The Hysterectomy

Contents

1. What the operation removes
2. A name older than the anatomy
3. How often it is performed
4. The reasons behind it
5. Treatments tried before it
6. From one large incision to several small ones
7. Choosing among the routes
8. Recovery and the changes that follow
9. What remains unsettled

Hysterectomy by the vaginal route and by the abdominal route is part of Candace Cooley’s surgical experience, and the operation usually ends in an ordinary scene. On the morning after surgery a woman, a composite of many, walks the ward corridor beside a nurse, a thin catheter that drained her bladder overnight soon to come out, her discharge planned for that day or the next. The Office on Women’s Health describes exactly this pattern: most patients stay one to two days, are encouraged up and moving early, and may need a catheter for a day or two.¹ Behind that routine lies a long history.

What the operation removes

A hysterectomy removes the uterus, usually the whole organ. A total hysterectomy takes the uterus and cervix; a partial, also called subtotal or supracervical, leaves the cervix; a radical operation, used mainly for some cancers, also removes tissue beside the cervix and the upper vagina. The fallopian tubes and ovaries may or may not be taken in any of them. Periods end after any form of the operation, and pregnancy is no longer possible. When the ovaries stay, they usually go on making hormones, so other signs of menopause need not follow at once, although some women reach it a few years earlier than average.¹

A name older than the anatomy

The word itself is a relic. Writing in The Conversation, the author traces it to hystera, the ancient Greek for uterus, and to hysteria, a supposed disorder blamed on a wandering womb and dropped as an official diagnosis only in 1980.⁸ In a survey of almost 500 Australian adults, one in five thought the operation removed the ovaries. The author argues for uterectomy, a term that names the organ.⁸

How often it is performed

Nearly 500,000 women in the United States have a hysterectomy each year, making it the second most common operation among women after cesarean birth.¹ Other estimates run higher, above 600,000 a year.⁴ The same essay that questions the name puts the Australian figure at about one woman in three, and calls the operation one of the most common worldwide.⁸

Figure

Hysterectomy in the United States

Hysterectomies each year

Nearly 500,000

Rank among operations on women, after cesarean birth

Second

Usual hospital stay

One to two days

The reasons behind it

Common reasons include uterine fibroids, heavy or unusual bleeding, uterine prolapse, endometriosis, adenomyosis and cancer or precancer of the uterus, cervix or ovaries.¹ When fibroid symptoms are severe, they head the list of causes in the United States. NPR has reported that Black women undergo the operation at a rate at least double that of white women, that one researcher found it historically overused, and that patients have organized to ask for treatments that keep the uterus.⁹

Treatments tried before it

Hysterectomy is major surgery, and many conditions have other options first. Fibroids often get smaller once periods stop, so watchful waiting suits some women. Pelvic floor exercises and a pessary can help prolapse. Myomectomy removes fibroids and leaves the uterus; endometrial ablation destroys the lining to stop heavy bleeding; uterine artery embolization shrinks fibroids by blocking their blood supply.¹ The Office’s fact sheet notes that a doctor may try such procedures before removing the uterus.²

From one large incision to several small ones

Abdominal hysterectomy, done through one large incision, is the oldest of the approaches.¹⁰ A different path opened in 1989, when Reich and colleagues described the laparoscopic assisted vaginal hysterectomy, as OBG Management recounted.⁵ The laparoscopic story runs back through the gynecologists who first operated through a scope. Change was slow: in a JAMA study of 264,758 women treated between 2007 and 2010, abdominal operations still made up about 47 percent, though their share fell from 54 percent to 40 percent as laparoscopy rose, CBS News reported.¹⁰

Figure

How hysterectomies were performed, 2007 to 2010

• Abdominal47
• Laparoscopic29
• Vaginal21
• Robot assisted4

percent

Choosing among the routes

The specialty’s Committee Opinion No 701 lists what shapes the choice for benign disease: the size and shape of the vagina and uterus, access to the uterus, disease beyond it, other procedures needed, the surgeon’s training and volume, the hospital’s equipment, urgency and the informed patient’s preference.³ Vaginal and laparoscopic routes are called minimally invasive because they avoid a large abdominal incision; the vaginal approach is preferred among them, laparoscopy is the alternative when it is not feasible, and open surgery remains important for some patients.³

A structured guide in Contemporary OB/GYN adds bedside detail: the angle of the pubic arch, the breadth of the vaginal apex, uterine descent, and a uterus of about 12 cm or less usually permitting the vaginal route. It frames conversion to a larger approach as a choice made to finish safely, not as a failed plan.⁴ The abdominal route is still chosen when extensive exploration or cancer surgery is needed.⁵

Robotic surgery is grouped with laparoscopy in that guide. The surgeon sits at a console and steers instruments on mechanical arms, and supporters say it can help in technically difficult cases, such as women with several earlier abdominal operations or a large uterus.⁷⁴

Recovery and the changes that follow

Figure

Recovery by route

	Abdominal	Vaginal, laparoscopic or robotic
Incision	A cut, usually in the lower abdomen	A small cut in the vagina, or very small cuts in the abdomen
Hospital stay	Usually one to two days, sometimes longer	Usually one to two days, some go home the same day
Return to normal activities	Four to six weeks	Three to four weeks

Recovery after abdominal surgery takes four to six weeks, and after the vaginal, laparoscopic or robotic routes about three to four.¹ A 2009 review of 34 studies covering 4,495 women found faster recovery and fewer infections with vaginal than abdominal operations, and less blood loss, shorter stays and a quicker return to normal life with laparoscopic ones.¹⁰ Hysterectomy is a relatively safe operation, with a mortality rate of 1 to 2 per 1,000.⁵ If both ovaries are removed, menopause symptoms can begin at once and may be stronger than with natural menopause; some women also report vaginal dryness, lower desire or a sense of loss.²

What remains unsettled

Several questions stay open. Whether to keep the ovaries remains a weighing of ovarian cancer risk against the protection estrogen gives the heart and bones, and recent studies suggest that removing only the fallopian tubes may lower the risk of the most common ovarian cancer.¹ Robotic surgery spread quickly, reaching 22.4 percent of hysterectomies at hospitals three years after a robot arrived, yet a study in Obstetrics and Gynecology found it cost close to $2,500 more per patient with similar outcomes.⁷⁶ Why so many operations stayed abdominal despite evidence favoring smaller incisions is still argued, with training often blamed, and so is the name.⁴¹⁰ Which route and which organs are right for one woman is a decision for her and her own surgeon. The next entry looks at hysteroscopy, a way of seeing inside the uterus without removing it, and the midurethral sling shows how gynecologic surgery treats a different problem.