structural support of the uterus.
If the cervix is left in place, the cardinal and uterosacral ligaments remain. If the cervix is removed, these ligaments are cut and sutured where they attach to the cervix. Women worry that after a hysterectomy they will have a big “hole” in the pelvis where the uterus and cervix used to be. There is no hole after surgery because the bowel and bladder, which are also located in the pelvis, naturally expand to fill the space where the uterus and cervix had been. The bowel and bladder regularly expand and contract in size with normal bowel and bladder function. These organs have more freedom to occupy the middle of the pelvis following hysterectomy.
If the cervix is removed and these ligaments are cut, the bowel, bladder, and rectum, which rest on the cervix or lower part of the uterus, may be pulled downward by the force of gravity over time. This has historically been a major problem following hysterectomy. However, these ligaments also tend to be stretched during childbirth, and in the past women had more children and more vaginal deliveries than women do today. Thus, it is not clear whether this risk will be the same for women in the future as it has been in the past. There is also increasing evidence that particular women with less strong collagen or problems with extracellular matrix (ECM) may have an increased risk of prolapse.
The randomized clinical trial comparing TAH and SCH can guide us on this issue, as well. This study reported that women who underwent SCH had fewer intraoperative complications and a quicker recovery than women undergoing a TAH. However, approximately 7 percent of women who had an SCH had some sort of cyclic bleeding. This cyclic bleeding is typically spotting or staining and is much less heavy than a normal period, but it occurs at the same time (monthly) in response to the changes in the ovarian hormones that cause normal periods. Over the first year there were no differences in bladder functioning or prolapse, but there were a few women in the SCH group who had prolapse of their cervix. Finally, over the first two years of follow-up there was improved quality of life and sexual functioning (as we discussed previously) in both groups.
Most doctors believe that the reason for cyclic bleeding following SCH is that some of the endometrial lining in the uterus was left behind with the cervix. For that reason, many gynecologists will remove the innermost part of the cervix at the same time. However, there is some recent evidence that the cervix may respond to hormones, as well, and this may be a complication that cannot be avoided. Thus, the randomized study was important in uncovering new issues not seen in prior studies of hysterectomy.
There is no one-size-fits-all answer to the question of whether the cervix should be removed for the woman who is at low risk for cervical cancer. The studies looking at short-term sexual function and prolapse suggest that SCH is not as beneficial as previously supposed. However, for a woman who undergoes a hysterectomy in her thirties or forties, the real concern is not two years down the road but decades later.
Until we have long-term outcome studies, every woman will need to make her own choice based on individual factors. A woman who unfailingly goes for routine preventive medical care is a better candidate for an SCH than a woman who is unlikely to go for a Pap smear every few years following SCH. Likewise, if pressure against the cervix is a critical part of a woman’s sexual response, an SCH may be a better choice. Some gynaecologists counsel women that there is a chance of forming cervical fibroids following a supracervical hysterectomy, although this is likely a very small risk. Rarely, the cervix later needs to be surgically removed in a separate procedure (termed a trachelectomy), and so, for the woman who wants to minimize her chance of future surgery, a TAH may be preferable.
The Surgical Approach for Hysterectomy
Most surgeons would agree that if a vaginal hysterectomy can be done, this is the best treatment option. Information suggests that women undergoing vaginal hysterectomy have a quicker recovery and fewer complications than women undergoing an abdominal hysterectomy. Although the approach of vaginal hysterectomy is straightforward with a normal-sized uterus, the larger the fibroids, the more compli-cated the procedure. Surgeons who are expert with vaginal hysterectomy are often able to remove uteruses that are 12–16 weeks’ gestation size; however, it is rare to find a surgeon comfortable with vaginal hysterectomy for a uterus larger than this.
In addition to size, there are other reasons that a vaginal hysterectomy might not be appropriate. If a woman has had prior infection or scar tissue, this would limit the ability to safely remove the uterus without injuring adjacent tissue. For these women, a laparoscopically assisted vaginal hysterectomy may be appropriate. This procedure allows the surgeon to visualize the ovaries and the uterus using a laparoscope placed at the belly button and to be able to potentially perform part of the operation through the small laparoscopic incisions. However, this is generally a more time-consuming and expensive procedure than a regular vaginal hysterectomy. In addition, both of these approaches require removal of the cervix, since the cervix is the first part of the uterus to be freed up in a vaginal approach.
A newer approach is a laparoscopic supracervical hysterectomy. This requires a surgeon with special laparoscopic skills. The upper uterus (fundus) can be mobilized in this way and the cervix left in place. Again, however, size is a factor. If the uterus extends above the belly button, placing a laparoscope in this position to visualize the procedure is difficult. Also, the gynecologist must be able to manipulate the uterus well enough that he or she can go to both the right and the left sides of the uterus to secure the major blood vessels. Sometimes the fibroid extends so far out to the pelvis that this is difficult.
Treatment with a gonadotropin-releasing hormone (GnRH) agonist is sometimes used to facilitate these less invasive treatments, converting what would have been an abdominal hysterectomy to a vaginal or laparoscopic approach. However, in addition to considering the side effects (as discussed here: Gnrh-agonists, add-back-therapies and gnrh-antagonists) and cost of the medication, before utilizing this option a woman needs to discuss with her doctor what the odds are that GnRH-agonist treatment will allow the intended surgery. Although the average uterine shrinkage following several months of GnRH-agonist treatment is 30 to 60 percent, there is variability, and some women have little or no shrinkage with therapy. In some situations, given the size and position of the uterus, 75 percent shrinkage might be necessary to make a particular surgical option possible. While in medicine there is no “sure thing,” it is worth knowing at the outset of therapy whether you are aiming for a long shot or whether you have a good chance of reaching your goal.
As with a laparoscopic myomectomy, with a laparoscopic hysterectomy the tissue needs to be morcellated, or cut into small pieces, to be removed. Therefore this type of hysterectomy is not appropriate if there is suspicion of cancer. For cancerous tumors, understanding the relationship between the tumor and the other uterine layers is critical.
Finally, abdominal hysterectomy is usually the last choice for women with fibroids. But for women with either large fibroids or prior fibroid surgeries, it is often the only feasible choice. Many of the considerations regarding the incision, blood loss, and other complications are the same as those discussed here:in the article on abdominal myomectomies. Complications occurring with hysterectomy appear to increase with increasing size of the uterus.
Choosing to have a hysterectomy is a difficult decision. In many ways it was easier in the “good old days,” when the doctor made all the decisions. Most women would like to avoid this major surgery, however, and it makes good sense to weigh the risk and benefits for you. However, hysterectomy remains a good choice for women with large fibroids that are not approachable by other techniques, for women with prior attempts at symptom control who have had no success in controlling their symptoms, or for women with recurrent fibroids.