Hysterectomy


Hysterectomy is the surgical removal of the womb.


Often, this is considered as a last ditch attempt after failed medical treatment to treat patients with severe heavy menses causing anaemia that require frequent blood transfusions (e.g. submucosal fibroid, idiopathic), severe abdominal pain related to menses (e.g. endometriosis, pelvic inflammatory disease, adenomyosis), large probably benign tumours (e.g. fibroids, adenomyosis, ovarian cysts) or possibly or confirmed cancerous growths (e.g. cancer of cervix, uterus and / or ovary).


This can be performed via vaginal approach or abdominal approach. The vaginal approach may be preferred if there is some prolapse of the uterus vaginally and the uterus is not too big to remove vaginally. The transabdominal approach may be necessary if the uterus / ovaries are too big to remove vaginally, and can be removed via an open incision (usually using the same incision as that for a Caesarean section or a midline incision) or a laparoscopic approach (i.e. keyhole surgery).


For hysterectomy, one could consider either:

a) total hysterectomy where the uterus and the cervix are both removed. This is especially so if there is disease within the cervix. Even if there is no disease within the cervix, it would reduce the need for future surgery if disease of the cervix were to occur e.g. precancerous or cancerous changes of the cervix.

b) subtotal hysterectomy where the body (but not the cervix) of the uterus is removed. This may be desired if a recent HPV and Pap smear of the cervix were normal, with no past history of HPV or Pap smear abnormalities of the cervix. Retaining the cervix shortens the surgery and avoid possible risks of injury to the ureters which are closely related to the cervix. Hence not having to remove the cervix means that there is reduced risks of injuring the ureters during the operation. Keeping the cervix also supports the pelvic structures which may reduce the risk of the vaginal vault prolapse in future especially during the postmenopausal years. In addition, the inner lining of the cervix continues to produce mucus. Some believe that this might reduce dryness during sexual intercourse. However keeping the cervix might lead to continued cyclical menses from the inner lining of the cervix, with a potential that future surgery might be required if disease of the cervix were to occur.


During the hysterectomy, one should consider the additional options of:

a) removal of both fallopian tubes - this is recommended as it reduces the future subsequent risk of development of ovarian cancers.

b) removal of one or both ovaries - this may be recommended especially if there is concomitant disease of the ovaries e.g. endometriosis, benign or possibly cancerous ovarian tumours. If both ovaries are removed before onset of menopause, this would bring on an earlier onset of menopause. Even after menopause, the ovaries in the first 10-20 years still produce some androgen hormones which may be beneficial to health. However, removing both ovaries, even if they appear normal, would reduce the risk of subsequent benign or cancerous ovarian diseases that may require further treatment or surgery. It is best to discuss with your gynaecologist on what may be more appropriate for you.