FAQ - Hysterectomy

Hysterectomy

Why is surgical removal of the uterus done ?

Surgical removal of the uterus is called hysterectomy. If any specific disease affects the uterus then this procedure is done. In our society because of the fear of undergoing this operation the patients do present late with the progressed form of the disease. While on the other hand sometimes this procedure is carried out without any pinpoint reason for doing so. Either of this is totally incorrect. So as to prevent any of these mishaps the patients (women) must know the exact indications, possible complications and the procedure itself. The female internal reproductive organs are in the lower abdomen ( pelvis). If longitudinal & coronal section of the lower abdomen is taken then the position of the internal reproductive organs can be understood.

There are four parts of the female genital tract

(1) Uterus-The organ responsible for M. C. & in which the foetus grows. (2) Ovaries - The part of the female genital tract from where the ovum is released. (3) Fallopian tubes - The tubes which carry the ovum from the ovaries to the uterus. (4) Vagina. If any of these parts of the female genital tract get affected then hysterectomy may be required –

1) Benign tumour of the uterus

Approximately 15% of the females have multiple tumour like growths called Fibroids showing whorled pattern on cross-section. These tumours are estrogen dependent So after menopause as estrogen levels decrease the tumour size regresses. Its conversion into carcinoma is very rare. In some patients because of the tumour there is excessive bleeding during menstruation, severe pain, difficulty in urination or defecation. If there are any of these complaints or if the size of the tumour grows rapidly then the tumour has to be removed. If there are multiple fibroids, the patient does not wish for any child (family is complete) then instead of removing the tumours the removal of the uterus would be more beneficial because removal of multiple fibroids is difficult. During removal of fibroids severe bleeding may occur and there is a possibility that new fibroids may arise. Hence removal of the uterus would be more appropriate.

2) Prolapse of uterus (descent of the uterus)

Because of the rope like strong ligaments and muscles of the lower abdomen the uterus remains in its normal place. However it may get displaced down due to : (i) Improper conduction of deliveries. (ii) More number of deliveries with short intervals in between. (iii) Improper diet & old age cause weakness in the supporting ligaments. (iv) Inadequate exercise after the delivery causes the uterus to descend down. (v) Inherent weakness of the ligaments. If not paid attention to, uterus descends in the vagina which causes difficulty in urination, passage of white coloured or blood stained discharge at times. If the patient is more than 40 yrs, does not wish for a child, has attained menopause and if is willing for the operation, hysterectomy may be performed. If the patient is young, if the uterus prolapses (descends down) after delivery then by giving the patient specific exercises this defect can be corrected. There are some operations which can restore the normal position.

3) Inflammation of pelvic reproductive organs

If uterus, fallopian tubes and the ovaries and the surrounding parts undergo infection by specific organisms the infection sometimes doesn’t subside even after using proper antibiotics. In these patients pain in abdomen, difficulty in defecation, pain during coital activity, menstrual disorders and other complaints are sometimes very severe & disturbing. Because these complaints do not subside by antibiotics the uterus may be removed as a last option.

4) Growth of Endometrium (inner lining of uterus)

In some females endometrial tissues grow in the uterine musculature or outside it. During menstrual cycle bleeding occurs from these endometrial segments at wrong sites. So during this there is abdominal pain and different organs may adhere to each other. In some patients medicines like Danazol is effective and by a minor surgery these tissues can be destroyed. If this doesn’t help major surgery has to be done. Along with uterus ovaries are also removed. This is done as even if surgery is done carefully some microscopic segments may persist. Because of the oestrogen secreted by the ovaries some bleeding does occur during menstrual cycle. If ovaries are removed then the bleeding (from these segments) might stop and disease might be cured.

5) Cancer

For the treatment of cancer of the uterus or the ovaries the uterus, ovaries & fallopian tubes have to be removed. This is because cancer spreads from one part to the other very fast. Many a times all the three are affected to a small extent. Only after knowing the extent of cancer further course of treatment can be decided. If the cancer is in advanced stage doing hysterectomy is not beneficial. In India cancer of the cervix (mouth of uterus) is most commonly seen. If the cancer is in the early stages and the uterus is removed this can prove as a definite cure. The surgical removal of uterus and I or x-ray radiation may be given according to the stage of cancer, patient factors etc.

6) Excessive bleeding during menstruation -

If there is imbalance between the different hormones which are responsible for proper menstruation then there may be excessive bleeding during menstruation (passage of clots, frequency of menstruation, blood flow for more number of days) Proper medication may cure this but if the patient does not show any response hysterectomy is indicated. In some of these patients the layers of the uterus are affected by cancer. (If precancerous stage is present if may turn into carcinoma). The endometrium is removed by curetting and observed under the microscope if carcinomatous changes are seen then removal of the uterus is essential. By a new technique (TCRE) the endometrial layer (inner layer of the uterus) can be destroyed without removal of the uterus. But taking into consideration the complications & difficulties during the procedure it is not suitable for all the patients. If due to obesity or other reasons the uterus cannot be removed then this technique can be used.

7) Post delivery complication-

After delivery in some patients because of non contracted uterus the bleeding continues. By using appropriate medicines many a times it is controlled. But if it does not come under control then it endangers the life of the mother. In these instances the blood vessels which supply the uterus can be tied by different surgical procedures to stop the bleeding. But even after this if bleeding doesn’t stop then removal of the uterus has to be done as an emergency operation. During delivery if the uterus tares off in an irregular fashion and if it is not possible to stitch it then it has to be removed immediately to avoid blood loss. Or if there is severe infection in uterus it may have to be removed.

Along with the uterus are the ovaries or fallopian tubes removed ?

In cancer as stated above the ovaries” & the fallopian tubes are removed. In some diseases the fallopian tube is removed but vagina is not removed. For ovary one has to decide according to the patient. When age advances there is possibility of having carcinoma of the ovaries, which cannot be detected earlier. It is easy to remove the ovaries with the uterus, so many gynecologists, prefer to remove ovaries taking into consideration the possibility of ovaries developing cancer. But when ovaries are removed hormonal production does not take place so the following symptoms are seen - Those changes that are seen during menopause are seen at a very early age rapidly. Because of the thickening of arterial wails there are chances of developing heart diseases. Bone calcium becomes less and there is bone rarefaction. Because of the paucity of female hormones there are hot flushes, palpitations, sweating, loss of skin luster, vaginal dryness, increase in infection rate, irritability, loss of sexual desire. Because of these symptoms the ovaries are to be removed only when indicated. If any disease affecting the ovaries-eg. infection (inflammation) affecting the female genital tract, the uterus along with the ovaries are to be removed. During the surgery if there are any signs showing ovarian cancer they have to be removed. Endometrium : If it grows in wrong place then as stated above the uterus along with the ovaries have to be removed. Nearest relatives of the patient, in their youth having carcinoma of intestines, ovaries, uterus, breast if any should be enquired and then there is a possibility of having ovarian carcinoma so ovaries are to be removed. After removal of the ovaries oestrogen deficiency may occur so supplementary oestrogen tablets should be given so that symptoms occurring due to oestrogen deficiency are not seen.

Are there any complications of hysterectomy ?

In medical science during the last 20 yrs due to recent advances complication rate has reduced. But it is a major surgery. In spite of taking proper precautions 1: 1000 deaths may occur and some may suffer from minor to major complications. Anaesthetic complication, excessive bleeding or infection of the wound and other complications may occur as in any other surgery. Main danger : injury to adjacent organs like bladder, ureter or intestine may occur. If these organs are adherent to each other due to some disease the possibility of damaging the 30 organs may be increased. Sometimes due to improper healing of the vault, white discharge or blood stained discharge is seen.

After removal of the uterus is there any empty space produced? Does the femininity end ?

No. As compared to abdominal cavity the space occupied by the uterus is very small. So there is no space produced after hysterectomy. The very small space created is filled by intestines easily. As the vagina is not removed the intercourse is possible. But as the ovaries may be removed the menopausal symptoms can be seen earlier.

What is meant by abdominal or vaginal hysterectomy ?

Abdominal surgery is by taking incision on abdomen. It there are adhesions of uterus with other organs or if there is cancer or some other indications then abdominal hysterectomy is done. There is scar over the abdomen due to this procedure. If there is descent / prolapse of the uterus then vaginal hysterectomy is done. So there is no scar over the abdomen but this is a skillful surgical procedure.

 

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