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:
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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.
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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.
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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.
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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.
The aims
We aim to stop your pain and heavy bleeding by taking out the whole of your uterus and cervix. This is called a total hysterectomy. If we take your uterus out through your vagina it is called a vaginal hysterectomy. If we take it out though your abdomen it is an abdominal hysterectomy. We can do a vaginal hysterectomy with no cuts in 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 structures.
A vaginal hysterectomy is often easier when also using keyhole instruments put through small cuts in your abdomen. We use a telescope, called a laparoscope. This operation is called a laparoscopically assisted vaginal hysterectomy or LAVH for short. We use the keyhole instruments to free off your uterus from the tissues and ligaments that hold it in your pelvis. Keyhole instruments can also make removing your ovaries a safer possibility.
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.
The benefits
You will not have any more periods after we remove the whole of your uterus. Any pain should also go. Sometimes pain continues if it has another cause, such as an irritable bowel. Many women find their sex life improves after hysterectomy, once irregular bleeding and pain has gone.
If we remove your cervix you will not need smear tests in the future. If we leave your ovaries, any pre-menstrual syndrome (PMS) may continue.
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 special 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. There are separate leaflets within 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 the 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. There is a separate leaflet within this series covering myomectomy.
- 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.
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.
If you have unhealthy ovaries that we need to remove, a vaginal hysterectomy is not usually an option unless it is assisted with keyhole instruments. We do not need to remove healthy ovaries. 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 consider having your ovaries removed at the time of the hysterectomy to avoid this risk.
As well as the alternatives to a hysterectomy there are alternative methods of doing a hysterectomy. These include:
Sub-total vaginal hysterectomy - During this operation we only remove the body of your uterus through your vagina. We leave your cervix in place. It is not a common operation and is not always possible.
Total abdominal hysterectomy - This is an open operation to remove your uterus and cervix through a cut in your abdomen. 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 tubes at the same time, if needed.
