Hysterectomy

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Hysterectomy

A hysterectomy (from Greek ὑστέρα hystera "womb" and εκτομία ektomia "a cutting out of") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions.[1] Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons. [2]

Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes her hormonal levels considerably, so the surgery is normally recommended for only a few specific circumstances:

* Certain types of reproductive system cancers (uterine, cervical, ovarian) or tumors
* As a prophylactic treatment for those with either a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from such cancers
* Severe and intractable endometriosis (overgrowth of the uterine lining) and/or adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall) after pharmaceutical and other non-surgical options have been exhausted
* Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta accreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive postpartum bleeding
* For transmen, as part of their gender transition
* For severe developmental disabilities

Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids with reconstruction of the uterus, has been performed for over a century.[specify]

The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age.

Some women's health education groups such as the Hysterectomy Educational Resources and Services (HERS) Foundation seek to inform the public about the many consequences and alternatives to hysterectomy, and the important functions that the female organs have all throughout a woman's life. [3][4] [5]


Incidence

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 genetic females can be expected to have a hysterectomy by age 60.[6] There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.[6]

In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are removed in about 20% of hysterectomies.[7]

Indications

Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.[8]

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); uterine artery embolization, high intensity focused ultrasound or watchful waiting. In mild cases, 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 laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.

Technique

Hysterectomy can be performed in different ways. Traditionally, it has been performed via either abdominal incision (total abdominal hysterectomy, or TAH, via laparotomy) or vaginal canal (vaginal hysterectomy). However, the vaginal route cannot be used if the "supracervical" procedure is desired. With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because the procedure is much less invasive and the post-operative recovery is much faster with fewer complications. LAVH is performed such that the final removal of the uterus (with or without removal of the ovaries) was via the vaginal canal. Thus, LAVH is also a total hysterectomy, namely, the cervix must be removed with the uterus. The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. For large multifibroid uteri total laparoscopic hysterectomy can be performed with the use of in situ morcellation by gynecologists who are experienced in laparoscopic techniques.[9]


Most hysterectomies in the United States and in most parts of the world are done via laparotomy. A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.

Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated, without data, that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings[10]:

1. There was no difference in the rates of incontinence, constipation or measures of sexual function.

2. Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates.

3. Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy.

4. There was no difference in the rates of other complications, recovery from surgery, or readmission rates.

In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse[11]. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smears to check for cervical dysplasia or cancer.

Recent technological advancement introduced the robot-assisted laparoscopic hysterectomy into the practice of gynecology. It is essentially the same as the surgeon-operated laparoscopic hysterectomy, however, the robot-controlled laparoscopic system offers superior 3D visualization along with greatly enhanced dexterity, precision and control in an intuitive, ergonomic interface with breakthrough capabilities[12]. The major issue is the capital investment for the robot system, which can easily go beyond $1,000,000 per system.

A new technique called "Intrastromal Abdominal Hysterectomy" was recently developed aiming at sparing nerves, no blood loss and no disturbances to the pelvic support system[13]. A total of 40 women were placed in this prospectively randomized clinical trial of this procedure. The average age of the participating women was 50.6 years. Patients were randomized into two groups: the study group and the control group. In the study group (n=20), Intrastromal Abdominal Hysterectomy was performed, and in the control group (n=20), a conventional hysterectomy was performed. All operations were performed by the same surgeon in order to minimize any bias due to differences in surgical technique and style. The results showed that there are significant differences in favor of the study group in terms of the blood loss and short hospital stay.

Types of Hysterectomy:

* Radical hysterectomy : complete removal of the uterus, upper vagina, and parametrium
* Subtotal hysterectomy : removal of the fundus of the uterus, leaving the cervix in situ
* Total hysterectomy : Complete removal of the uterus including the corpus and cervix

Benefits

Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy.[14] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only hormone replacement therapy (HRT) to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT.[15]

The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.[16]

One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[17]. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome. Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder[18].

Risks and side effects

The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average.[19] 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 systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally-occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce natural female hormones even after the cessation of menstrual periods.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies.[20][21][22][23][24][25] 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.

Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those 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.[specify]

Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact.[26] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[27] while increased testosterone levels in women are associated with a greater sense of sexual desire.[28] Hysterectomy has also been found to be associated with increased bladder function problems, such as urinary incontinence.[29]Hysterectomies have also been linked with higher rates of heart disease and weakened bones.[30]

Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.[31]

Alternatives

Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding (DUB) 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 and the uterus reconstructed. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically.[32] Various other techniques (such as uterine artery embolization, Myolysis, radio frequency ablation, 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.[33]

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation.[34]

Uterine artery embolization, this approach blocks the arteries that supply blood to uterus. It is a minimally-invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated—drowsy and feeling no pain. It can be used to control bleeding in conditions like postpartum hemorrhage[35] and for treatment of uterine fibroids.

Embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally-invasive procedures under radiological guidance. The radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter-like a piece of spaghetti) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (fluoroscopy). However, it is also important to note that significant adverse effects resulting from uterine artery embolization have been reported in the medical literature[1] [2]. Death from embolism, or septicemia (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure.[36] Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for administration of intravenous antibiotics. [37] Misembolization from microspheres or polyvinyl alcohol (PVA) particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body. [38] Ovarian damage resulting from embolic material migrating to the ovaries. Loss of ovarian function, infertility[39], and loss of orgasm. Failure of embolization surgery- continued fibroid growth, regrowth within four months. Menopause - iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels. [40] Post-Embolization Syndrome (PES) - characterized by acute and/or chronic pain, temperatures of up to 102 degrees, malaise, nausea, vomiting and severe night sweats. Foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus. Hysterectomy due to infection, pain or failure of embolization. [41] Severe, persistent pain, resulting in the need for morphine or synthetic narcotics. [42] Hematoma, blood clot at the incision site. Vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion (fibroids pushing out through the vagina), unsuccessful fibroid expulsion (fibroids trapped in the cervix causing infection and requiring surgical removal), life threatening allergic reaction to the contrast material, and uterine adhesions.

Gender transitioning
Main article: Sex reassignment surgery female-to-male

Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of gender reassignment surgery for transmen. Some in the FTM community prefer to have this operation along with hormone replacement therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition.[43] Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy)[44] to avoid undergoing multiple separate operations.

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