Hysterectomy: Pros and Cons

By Kerry Nelson

What is a hysterectomy?

A hysterectomy is an operation to remove the uterus. Some or all of the other reproductive organs, including the ovaries, may be taken out as well. If you are a woman living in the United States, there's a one in three chance that you'll have a hysterectomy by the age of 60.

Each year US doctors perform about 600,000 hysterectomies. Indeed, after cesarean section, hysterectomy is the most commonly performed major operation on women in the country. Some of these operations are necessary to stop the growth of cancers of the uterus, ovaries, or cervix (if it's advanced). The majority of hysterectomies, however, are done to treat noncancerous conditions such as uterine fibroids, endometriosis, and uterine prolapse. Yet many of these problems may be alleviated using less invasive methods.

Doctors used to view the uterus as largely expendable once a woman was past the childbearing years; the uterus was sometimes removed during fibroid surgery simply to eliminate the possibility of uterine cancer. But this attitude is rapidly changing. Today many doctors realize the uterus appears to play a role in regulating hormones, and don't advise removing it unless it's completely necessary.

Why are hysterectomies controversial?

Critics contend that in the past some doctors, with the goal of preventing uterine cancer, have prescribed hysterectomies to women who didn't need them. In very rare cases, doctors have been charged with using hysterectomies as a form of birth control or involuntary sterilization, especially for women of color. There have also been cases where hysterectomies were performed without the knowledge or consent of the patient.

For many women, the biggest drawback to a hysterectomy is loss of fertility. Once you have a hysterectomy, you cannot conceive, and for many women of childbearing age, this is a significant loss. Some women experience a loss of sexual desire, although this problem appears treatable with hormone therapy. Women who feel pushed into a hysterectomy may also have a negative reaction to it.

When should I get a hysterectomy?

If you have cancer of the uterus or the ovaries or advanced cancer of the cervix, the surgery could save your life. In these cases, a hysterectomy, possibly including oophorectomy (removal of one or both ovaries), can banish the cancer and may prevent the spread of cancerous cells. Hysterectomy is also sometimes the only option for women with very large uterine fibroids or ovarian cysts, advanced pelvic inflammatory disease, or severe complications during pregnancy. Cesarean hysterectomy may be performed after delivery to stop life-threatening bleeding from the uterus.

If you have already had children or don't want to have children, it may make sense to have a hysterectomy for a less serious condition if other approaches have failed -- if, say, you've suffered years of fibroid pain and excessive bleeding that don't respond to drugs or other treatments. In such circumstances, some women report that this "politically incorrect" operation has freed them from years of misery.

Are there alternatives to hysterectomy?

For some of the problems for which hysterectomy is prescribed, other approaches might suit you better. In the early stages of cancer of the cervix, ovaries, or uterus, a hysterectomy may not be necessary. And for conditions such as uterine fibroids, which are not life-threatening, you can consider a wealth of alternatives, including drug therapy and less invasive surgeries. Conditions that don't usually require hysterectomy include:

  • Abnormal menstrual bleeding
  • Uterine fibroids (unless fibroids are causing such severe chronic and acute bleeding that the resultant anemia is life-threatening)
  • Endometriosis
  • Dropped uterus (uterine prolapse)
  • Precancerous cervical lesions
  • Chronic pelvic pain

Always get a second opinion if your doctor recommends a hysterectomy. Unless you have a life-threatening condition or you're sure that a hysterectomy is the right choice, you may want to explore other options.

How do I prepare for the surgery?

If you're having general anesthesia, you must not eat on the day of the surgery and should have only a light meal the night before. If you're getting a local anesthetic, you can eat normally. If you have mixed feelings about having a hysterectomy but you've decided to go ahead because your condition is serious, you may want to prepare yourself emotionally by reading up on the operation (see Resources ). You may also want to find a local or online support group or just talk to some good friends about your feelings.

What happens after the operation?

You'll stay in the hospital for a few days, then be told to rest at home for a number of weeks -- usually at least a month. While in the hospital, you'll probably be hooked up to an IV and, to empty your bladder, a catheter. Women who have abdominal hysterectomies generally need to stay in the hospital a day or two longer than women who have vaginal hysterectomies. (Vaginal hysterectomies don't require opening the abdomen, so gastrointestinal function returns in a rapid fashion. Patients, in fact, can usually eat the day of surgery after a vaginal hysterectomy.)

For the first few weeks of your recovery, you will likely need to avoid lifting heavy objects as well as strenuous exercise. Your doctor may also recommend that you abstain from sexual intercourse during this time.

What are the side effects of a hysterectomy?

Some studies have shown that 10 to 40 percent of women experience a decrease in sexual response or libido following the operation. This may be related to a testosterone deficiency that can develop if the ovaries are removed, which in turn reduces the production of androgens. This imbalance can be treated through hormone therapy, including the use of natural testosterone creams applied vaginally. (Most hysterectomies spare the ovaries, however, thus sparing ovarian hormonal function.) Since contractions of the uterus can contribute to orgasm, some women report that they have more difficulty reaching a satisfying orgasm.

A recent study, however, found no real difference in women's sexual response before and after a hysterectomy. Some women even reported an improvement! Of course it's not terribly surprising that women who've long endured excessive bleeding and pain during intercourse as a result of fibroids would indeed have a better sex life after the operation.

Since the nerves to the bladder pass near the uterus and may be damaged during a hysterectomy, women who've had the surgery are at higher risk for developing stress incontinence (some urine is released when exercise, sexual activity, sneezing, or coughing puts pressure on the abdomen). This can usually be resolved through regular practice of Kegel exercises, simple pelvic muscle exercises that can be done at home or even driving a car.

What resources are available?

For help in dealing with any difficult emotional, sexual, physical, or psychological effects of your hysterectomy, you might consider joining a support group. Other women who've gone through the procedure may offer valuable advice as well as comfort. You can find groups through the Hysterectomy Educational Resources and Services Foundation (HERS), http://www.hersfoundation.com or (610) 667-7757. You might also ask your gynecologist or local women's health clinic about support groups in your area.

References

Reich H. Issues surrounding surgical menopause. Indications and procedures. J Reprod Med 2001 Mar;46(3 Suppl):297-306.

Rhodes JC, et al. Hysterectomy and sexual functioning. JAMA 1999 Nov 24;282(20):1934-41.

Brigham Narins, Editor. World of Health:573-4. The Gale Group 2000.

Mayo Clinic. Hysterectomy: Benefits and alternatives. March 2004.

National Women's Health Information Center. Hysterectomy. November 2002.

Centers for Disease Control. Women's Reproductive Health: Hysterectomy. May 2009.

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