The uterus is at the top of the vagina. It is about the size of your clenched fist. It is made of thick muscle and it is hollow. Inside the uterus there is a lining called the endometrium. The lowest part of the uterus, called the cervix, juts down into the vagina. Cervical smears are taken from the cervix. The main part of the uterus is called the body. At the top of the uterus there are two hollow tubes called the Fallopian tubes. There is one on each side. These end close to the ovaries.
Each ovary is slightly smaller than a golf ball. They lie deep in the pelvis just below the waist. The ovaries make hormones. Each ovary also contains tiny eggs, which are too small to see with the naked eye.
What does the uterus do?
The uterus is where a baby 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 in turn 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.
The aim of the operation is to stop your pain and heavy bleeding. We do a total hysterectomy, where we take out your uterus and cervix. This has several advantages:
- It is the best way to remove a large uterus.
- It is the safest way if there are a lot of adhesions around the uterus.
- We can examine the rest of the pelvis and abdomen.
- We can remove large ovaries at the same time if necessary.
Sometimes, if the cervix is healthy, we may not remove it; this is called a sub-total hysterectomy. You should continue to have regular smear tests. This may be a safer operation than a total hysterectomy if the lower part of the uterus has large fibroids or adhesions. If the ovaries are unhealthy we will usually remove them at the same time. It is not necessary to remove healthy ovaries. They would continue to produce hormones in the usual way.
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.
Women needing a hysterectomy for fibroids seem to have satisfactory sexual enjoyment before the operation. Many of these women report no improvement after hysterectomy, with just a few reporting reduced enjoyment. Other factors, such as any drugs you take 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.
A total hysterectomy is guaranteed to permanently stop your periods. After a sub-total hysterectomy there is a small chance of light periods from the cervical stump that is left behind. Any pain should also go. Sometimes, the pain may continue if there is another cause, such as an irritable bowel. If we remove your cervix you will not need smear tests in the future. Many women find their sex life improves after hysterectomy, once any irregular bleeding and pain have gone.
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 telescope examination of the inside of the uterus, called a hysteroscopy. The tests may show that the cause of your problems is dysfunctional bleeding. Treatment with hormones and other drugs can be very helpful for this, especially if your symptoms are mild. For dysfunctional bleeding that continues despite drug treatment alternatives include:
- A device, like a coil, which is put into the cavity of the uterus. It contains hormones that stop the endometrium working. This is called a Mirena IUS.
- Removing or destroying the endometrium without taking out the uterus. One such operation is called a transcervical resection of the endometrium or TCRE. There is a separate leaflet covering this operation within this series.
For fibroids alternatives include:
- Removing subserous fibroids through the hysteroscope using a special cutting instrument. This is called a hysteroscopic resection of fibroids.
- Removing other fibroids through the abdomen without removing your uterus. This is called a myomectomy. We do this using either the open or laparoscopic 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 the leg. It is moved to a position near the artery supplying blood to the fibroid. Tiny particles are injected down the catheter to block off the blood supply to the fibroid. This is called embolisation.
Discuss the risks and benefits of each type of treatment with your gynaecologist. 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 operations for removing the uterus.
Vaginal hysterectomy - We can remove the uterus through the vagina without cutting the abdomen. This is called a vaginal hysterectomy. It can be done if:
- the uterus is small
- there are no adhesions around the uterus
- the ovaries are healthy
- there is unlikely to be any other disease in the pelvis or abdomen.
The ovaries can also be removed this way, but there is a danger of damage to other structures.
Laparoscopically assisted vaginal hysterectomy - We may be able to use keyhole instruments to free the structures in the pelvis, when doing the operation through the vagina. These instruments also make removing the ovaries safer. This operation is called a laparoscopically assisted vaginal hysterectomy or LAVH.
There are separate leaflets in this series covering the various operations to remove the uterus.
The type of operation will depend on the reason for having your uterus removed. You should discuss the operation options with your gynaecologist.
What if you do nothing?
If you do nothing your periods are unlikely to get better until you reach the menopause. The average age of the menopause is 51 years, but it 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 they will slowly grow over time. They could become large enough to cause pressure on your bladder or bowel.
Who should have it done?
Hysterectomy is an operation guaranteed to stop your periods. It is a major operation. Once any serious cause for your heavy periods has been ruled out you should consider more conservative treatments before having a hysterectomy. Medication or the oral contraceptive pill are often effective. The Mirena IUS hormone contraceptive coil, unlike other coils, usually reduces the bleeding and is recommended as a treatment for heavy periods. If you try conservative treatments but still have problems, you should consider hysterectomy.
Who should not have it done?
A hysterectomy is a serious undertaking, especially since you cannot become pregnant after the operation. You must be sure about losing your uterus. Make sure you fully explore more conservative measures first.
Author: Dr David Hutchon M.R.C.O.G, F.R.C.O.G. Consultant Gynaecologist.
© Dumas Ltd 2006