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.