Women who are experiencing severe symptoms may be offered a hysterectomy. It can seriously affect your hormone balance as you can be plunged into an immediate, surgical menopause.

What is it?

A hysterectomy is an operation to remove the uterus. There are many different reasons you may have a hysterectomy including:

• Uterine fibroids that cause pain, bleeding, or other problems
• Uterine prolapse, which is a sliding of the uterus from its normal position into the vaginal canal
• Cancer of the uterus, cervix, or ovaries
• Endometriosis
• Abnormal vaginal bleeding
• Chronic pelvic pain
• Adenomyosis, or a thickening of the uterus

Hysterectomy for non-cancerous reasons is usually considered only after all other treatment approaches have been tried without success.

Is it always the same operation?

Depending on the reason for the hysterectomy, a surgeon may choose to remove all or only part of the uterus. Patients and their medical team sometimes use these terms inexactly, so it is important to clarify if the cervix and/or ovaries are removed.

There are five possible options for your surgeon:

1. A subtotal hysterectomy, a surgeon removes only the upper part of the uterus, keeping the cervix in place.

2. A total hysterectomy removes the whole uterus and cervix.

3. A radical hysterectomy, a surgeon removes the whole uterus, tissue on the sides of the uterus, the cervix, and the top part of the vagina. Radical hysterectomy is generally only done when cancer is present.

4. A oophorectomy is when the ovaries may also be removed, or may be left in place.

5. A salpingectomy is when the tubes are removed also.

So, when the entire uterus, both tubes, and both ovaries are removed, the entire procedure is called a hysterectomy and bilateral salpingectomy-oophorectomy.

Surgical approaches

Surgeons use different approaches for hysterectomy, depending on their experience, the reason for the hysterectomy, and a woman’s overall health.

The hysterectomy technique will partly determine healing time and the kind of scar, if any, that remains after the operation.

There are two approaches to surgery – a traditional or open surgery and surgery using a minimally invasive procedure or MIP.

Approach 1: An abdominal hysterectomy is an open surgery and is the most common approach to hysterectomy, accounting for about 54% for all benign disease.

To perform an abdominal hysterectomy, a surgeon makes a 5- to 7-inch incision, either up-and-down or side-to-side, across the belly. The surgeon then removes the uterus through this incision.

Following an abdominal hysterectomy, you will usually spend 2-3 days in the hospital.

Approach 2: An MIP hysterectomy can be done either as a vaginal or laparoscopic approach.

If vaginal, the surgeon makes a cut in the vagina and removes the uterus through this incision. The incision is closed, leaving no visible scar.

If a laparoscopic-assisted vaginal hysterectomy then the surgeon uses laparoscopic tools in the belly to assist in the removal of the uterus through an incision in the vagina.

Technology improvements have meant that you may also have a robot-assisted laparoscopic hysterectomy: This procedure is similar to a laparoscopic hysterectomy, but the surgeon controls a sophisticated robotic system of surgical tools from outside the body. Advanced technology allows the surgeon to use natural wrist movements and view the hysterectomy on a three-dimensional screen.

In general, an MIP allows for faster recovery, shorter hospital stays, less pain and scarring, and a lower chance of infection than does an abdominal hysterectomy.

You are generally able to resume normal activity within an average of three to four weeks, compared to four to six weeks for an abdominal hysterectomy.

Not every woman is a good candidate for a minimally invasive procedure. The presence of scar tissue from previous surgeries, obesity, the size of the uterus, and health status can all affect whether or not an MIP is advisable. You should talk with your doctor about whether you might be a suitable candidate.

Are there any risks?

Most women who undergo hysterectomy have no serious problems or complications from the surgery. However, hysterectomy is considered a major surgery and is not without risks. Those complications include:

• Urinary incontinence
• Vaginal prolapse (part of the vagina coming out of the body)
• Vaginal fistula formation (an abnormal connection that forms between the vagina and bladder or rectum)
• Chronic pain

Other risks from hysterectomy include wound infections, blood clots, hemorrhage, and injury to surrounding organs, although these are uncommon.

What to expect afterwards

After a hysterectomy, if the ovaries were also removed, you will be put into an immediate menopause. If the ovaries were not removed, they may continue to function for some time, but you may enter menopause at an earlier age than you would have otherwise.

Standard advice is to abstain from sex and avoid lifting heavy objects for six weeks after hysterectomy.

The role of hormones

After a hysterectomy most women are given HRT and often this will be oestrogen only as the general medical view is that women do not need progesterone after this operation. If given at all they are in the form of synthetic progestins which mimic the action of the natural hormone, but are associated with their own side effects such as abdominal pain or cramping, bloating or swelling of ankles or feet, blood pressure increase, headache, mood changes.

However bioidentical doctors disagree with this assessment as unopposed oestrogen poses increased risks for hormonal cancers, strokes and heart disease. Also progesterone is an essential hormone for bone building so with low progesterone levels after a hysterectomy a woman may be more at risk from osteoporosis.