HYSTERECTOMY

by The Obstetrics & Gynaecology Department of St. Georges Hospital, London

What is a hysterectomy?

A hysterectomy is the surgical removal of the uterus or womb, which usually includes the cervix. One or both of the ovaries may be removed at the same time as the hysterectomy. The operation to remove an ovary and fallopian tube is called a salpingo-oophorectomy.

The uterus may be removed through an abdominal incision or through the vagina.

The method used is determined by several factors. including your symptoms or complaints and the findings on examination.

What are the medical reasons for a hysterectomy?

Hysterectomy is usually necessary if the following become serious:

1. Vaginal bleeding not controlled by other treatment.
2. Uterine fibroids which cause pain, bleeding or have increased in size. (Fibroids are non-cancerous tumours made of muscle and fibrous tissue).
3. Early cancer of the uterus or ovaries.
4. Early cancer of the cervix.
5. Severe endometriosis. (Endometriosis occurs when tissue that normally lines the womb forms nodules in various places outside the womb, most commonly on the ovaries and tubes.)
6. Uterine prolapse (descent of the uterus with or without descent of the bladder and rectum).
7. Low abdominal pain possibly caused either by pelvic inflammatory disease or pelvic adhesions related to the uterus and not controlled by other treatment.

What are the physical effects of the operation?

A hysterectomy ends a woman's ability to menstruate or become pregnant.

Provided one ovary remains, a hysterectomy does not cause:

1. Hormone related problems;
2. Early menopause.

After a hysterectomy, the ovaries still produce hormones.

However, a natural menopause may occur a little earlier for some women.

If the ovaries are removed with the uterus prior to the menopause, there may be menopausal symptoms which can be treated satisfactorily by hormone replacement therapy. This is usually given either as a tiny implant under the skin at the time of surgery and repeated 6 months later, or as patches on the skin, or in tablet form.

Your doctor will discuss with you the most appropriate treatment for you.

The vagina and other genital organs are not affected by a hysterectomy and therefore a woman's sexual activity is not impaired and her sexual desire should not change.

What are the benefits of a hysterectomy?

A hysterectomy can end symptoms of pain and bleeding and in some cases act as a life saver. As a result many women find that a hysterectomy improves their health and well-being and ensures that they can continue to lead an active life.

It is important to understand exactly what a hysterectomy can mean to you and what benefits it will bring. Make sure that you understand from your doctor how the operation will affect the particular symptoms you have. You may find it helpful to write down any questions you have.

What are the risks and complications of a hysterectomy?

A hysterectomy is a major but common operation (approx. 50,000 hysterectomies are performed in the United Kingdom each year). Minor problems may occur after the operation, such as a slight fever or temporary difficulties in emptying the bladder, but these problems are usually corrected. As with any major abdominal or pelvic operation, serious surgical and anaesthetic problems rarely occur, but the risks and possible benefits of any operation must be considered before undergoing surgery.

What happens in hospital?

On admission to the ward, you will he seen by a nurse and later by a member of your gynaecological team.

Your operation and the type of incision you will have will be explained to you and you will be asked to sign a consent form. It is important to understand why you are having the hysterectomy and what will happen afterwards.

This is the time to ask any further questions.

Before your operation your urine will be tested and a sample of blood will be taken. If it is thought necessary, a chest X-ray and ECG (electrocardiogram to check your heart) may be arranged.

You will be seen by an anaesthetist.

The physiotherapist will come to see you before your operation to teach you deep breathing and leg exercises and to show you how to get in and out of bed correctly. She will show you how to cough without hurting yourself.

The nursing staff will advise you regarding all preparations necessary before going to the theatre, which will probably include a pubic shave and a bath. You will have nothing to eat or drink for at least six hours before the operation.

If you smoke, try to give it up some time before the operation. If you anticipate having any problems at home or need advice about available services (e.g. home help), then ask to see the hospital social worker who may be able to help you.

What happens after the operation?

When you first wake up, you will have a drip in your arm (which provides fluids or blood necessary for recovery). You may need to have a catheter (a small tube to drain urine from the bladder) and a drainage tube (to drain excess fluids from near your incision).

The nursing staff will take your blood pressure and pulse regularly to check that you are comfortable. You will be given pain killers, as necessary.

On the day after your operation, a doctor will see you and tell you the exact procedure carried out at your operation, and when you can start to drink. The nursing staff will encourage you to move and get out of bed. A physiotherapist will show you how to breathe and do simple exercises. Following the operation you may have a slight discharge or slight bleeding from the vagina. This is normal. However, if it becomes heavy in hospital or at home, you should inform your doctor.

Bowel and stomach gas can cause wind pains. If this problem continues, you may need suppositories to help you pass wind.

You will normally he in hospital for 2-7 days, but seldom more than 10 days. A vaginal hysterectomy usually means a shorter stay in hospital. Before you go home any stitches or clips will be removed.

What exercises can I take after my operation?

As soon as you wake up on the first day after your operation, do the breathing and leg exercises shown to you prior to your operation. Repeat them three or four times every hour, until you are fully mobile.

When you need to cough, sit up straight supported by the pillows, bend your knees, put your hand or fore arm over the wound and take a deep breath in, then cough. You may find it easier to cough if you hold a pillow against your stomach.

Many women suffer from wind pains after their operation. If this happens to you then try the following exercises as they may help to relieve wind pains.

1. Lie on your back, Gently and slowly, bend both knees. Keep them together and let them rock slowly from one side to the other.
2. Keep your knees bent and press the small of your back into the bed, then relax. Do this exercise gently and rhythmically.

When you get out of bed try to stand and walk "Tall". Bad posture can cause backache.

Exercises to strengthen your pelvic floor and tummy muscles

These can be started when you and your doctor feel you are ready. Your physiotherapist will teach you how to do them correctly.

• Pelvic-Floor - Lie on your back with your knees bent and slightly apart. Try to close the anal sphincter (the back passage) then close and draw up your vaginal muscles. Hold the muscles tight while you count to 4, then gently let go. Do this exercise 3 to 4 times every hour. You can do this exercise in any position including standing.
  The pelvic floor muscles are very important and play a major part in maintaining bladder and bowel control. Try to get into the habit of doing this exercise every day.
• Pelvic Tilting - Lie on your back with a pillow under your head and your knees bent up. Press the small of your back onto the bed and tighten your stomach muscles at the same time. Hold for a count of 5 and repeat 5 times.
• Head Raising - Lie on your back with knees bent up and press the small of your back into the bed. Gently supporting your head with one hand, tighten your tummy muscles and lift your head and shoulders off the bed. Repeat this exercise 5 times twice daily.

What will happen on my discharge from hospital?

Before leaving hospital, arrangements will be made for you to be seen in the out-patients clinic 6-8 weeks after your operation, where you will be checked to ensure you are fully recovered.

If you have been having any problems you should let the doctor know.

It is quite common for granulation tissue to form at the top of the vagina while it is healing and this can cause a discharge. This is easily treated in the outpatient clinic. Sexual intercourse may be resumed after your post operative visit if all is well.

Make sure you ask your doctor whether you need to be seen regularly and if smears still need to be taken.

What can I do when I go home?

During the first six weeks it is important to have a period of convalescence and to refrain from heavy lifting or straining. For the first two weeks at home you may need to take it easy so relax and make sure you rest every day. Continue to do the exercises you were taught in hospital.

Each woman is different in her speed of recovery. If a new activity makes you feel overtired, then this is a sign that you are overdoing things.

Here are some general guidelines

1. Avoid prolonged standing - do as many things as you can sitting down. Do not lift anything that weighs more than 6-8lbs for the first 4 weeks and try not to lift anything heavy for at least three months after your operation.
2. Remember walking is excellent exercise for you so do try to take a short walk each day. It is also quite safe for you to go up and down stairs from the first day you go home.
3. You may feel ready to drive 4-5 weeks after your operation but it is advisable to take someone with you on the first time.
4. You can go swimming when your wound is completely healed. Don't forget to ask your physiotherapist or your doctor any questions you may have about exercises and what you do when you get home.

Questions & answers

Q: Will a hysterectomy make me depressed?
A: Not specifically, but it is common to feel depressed or tearful after any operation and this includes a hysterectomy. Depression usually passes as your strength returns but if it persists you should see your GP.

Q: Will I put on weight?
A: No, a hysterectomy does not make you put on weight. However, lack of exercise and overeating during your recovery will. It is important to ensure that you are eating a balanced diet containing fresh vegetables and fruit.

Q: Will a hysterectomy affect my sex life?
A: No, the operation itself does not change your sex life and there should be no change in your sexual desire and satisfaction. It is often improved because your symptoms have been relieved.

Q: Will I go through an immediate change of life?
A: Only if both ovaries have been removed and you have not reached your menopause. You will be given hormone replacement therapy if it is suitable for you.

Q: What type of scar will I have?
A: You will have either a bikini scar or a vertical scar (extending downwards form you belly button ). They are chosen for different reasons, so ask your doctor before your operation which one you will be having. A vaginal hysterectomy has an internal scar only. One type of hysterectomy operation the "laproscopic assisted hysterectomy" can leave a series of small stabmark scars on the abdomen as well a vaginal scar.

Q: When can I drive?
A: You should be able to drive when you can confidently do an emergency stop without hurting your wound. This is usually after 3 weeks. It is also advisable that you check your insurance policy to ensure you are covered after major surgery.

Q: Is it true that a vaginal hysterectomy is less uncomfortable than an abdominal one?
A: Because there is no external incision through the abdominal wall, many women find that vaginal hysterectomy is less painful and may therefore make a faster physical recovery. However, caution with lifting still applies.

Q: When can I return to work?
A: This depends upon your speed of recovery and your job, but normally between 4 - 8 weeks. Your GP will advise you.

Q: Prior to the operation, I suffered from pre-menstral tension, will I still get it?
A: If your ovaries remain, you will continue to have cyclical changes and therefore symptoms related to premenstrual tension may occur, but usually to a lesser extent.

Q: Is the cervix (neck of the womb) always removed at a hysterectomy?
A: Most hysterectomy operations today remove the cervix with the uterus. In the past, and very occasionally today, the cervix is not removed. This is called a sub-total hysterectomy.

Q: Do I still need to have smears?
A: This will depend upon the reason for your hysterectomy. Ask your doctor.

Q: What happens to the eggs my ovaries produced each month?
A: These are absorbed within your body.

Q: I take the contraceptive pill - when should I stop taking it?
A: You are advised to stop taking your pill at least one month before your operation, but remember to use a barrier method of contraception until the time of the operation.

Q: Prior to the operation I suffered from backache - will a hysterectomy cure this?
A: Most backache is not caused by gynaecological problems. Your own doctor will be able to tell you if your symptoms will be relieved by a hysterectomy