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Vaginal hysterectomy: The operation
Vaginal hysterectomy: The operation
If you are considering having an hysterectomy or have one planned, it is important to know all you can about it. This includes:
- why you need this operation
- what it will be like
- how it will affect you
- what risks are involved
- any alternatives.
The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.
What is the problem?
You probably have painful, heavy, and/or prolonged periods. Heavy bleeding during a period is called menorrhagia. It affects about 22% of all menstruating women. Menorrhagia and pain during a period can occur at the same time and may have the same cause. The heavy bleeding may cause iron deficiency anaemia, which can make you feel tired and breathless. If your heavy periods are causing anxiety because of embarrassing accidents, and perhaps distracting or disrupting you from your work, then you may consider having a hysterectomy.
What is a vaginal hysterectomy?
A vaginal hysterectomy is an operation to remove your uterus through your vagina. It usually includes the neck of your uterus, called the cervix, as well as the body of your uterus. We do the operation through your vagina, so there are no cuts in the skin of your abdomen
If we remove the body of your uterus but leave your cervix in place, this is called a sub-total vaginal hysterectomy. This operation is uncommon and is not always possible. If we do not remove your cervix:
- you must continue to have regular cervical smear tests
- you may have harmless problems from your cervix in the future, such as polyps or vaginal discharge
- you may still have a small amount of period-like bleeding from your cervix.
If you have unhealthy ovaries it is more difficult to remove them with a vaginal hysterectomy, so we may have to do a different type of hysterectomy instead. If your ovaries are healthy we do not have to remove them. They will continue to produce hormones as usual. One woman in every 250 develops cancer of the ovary at sometime in their lives. Having a hysterectomy does not alter this chance. You may wish to discuss the option of having your ovaries removed at the time as the hysterectomy to avoid this risk.
A hysterectomy is a serious undertaking, especially since you cannot have children after the operation.
What is the uterus?
To explain where your uterus is and what it does, the best place to begin is the vagina. Your vagina is a tube about five inches long. It runs from just in front of your rectum up into your pelvis. It is just behind your bladder. You can feel your bladder in your abdomen when it is full of urine.
At the top of your vagina is your uterus. It is about the size of your clenched fist. It is made of thick muscle, but it is hollow inside with a special lining called the endometrium. The lowest part of your uterus, which juts into your vagina, is ‘the neck of the womb’, also called your cervix. Cervical smears are taken from the surface of your cervix.
The rest of your uterus is called the body. It thins out at the top to form two hollow tubes called the Fallopian tubes. You have a Fallopian tube on each side. These run sideways to end near your left or right ovary.
Your ovaries are slightly smaller than a golf ball. They lie deep in your pelvis just below your waist. Your ovaries make hormones and contain tiny eggs, which are too small to see with the naked eye.
What does the uterus do?
The uterus is where a baby normally develops during pregnancy. About once a month an egg in one of the ovaries grows and breaks free from the ovary. It moves into the Fallopian tube and travels down the tube towards the uterus. At the same time, hormones make the endometrium thicker so that if the egg is fertilised by a sperm it can lodge in the uterus.
Often, the egg is not fertilised and it dies. The hormones change and the endometrium also dies and is shed. There is some bleeding from the raw endometrium for a few days. This is a typical period. The cycle then starts again for the next month. If the egg is fertilised it starts making extra hormones. These make the uterus and endometrium grow to take the developing baby.
After the age of about 45 years the ovaries stop making some of the female hormones. Eggs are not released each month. The endometrium is no longer shed. The periods stop. This is called the change or the menopause. The changes in hormones often cause hot flushes and dizzy spells. Sometimes the periods become very heavy during this time.
What has gone wrong?
There are several possible causes of your heavy or painful bleeding:
- Fibroids - These are lumps in the wall of the uterus and are a very common reason for heavy or painful periods. They are benign tumours made of muscle and fibres. They make the surface of the endometrium larger. This makes the periods heavier and more painful.
- Adenomyosis - In this condition some endometrium is present in the muscle walls of the uterus. With each period bleeding into the muscle gives a lot of pain. A reaction by the normal endometrium to the trapped blood makes the periods heavy.
- Endometriosis - In this condition other tissues act as if they are endometrium. The tissue is usually within the pelvis, especially around the ovaries. During each period there is bleeding into the endometriosis tissue. This internal bleeding leads to pain and a local reaction. The local reaction may be a collection of old blood, called a chocolate cyst, or adhesions of the ovaries, which can become stuck to the back of the uterus. Removing the uterus and the ovaries may be the only cure.
- Dysfunctional uterine bleeding - This is when we cannot find a clear cause for your bleeding problem. In some way the shedding of the endometrium is not working properly.
You should discuss why you need a hysterectomy in your case and if there are any treatments other than surgery.
We aim to stop your pain and heavy bleeding by removing the whole of your uterus and cervix through your vagina. This is called a total vaginal hysterectomy. You can have a hysterectomy done through your vagina without opening your abdomen if:
- your uterus is small
- you have no scarring from previous infections or operations around your uterus
- your ovaries are healthy
- you are unlikely to have another disease in your pelvis or abdomen.
It may be possible to remove your ovaries and Fallopian tubes during a vaginal hysterectomy, but this gives a danger of damage to other parts of your pelvis.
You will not have any more periods after we remove the whole of your uterus and cervix. Any pain should also go. Sometimes pain continues if it has another cause, such as an irritable bowel. If we leave your cervix in place you have a small chance of having light periods from the cervical stump.
If we remove your cervix you will not need smear tests in the future.
Sexual enjoyment and hysterectomy
Many women worry that a hysterectomy will reduce their sexual enjoyment and ability to orgasm. They may have fears of low sex drive, low sexual activity, painful intercourse, difficulty reaching orgasm and reduced feeling. Studies have shown that these fears are groundless. The problem that makes a hysterectomy necessary may be interfering with sex. After a hysterectomy most women have more frequent and more enjoyable intercourse.
Most women needing a hysterectomy for fibroids seem to have satisfactory sexual enjoyment before their operation. Many of these women report no improvement after hysterectomy, with just a few reporting reduced enjoyment. Other factors, such as medicines or the oral contraceptive pill, may also reduce sex drive.
In many women orgasm follows stimulation of the clitoris and labia alone. For others, orgasm is related to the movement of the cervix and uterus, called an internal orgasm. Women who have internal orgasms may consider a sub-total hysterectomy, where the cervix is not removed.
Are there any alternatives?
Before treatment we do tests to find the cause of your bleeding and pain. These tests may include an ultrasound scan. We may also do a hysteroscopy, where we examine the inside of your uterus with a telescope, called a hysteroscope.
The tests may show that the cause of your problems is dysfunctional bleeding. Treatment with hormones and other drugs can help, especially with mild symptoms.
For dysfunctional bleeding that continues despite drug treatment alternatives include:
- A device, like a coil, put into the cavity of your uterus. It contains hormones that stop your endometrium working. This is called a Mirena IUS.
- Removing or destroying your endometrium without taking out your uterus. One such operation is a transcervical resection of the endometrium or TCRE. We can also permanently destroy it with an operation called a hysteroscopic endometrial ablation. There are separate leaflets in this series covering the various operations to remove or destroy the endometrium.
For fibroids alternatives include:
- Removing fibroids just under the lining of your endometrium with a special cutting instrument put through a hysteroscope. This is a hysteroscopic resection of fibroids.
- Removing other fibroids through your abdomen without removing your uterus. This is called a myomectomy. We do this using either the open or keyhole method.
- Cutting off the blood supply to single fibroids causing them to shrink. This operation would be guided using an x-ray. A catheter is passed into an artery in your leg. We thread it along to a position near the artery supplying blood to the fibroid. We inject tiny particles down the catheter to block off the blood supply to the fibroid. This is called embolisation.
There are separate leaflets in this series covering the various operations to remove fibroids without removing the uterus. Discuss the risks and benefits of each option with your gynaecologist.
Only a hysterectomy is guaranteed to permanently stop heavy periods. If you have other problems with your uterus, such as a prolapse or disease of the cervix, a hysterectomy is likely to be the best treatment. There are other types of hysterectomy operation:
Laparoscopically assisted vaginal hysterectomy (LAVH) - This is the same as a vaginal hysterectomy except we also use keyhole instruments. These are put through small cuts in your abdomen. We use the keyhole instruments to free off minor adhesions and cut the ligaments holding your uterus in place. They can also make removing your ovaries safer. There is a separate leaflet for this operation within this series.
Total abdominal hysterectomy - This is an open operation to remove your uterus and cervix through a cut in your tummy. It is the best way to remove a very large uterus with fibroids and is the safest method when there is scarring around the uterus from endometriosis. We can fully examine your pelvis and abdomen and easily remove large ovaries and their tubes at the same time if needed. There is a separate leaflet covering “abdominal hysterectomy” within this series.
Sub-total abdominal hysterectomy - This is an open operation to remove your uterus through a cut in your abdomen while leaving your cervix in place. If we do not remove your cervix:
- you must continue to have regular smear tests
- you may get harmless problems arising from the cervix in the future, such as polyps or vaginal discharge
- you may have a small amount of period-like bleeding from the inside of your cervix. This only occurs in a small number of women
What if you do nothing?
If you do nothing, your periods are unlikely to get any better until you reach the menopause. The average age of the menopause is 51 years, but can go on to the age of 56 years. You must be prepared to put up with your period problem until you reach the menopause. If your problem is due to fibroids, these will slowly grow over the years. They could become large enough to cause pressure symptoms on your bladder or bowel.
Who should have it done?
A total hysterectomy is guaranteed to stop your periods but it is a major operation. Once we rule out any serious cause for your heavy periods, you should consider more conservative treatments before you decide on a hysterectomy.
Drug treatment or even the oral contraceptive pill are often effective. The Mirena IUS is a hormone contraceptive coil that usually reduces the amount of bleeding during periods and is used to treat heavy periods.
Consider hysterectomy if you still have problems after trying the other forms of treatment.
Who should not have it done?
You must be sure about losing your uterus. You cannot become pregnant after a hysterectomy. Make sure you fully explore other treatments first.
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