Hysterectomy

A hysterectomy is the surgical removal of the uterus, usually done by a gynecologist. Hysterectomy may be total (removing the body and cervix of the uterus) or partial (also called supra-cervical). Surgical removal of the ovaries (oophorectomy) with the uterus is called an ovariohysterectomy or "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (abbreviated TAH-BSO), a method used in spaying. However, the term "hysterectomy" is often used colloquially, yet incorrectly, to refer to any procedure involving the removal of any of the female reproductive organs. According to the National Center For Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60. There are currently an estimate of 22 million women in the United States who have undergone this procedure.

Technique
Although more hysterectomies are performed via a full abdominal laparotomy with a lengthy incision, the uterus can also be removed with a vaginal hysterectomy or a laparoscopic assisted vaginal hysterectomy. Whether the surgery is performed abdominally, vaginally, or laparoscopically a hormone responsive sex organ is removed, the vagina is shortened, and uterus is removed.

The newest technique is robotic-assisted laparoscopic hysterectomy. Unlike open abdominal hysterectomies, robotic hysterectomy does not require a large incision. It instead requires a few tiny incisions, just large enough to allow the passage of thin instruments. This method substantially reduces pain, blood loss, scarring, risk of infection, and it shortens hospital stay.

There is also Laparoscopic Supracervical Hysterectomy. Like Laparoscopic Assisted Vaginal Hysterectomy it requires a minimum of three incisions. The body of the uterus is removed, leaving the cervical stump.

Indications
Although there are conservative alternatives, hysterectomy is performed for uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage. Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some women. Many alternative treatments are available Pharmaceutical (the use of NSAIDs for the pain or hormones to suppress the menstrual cycle), myomectomy, and often no treatment is necessary. If the fibroids are inside the lining of the uterus, submucosal, and are smaller than 4cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4cm and fibroids located in other parts of the uterus can be removed with a myomectomy where a horizontal incision is made above the pubic bone.

Transsexuals undergoing sex reassignment surgery as part of a female-to-male (FTM) transition commonly have elective hysterectomies and oophorectomies to remove the primary sources of female hormone production. For health reasons, some FTMs have these organs removed prior to full sex reassignment surgery, as it reduces risk for developing Polycystic ovary syndrome and other ovarian and uterine problems due to the higher doses of testosterone being administered as part of the process; some, however, wait to have a hysterectomy and oophorectomy as part of the full sex reassignment surgery procedure to avoid having multiple surgeries over the course of their transitions.

Risks & Side Effects
The average onset age of menopause in women who underwent hysterectomy is 3.7 years earlier than normal. . This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal system. This is referred to as surgical menopause, though this may be misleading in that it implies that surgical menopause is the same as natural menopause. In fact, there are several key differences: surgical menopause occurs at an age when a woman is not naturally designed to live without ovarian hormones, and therefore, the problems that accompany lack of hormones will likely be greater than those that accompany natural menopause; with the ovaries removed, the small quantities of hormones that menopausal ovaries produce, notably testosterone, are absent, which can also result in worse menopausal symptoms; the removal of the uterus may occasion problems that are absent in natural menopause.

For example, a menopausal woman has a three times greater risk of developing cardiovascular disease   such as atherosclerosis, peripheral artery disease and myocardial infarction when compared to premenopausal women. However, it is noted that the risk of developing these diseases are no higher than that in men of the same age.

Several studies have found that osteoperosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.

The ovaries produce many hormones needed for pregnancy and expression of secondary sex traits. The ovaries produce dozens of hormones a woman needs throughout her entire life[6], released directly into the blood stream in a continuous fashion, in response to and as part of the complex endocrine system. As with other hormone-producing glands, the functions of the ovaries cannot be replicated by hormone replacement therapy (HRT). The Physilogy of Sexual Arousal in the Human Female: A recreational and Procreational Synthesis Archives of Sexual Behavior 2002 p.405-411

Women who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.

Women who have undergone a hysterectomy with both ovaries conserved typically have reduced testosterone levels as compared to intact women. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.

Other studies have examined these risks and found no correlation between them and hysterectomy. In the case of sexual function after hysterectomy, studies which find a favorable outcome (i.e., improved sexual wellbeing after hysterectomy) have compared women's sexual function after hysterectomy to the same women's sexual experience before surgery, when they were still dealing with serious uterine problems and may have been stressed about their upcoming surgery. In contrast, the study which found hysterectomy was associated with a reduction in sexual wellbeing, compared women treated with hysterectomy to those whose uterine problems were resolved without removing their uteruses. Collectively, these studies suggest that women experience the greatest sexual wellbeing when they have a healthy uterus (including those whose uteruses have become healthy after treatment) -- yet sexual experience may improve after hysterectomy, once the problems requiring treatment have been resolved and the stress leading up to surgery has passed.

Statistics about the consequences of hysterectomy are at www.hersfoundation.org.

In short, the research suggests that retaining both the uterus and the ovaries are essential for sexual function,, in cardiovascular health, in bone health.

Alternatives
Many alternatives to hysterectomy exist. For example, women with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.

Each treatment option requires skills specific to it. It is unlikely that any one health care practitioner will offer all available therapies.

New treatment options have begun to decrease the number of hysterectomies performed in the United States, Canada, and Britain. Despite the availability of alternative treatments to hysterectomy, many women still have traditional hysterectomy, though some of these other techniques, such as myomectomy, uterine artery embolization and endometrial ablation might be equally as effective and less invasive or life-changing than hysterectomy. For some patients, these alternatives are not appropriate, or may have been previously tried and been found unsuccessful. All patients should be counseled on alternative therapies and offered them if appropriate.

Menorrhagia (heavy or abnormal menstrual bleeding) may be treated with the less invasive endometrial ablation.