Hysterectomy

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Overview
A hysterectomy (from Greek hystera "womb") 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"). In 2005, there were 617,000 hysterectomies performed in the USA. During a hysterectomy, in the last decade, an average of 73% of surgeons removed ovaries and fallopian tubes during the same operation, a procedure known technically as bilateral salpingo-oophorectomy and less formally as ovariohysterectomy.

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


 * Certain types of reproductive system cancers (uterine, cervical, ovarian);
 * 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 intractible 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.

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 that leaves the uterus intact, has been performed for over a century.

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. 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. There are currently an estimate of 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.

Both the uterus and the ovaries have important life-long functions in the maintenance of a woman's health, and there is never an age or a time when the uterus and ovaries are not essential to health and well-being. Additionally, the removal of otherwise healthy ovaries is a form of castration because it involves removal of the female gonads, which many opponents and even some supporters of hysterectomy do not support.

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 (overgrowth of the uterine lining), 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.

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
Most hysterectomies in the United States and in most parts of the world are done via laparotomy, sometimes called the "open technique" or "open hysterectomy". A transverse incision (Pfannenstiel's 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.

An increasing number of uterine removals not involving removal of the ovaries are done through the cervix ("supracervical"), reducing the size of the incision and the recovery time as well. In this technique, the uterus is accessed either via the vaginal canal or through an incision inside the navel (or sometimes both, depending on the uterine problem being addressed by the surgery). The uterus itself is detached at the top of the cervical neck and pulled back through the vaginal canal (or out through the navel incision if fibroids or other indications prevent it from being able to pass through the cervix), after which the cervical neck is stitched shut. This provides the patient with a comparatively normal-length vagina which helps provide some support to the bladder, as well as a significantly decreased recovery time. The main drawback with supracervical hysterectomy is the increased risk of cervical prolapse due to the removal of the much stronger uterus (which would normally support the organs around it to prevent prolapse). This surgery also does not eliminate the possibility of cervical cancer, since the cervix itself is left in place; those who have undergone this procedure must still have regular PAP smears to check for cervical cancer.

The newest technique is robotic-assisted laparoscopic hysterectomy. Instead of a large incision, a few tiny incisions are made through which thin instruments are passed. This new technique significantly reduces scarring, pain, healing time, blood loss, and duration of hospital stay when compared to open technique.

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. In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only 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.

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 intractible gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.

One of the conditions most cited by women who have complex pelvic and reproductive issues is pain. 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.

Risks and side effects
The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average. 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. Although sometimes referred to as surgical menopause, that is incorrect and misleading because it implies that its effects are the same as with natural menopause. In fact, those who are naturally menopausal have the benefit of the functions of their uterus and ovaries (which continue to produce small amounts of hormones even after natural menopause), while those who undergo hysterectomy and/or removal of the ovaries have a permanent loss of their functions.

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. 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.

Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact. Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density, while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence.

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.

Alternatives
Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding 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 without removing the uterus. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, 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.

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

Gender transitioning
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. 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) to avoid undergoing multiple separate operations. Many FTM never complete "bottom surgery" for a number of reasons, and instead choose to have their breasts and reproductive organs removed to eliminate all outward appearances of their femininity.