Over 30,000 hysterectomies are performed annually in Australia. Considered a major operation, it involves removing the uterus (or womb). (‘Hyste-’ refers to the uterus, and ‘-ectomy’ means means ‘cutting out’.) But there’s more to it than that: why and how are hysterectomies performed? Read on for more details…

Relevant anatomy

To understand the basics about hysterectomy, it helps to grasp some basic anatomy. As you can see in the diagram below:

(Source: https://www.healthdirect.gov.au/female-reproductive-system )

• Uterus (aka. the womb) is the muscular organ in which babies grow. The lining of the uterus is called the ‘endometrium’. When you have a period, it is your endometrium shedding that causes blood to come out of your vagina.
• Ovaries: the organ on each side where female hormones (oestrogen and progesterone) are produced, and eggs stored. Every month, an egg is released from one or other ovary, in a process called ovulation.
• Fallopian tubes: two thin tubes that go from the top part of the uterus on either side, and extend out towards the ovary on that side. During natural conception, the Fallopian tube is where the egg and sperm meet and combine, in a process called ‘fertilisation’.
• Cervix: the muscular ‘neck’ of the womb, which remains tightly closed when not pregnant. During labour, it opens to allow the baby to be born vaginally.
• Vagina: the muscular tube connecting the cervix to the outside world.

Reasons to consider a hysterectomy

You may be considering having a hysterectomy for any number of reasons. For many of the conditions below, your doctor may have previously suggested non-surgical management, such as: expectant (ie. watch and wait); lifestyle (eg. dietary); allied health (eg. physiotherapy, dietetics); and / or medical (eg. tablets, injections). If these management methods have not been sufficient, or if you want to proceed straight to surgical management, hysterectomy may be an appropriate option.

The most common reasons for which hysterectomy is undertaken are:

• Fibroids: very common, non-cancerous overgrowths of the muscle of the uterus. Fibroids can cause many different symptoms, including: heavy periods, abdominal bloating, constipation and needing to empty your bladder more often. (Feel free to read our previous posts for more details: https://www.mavencentre.com.au/blog-category/fibroids/ )
• Adenomyosis: common, non-cancerous condition in which the lining of the uterus (the ‘endometrium’) grows a little too deep, into the muscle of the uterus. Adenomyosis can cause both heavy and painful periods. (Feel free to read our previous blog post for more information about adenomyosis: https://www.mavencentre.com.au/maven-journal/adenomyosis-endometriosis-poor-cousin/ )
• Endometriosis: a very common condition, which often causes extremely painful periods. If you have completed your family, and need keyhole surgery to have endometriosis removed, your gynaecologist may also suggest having your uterus removed, to decrease the chance of endometriosis coming back again.
• Prolapse: a common condition, in which a woman’s pelvic organs (eg. uterus, bladder and / or bowels) bulge down into the vagina. If the uterus is thought to be the main culprit, your gynaecologist may suggest a hysterectomy to help treat your prolapse.
• Possible endometrial cancer: if cancer of the lining of the uterus is suspected, your doctor may refer you to see a gynae-oncologist (a gynaecologist who specialises in women’s cancer surgery) to have a hysterectomy.
• Chronic pelvic pain: while removing the uterus takes away a possible factor that may be contributing to chronic pelvic pain, having a hysterectomy is not a guarantee that your chronic pelvic pain will be cured.

It almost goes without saying that once you have had a hysterectomy, and your uterus removed, you won’t be able to bear your own children. Future options to have chlidren include adopting and surrogacy.

Different types of hysterectomy, based on exactly which body parts are removed

There are several different types of hysterectomy, depending on what surrounding body parts are also removed: principally, the cervix and / or the tissue supporting the uterus.

• Total hysterectomy: removal of the uterus and the cervix
• Sub-total hysterectomy: removing the uterus, and leaving the cervix inside your body. This is sometimes called a ‘partial’ or ‘supracervical’ (above the cervix) hysterectomy.
• Radical hysterectomy: removal of the uterus, cervix, the ‘parametrium’ (supportive ligaments and tissues around the uterus), the upper part of the vagina, and the lymph nodes in the pelvis. This operation should only be performed by a gynae-oncologist, who is a gynaecologist who has completed an additional three years of training in surgical techniques for women with pelvic cancers.

What about my Fallopian tubes?

As noted in the diagram above, the Fallopian tubes are thin muscular tubes that extend from each top corner of the uterus, out towards the ovaries. The only purpose Fallopian tubes serve is for egg and sperm to meet, to have a baby; the Fallopian tubes do not produce any hormones. If your uterus is being removed, you won’t be able to carry your own baby in future, so you’ll never need your Fallopian tubes again.

There is growing evidence that many ‘ovarian’ cancers actually start in the Fallopian tubes. So having Fallopian tubes removed reduces your risk of ovarian cancer in future by approximately 50%.

Because of the above, it is now standard practice to remove both Fallopian tubes whenever performing a hysterectomy: a procedure called a ‘bilateral salpingectomy’. (Bilateral means both left and right sides, -ectomy means cutting out, and salpinge- refers to the Fallopian tubes.)

What about my ovaries?

As you can see in the diagram above, the ovaries are small white organs that are about the size of an almond in its shell. Paired organs (ie. one on the left side and one on the right side), the ovaries produce female hormones (eg. oestrogen and progesterone). An egg is released from an ovary at ovulation.

The female hormones produced by the ovaries help to maintain both bone health (ie. prevent osteoporosis), and cardiovascular (blood vessel) health. When a woman goes through menopause, the ovaries gradually slow down and shut up shop. As a result, the levels of female hormones the ovaries produce slowly declines.

There is good evidence that even after menopause (up to the age of 60 years old), the ovaries produce small amounts of female hormones, which help to maintain both bone and cardiovascular health. This hormone production stops at 60 years old.

There is no benefit to keep your ovaries after the age of 60yo. Hence, if you are having an operation to remove your uterus at or after 60yo, your gynaecologist may also recommend having your ovaries removed, which is called ‘oophorectomy’. Having your ovaries removed almost completely negates the risk of ovarian cancer in future.

If you are having a hysterectomy between the ages of 45 and 60 years old, and one of your ovaries is abnormal (eg. has a large ovarian cyst), your gynaecologist may suggest removing the ‘bad’ ovary (with the cyst), and keeping the ‘good’ one. While not evidence-based, some think this may be a reasonable compromise: it removes the malfunctioning ovary, while keeping your good remaining ovary to help support your bone and cardiovascular health.

If you are having a hysterectomy before the age of 45yo, and both your ovaries are normal, your gynaecologist will probably suggest that you keep both of your ovaries. After your uterus is removed, your ovaries will continue to produce the monthly ups and downs of female hormones, which may lead to ongoing monthly symptoms such as: breast tenderness, emotional fluctuations, and crying and eating chocolate (or is that just me?!).

The technical term for having an ovary removed is ‘oophorectomy’. ‘Unilateral oophorectomy’ means having one ovary removed, while having both ovaries removed is called a ‘bilateral oophorectomy’.

Different ways gynaecologists can approach a hysterectomy

There are several differents ways in which gynaecologists can remove a uterus. These include:

• Abdominal / open hysterectomy, in which a big (approx 10 – 15cm) cut is made in your tummy to remove the uterus. This scar may be vertical (called a ‘midline laparotomy’) or horizontal (called a ‘transverse suprapubic’ incision, like a Caesarean section).
• Laparoscopic / keyhole hysterectomy, in which the hysterectomy is completed through four small (≤ 10mm) incisions in your tummy. The uterus is then removed either through the vagina, or cut into small pieces and removed through the bellybutton incision (using a process called ‘morcellation’).
• Robotic hysterectomy. From the patient’s point-of-view, this is similar to a keyhole hysterectomy, in that it is performed through four small incisions in your tummy. The key difference is that the surgeon is sitting at a ‘console’ in the corner of the operating theatre, controlling the robotic arms that are attached to the surgical instruments inside your tummy.
• Vaginal hysterectomy, in which the surgeon sits between your legs and operates through your vagina to remove the cervix and uterus. You would not have any scars on your tummy after a vaginal hysterectomy, as the operation is performed completely from below.
• vNOTES hysterectomy: a combination of keyhole and vaginal hysterectomies. The gynaecologist sits between your legs, and uses keyhole surgery techniques through your vagina to remove your cervix and uterus that way.

How do gynaecologists decide which way to perform your hysterectomy, surgically?

There are several factors that your gynaecologist will consider, when thinking about the best way to approach your hysterectomy surgically. These include:

• The size of your uterus
• What operations you’ve had in the past (in particular, how many Caesarean sections you’ve had)
• The reason for the hysterectomy (eg. lots of large fibroids versus unwanted fertility)
• The likelihood of other concurrent conditions (eg. endometriosis, which is most easily removed during keyhole surgery)
• Whether any other internal organs will be removed during the operation (eg. Fallopian tubes and / or ovaries)
• Your gynaecologist’s experience and surgical skills. Not all gynaecologists are able to safely perform all types of hysterectomy (open / keyhole / vaginal and vNOTES).

Topic area frequently asked questions

What complications can occur during a hysterectomy?

No operation is without risk. Possible complications during or after a hysterectomy include:

• Bleeding
• Infection
• Damage to internal organs (bladder / bowel / ureters) or blood vessels
• Anaesthetic complications

Please discuss the potential risks of hysterectomy with your gynaecologist.

Will I still have periods after having a hysterectomy?

No. The uterus is the source of bleeding during menstrual periods. So removing the uterus means your periods will stop. If you keep your ovaries, you may continue to have other monthly symptoms (such as breast tenderness), up until your natural menopause. The average age of menopause is 51 years old.

What are the pros and cons of having my cervix removed during my hysterectomy?

Some doctors used to think that removing the cervix at hysterectomy (which is called a ‘total hysterectomy’) leads to decreased female sexual satisfaction. Greater understanding has been gained since then, showing that most women experience the vast majority of their sexual satisfaction from stimulation of the clitoris. Hence, removing the cervix does not have any impact on this type of sexual satisfaction.

There is a slightly increased risk of prolapse if your cervix is removed during your hysterectomy operation. To reduce this risk, many laparoscopic gynaecologists, when removing the cervix, make sure to include some supportive ligaments in the row of stitches at the top of the vagina.

When can I go back to work after a hysterectomy?

This depends on the surgical approach.

After having a laparoscopic (keyhole) hysterectomy, most patients stay in hospital for one night only. Most women who work a desk-based job will feel up to going back to work after two weeks off. If you work a more physical job, you may find you need three weeks off work.

After an open (or ‘abdominal’) hysterectomy, you would need to stay in hospital for 2 – 3 nights, and have 4 – 6 weeks off work.

After a vaginal hysterectomy, you will need 1 – 2 nights in hospital, and can go back to work after 2 weeks.

When can I have sex after a hysterectomy?

If you have a total hysterectomy (in which both the uterus and cervix are removed), you will have a row of stitches at the top of your vagina, where the cervix used to be. To enable this row of stitches to heal fully, it is recommended that you don’t have penetrative (penis in vagina) sex for at least six weeks after your operation.

Do I need to keep having cervical screening tests (the new name for Pap smears) after my hysterectomy?

If you have had a ‘total hysterectomy’ (and your cervix removed, along with your uterus), you do not need to have any more cervical screening tests done in future.

Conclusion

If your gynaecologist has suggested a hysterectomy as an option for you, it’s important to understand exactly which body parts will be removed (uterus and Fallopian tubes +/- cervix +/- either or both ovaries), and how your surgeon will approach the operation (using either an open, keyhole, vaginal or vNOTES approach). Knowledge is power, so please make sure you understand why and how your gynaecologist will perform your hysterectomy before proceeding. While a major operation, having a hysterectomy may give you a much-needed new lease of life!