Hysterectomy is the removal of the uterus and cervix but not necessarily the removal of the ovaries. With the advancement of new technology, a hysterectomy is becoming easier to perform and faster to recover from. This surgery usually takes 45 to 90 minutes to perform. After a hysterectomy, you may never require another pap smear in the future, as long as you have never had a history of abnormal pap smears. There are several methods that Newburgh, IN gynecologists, Dr. Cindy Basinski and Dr. Rupal Juran use to perform a hysterectomy, but 99% of the time your hysterectomy will be accomplished laparoscopically. This means it will be performed with tiny incisions on your abdomen, rather than a large incision, and your hospital stay will be less than 24 hours. All surgery has risks and benefits, and the following is a list of risks associated with hysterectomy.
Major Operative Risks
- Operative injury to surrounding organs such as the bladder, ureters (kidney tubes), intestines, and blood vessels
- Bleeding that may on occasion require transfusion
- Risks associated with general anesthesia
Types of Hysterectomy
Laparoscopic Assisted Vaginal Hysterectomy (LAVH) or Total Laparoscopic Hysterectomy (TLH)
This method of hysterectomy is the most common way that we choose to remove a patient’s uterus and cervix. Over 99% of hysterectomies we perform each year are completed this way. LAVH/TLH requires a patient to remain in the surgery center or hospital for 10 to 23 hours. Many patients are able to drive after one week and most patients can return to part-time work in 2 weeks and full-time work in 3 weeks, depending on your type of work. Sexual intercourse and normal exercise routines can be resumed in 6 weeks.
With an LAVH or TLH, a small 1/4th inch camera is inserted into the belly button area, allowing us to visualize the uterus, ovaries, intestines, and other intra-abdominal structures. Two or three other smaller incisions total will be made in the lower abdominal area and above the pubic bone so other instruments can be used to assist in the surgery. Scar tissue from previous surgeries can be evaluated and removed, if necessary, and pelvic diseases such as endometriosis, abnormally enlarged ovaries, or other pelvic organ abnormalities can be visualized and treated prior to removing the uterus and cervix. The connections and blood vessels of the uterus and cervix to the pelvic area are carefully separated and blood vessels are sealed. The uterus and cervix are then removed through a small vaginal incision. This vaginal incision, which is at the very top of the vagina, is then closed up, leaving the remainder of the vagina unchanged. If we have decided that you will also have your ovaries removed, these will be removed through that same vaginal incision at the same time that your uterus and cervix are removed. We usually remove the fallopian tubes at the time of hysterectomy, as they serve no function once your uterus is removed, and there is also a theory that some ovarian cancers may originate in the fallopian tubes.
Total Abdominal Hysterectomy
This surgery is performed through an incision on the abdomen that is like a C-section incision, just above the pubic hairline. While over 99% of our hysterectomies are performed laparoscopically, meaning through small incisions, some patients may need a large incision instead. This is usually for women with very large uteri due to large fibroids, women with a lot of scar tissue due to previous surgeries, or women that we may be concerned have a cancer of the female organs. This method of hysterectomy will require a two-day hospital stay and a full six weeks of recovery before a return to work. Sexual intercourse and normal exercise can be resumed in 6 to 8 weeks after surgery.
Because recovery after total abdominal hysterectomy is longer and more difficult compared to LAVH or TLH, Dr. Basinski and Dr. Juran are committed to avoiding this method of hysterectomy. We have experience removing even very large uteruses and performing complicated surgery laparoscopically, and therefore it is only the minority of cases that require a large incision.
Laparoscopic Supra-Cervical Hysterectomy
This is a type of partial hysterectomy that involves removing only the uterus and not the cervix. The abdominal incisions are similar in position to those used to perform an LAVH or TLH. With Laparoscopic Supra-Cervical Hysterectomy, or LSH, the uterine connections to the pelvic area are taken down and blood vessels are sealed. The uterus is disconnected from the top of the cervix and a device called a morcellator is used to remove the uterus from the abdomen in small pieces.
The main advantage to this surgery is that recovery is very fast. Most women can return to work in one week while sexual intercourse and exercise can resume in one month. There are other proposed but not proven advantages like increased support to the vagina and decreased infection risk to surgery. Drawbacks include the need for continued pap smears in the future, possible need for future surgery due to cervical cancer, and up to 10% risk of continued small periods from the cervical stump. However, for women with no history of abnormal pap smears, uterine cancer, and a desire to keep the cervix, LSH may be an option for them.
This type of surgery is not performed very often by Dr. Basinski or Dr. Juran because of the risk of disease spread during morcellation, risk of unresolved bleeding or pain if the cervix is not removed, and the continued need for pap smears. That being said, we do perform these surgeries for certain women if they are good candidates to keep their cervix and have a desire to do so.
Long-term satisfaction with a hysterectomy is very high. Most studies show that 90% to 95% of women will be happy with their choice of a hysterectomy. Sexual functioning for the vast majority of women is unchanged or improved. Women still experience orgasm and their partners are unable to notice a difference during intercourse. However, some long-term issues can occur. For a very small amount of women, they experience difficulty with sexual intercourse causing pain. Some women also experience abdominal pain from scar tissue related to the healing process. Fortunately, this only occurs in a very small fraction of women (<5%).
Should I Remove My Ovaries During a Hysterectomy?
The most common question women ask when considering a hysterectomy is, “Should I remove my ovaries?” There are advantages and disadvantages to either decision. Ultimately, it is the patient that will need to make her own decision after considering all the factors that may be important to her. The surgery performed to remove both ovaries and the fallopian tubes is called Bilateral Salpingo-oophorectomy (BSO).
The Case for Keeping the Ovaries
Ovaries are the organs that produce hormones for women. These hormones include estrogen, progesterone, and testosterone. Once a woman becomes menopausal, at an average age of 52 years old, her ovaries no longer produce estrogen and progesterone, but does make a small amount of testosterone. If a woman has both her ovaries removed at the time of her hysterectomy, she will typically enter menopause within days of surgery. All women experience their menopause differently, but this typically means hot flashes, mood swings, and vaginal dryness leading to difficulty with intercourse. Such symptoms can be treated with hormonal replacement theory in the form of an estrogen pill or an estrogen patch.
Other changes that occur after the ovaries are removed include increased risk of heart disease, Alzheimer’s disease, colon cancer, and decreased quality of life. If only one ovary is removed, the remaining ovary will increase production of hormones to match the amount produced by two ovaries. So, if one ovary is removed, no real changes in hormone levels will occur.
Many women are concerned about their risk of developing ovarian cancer. All women have a lifetime risk of ovarian cancer of 1 in 70. To compare this to other common diseases, all women have a lifetime risk of heart disease of 1 in 3 and a lifetime risk of breast cancer of 1 in 8. Therefore, for patients at average risk of developing ovarian cancer, if their ovaries appear normal and they do not have other reasons to remove their ovaries, we typically recommend keeping the ovaries.
The Case for Removing the Ovaries
Ovarian removal at the time of hysterectomy can be accomplished very easily. There is only a very small difference in the surgery for a GYN surgeon to remove the ovaries. Surgical risk may be slightly increased but the cost difference to you or your insurance company is little to none.
There are some reasons why we may encourage ovarian removal for a patient:
Endometriosis is a female pelvic disease associated with pelvic pain, intestinal cramping, and other less common symptoms. Endometriosis can only be cured with ovarian removal or menopause and can only definitively be diagnosed with visualization of lesions in the pelvis at the time of surgery. If a woman with endometriosis opts to retain her ovaries at the time of hysterectomy, there is approximately a 50-50 chance she will need future surgery to remove her ovaries due to pain, ovarian cysts, or scar tissue. If a woman opts to remove her ovaries in light of endometriosis, there is only a 4% risk of surgery in the future for continued pain.
Family history of ovarian cancer is a situation in which ovarian removal may increase the lifespan of certain women. There are certain genetic risk factors that can be determined in families that markedly increase risk for death due to ovarian cancer. In this situation, when a woman has completed childbearing or reached the age of 35 years old, ovarian removal with hysterectomy may be warranted. A small minority (less than 5%) of all ovarian cancers are related to genetic mutations. 95% of ovarian cancers are “sporadic,” meaning they are unrelated to genetic risk factors. Based on your family history, we will discuss the options of genetic counseling and genetic testing with you:
- Pain associated with recurrent ovarian cysts may be a reason for some women to desire ovarian removal.
- Premenstrual syndrome may cause significant disability for some women and may warrant ovarian removal with hysterectomy.
- Ovarian tumors if found at the time of surgery, will usually warrant ovarian removal if they cannot be removed off of the ovary.
- Hormonal or menstrual migraines can be treated with ovarian removal.
- Post-menopausal or near menopausal women may desire ovarian removal to markedly reduce the risk of ovarian cancer in the future.
If a woman is less than 50 years old and elects to have her ovaries removed, we do highly encourage the use of estrogen/hormones until she is into her mid-fifties. Estrogen replacement in this group of women will decrease risk for heart disease, improve sexual functioning, strengthen bones, help maintain weight control, keep hair and skin younger appearing, and does not appear to increase risk for breast cancer. In studies, a woman who opts to use estrogen after hysterectomy and ovarian removal appear to live longer and do better than women who opt not to use hormones after hysterectomy and ovarian removal in this age group.