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Medically Reviewed On: October 27, 2004

Published on: January 30, 2004

By Christine Haran

Today it's almost commonplace for women to have their uteruses removed. In fact, hysterectomy is the most common major gynecological operation in the United States. One reason for its popularity is that this type of surgery can treat a wide range of conditions, from cancer to uterine fibroids. Over the last five years, however, there has been controversy about whether physicians have been too quick to recommend hysterectomy.

Hysterectomy is a procedure in which a woman's uterus is surgically removed, but her estrogen-producing ovaries, are spared. According to the American College of Obstetricians and Gynecologists, hysterectomy should only be recommended after alternative options have been explored with a patient, and that a woman who has been advised to have one should consider getting a second opinion.

A number of alternative procedures have been developed to treat fibroids, heavy menstrual bleeding and other conditions that might once have required the complete removal of the uterus. This may be particularly important for women who may want to preserve future fertility or who are poor candidates for surgery. But sometimes hysterectomy is the right choice, and newer, less invasive approaches have made it a much easier procedure from which to recover.

Below, Sandra Emmons, MD, an associate professor of obstetrics and gynecology at Oregon Health Sciences University (OSHU) and a physician in OSHU's alternatives to hysterectomy program, discusses women's options and how they can make the best possible decision.

What is a hysterectomy?
Well, the word "hysterectomy" means removal of the uterus and it encompasses the body of the uterus as well as the cervix. In talking about hysterectomy, we're not talking about removing the ovaries. I think one of the most common misunderstandings is that a woman having a hysterectomy has to have her ovaries out and therefore has to undergo menopause. It's certainly possible to leave the ovaries and remove the uterus and not cause a hormonal upset.

Why would a woman have a hysterectomy?
There are a lot of potential reasons why the uterus may be removed. On the most serious end of the spectrum, cervical cancer or uterine or ovarian cancer may prompt the hysterectomy.

A woman may have fibroid tumors, which is a benign condition that causes the smooth muscle of the uterus to grow, both inside and on the surface of the uterus, and become quite large. A woman may have a condition called adenomyosis, which also makes the uterus enlarge and bleed heavily with the periods. Women may have a condition called endometriosis, which causes pain with periods and sometimes even pain not associated with the menstrual periods. Women may have various prolapse conditions where the uterus falls outside the body through the vagina.

There are also some ovarian conditions such as premalignant ovarian cysts where both the uterus and the affected ovary are removed.

How can hysterectomy be performed?
There are several ways of doing a hysterectomy. The most common method is abdominal hysterectomy, which means that the uterus is removed through an incision made in the abdomen. A vaginal hysterectomy refers to removing both the uterus and the cervix through the vagina so that there is no abdominal incision.

Vaginal hysterectomy is actually the least invasive approach. But not every woman is a candidate for that type of surgery. It requires that the cervix be taken, so if a woman wants to preserve her cervix that is not possible to do with this method. The other usual reason she might not be a candidate is if the uterus is too large. A lot of women have a hysterectomy because of uterine fibroids and that may make the uterus too bulky to remove vaginally.

Then there are two ways of removing the uterus laparoscopically, which means that a fiber-optic instrument is used to examine the abdominal cavity. One is what's called a laparoscopically assisted vaginal hysterectomy. A laparoscope is used to disconnect a portion of the uterus that's inside the abdomen. Then a vaginal incision is made and the cervix and uterus are removed through the vagina.

A woman can recover more quickly from the laparoscopic method because the incisions are much smaller. And there is not nearly so much postoperative discomfort after the laparoscopic approach as there is with abdominal surgery.

How long is the recovery period?
It depends on what sort of hysterectomy is done and why she is having it. If a woman has a laparoscopic or vaginal hysterectomy and is not ill going into the procedure, she may recover in two or three weeks. But, if a woman has cancer and has a hysterectomy, it's probably going to take two or three months to recover. If a woman is severely anemic and has a hysterectomy, it will probably take a couple of months to recover and get the blood count back to normal.

When is hormone therapy an option?
Hormone therapy is an option that works very well for women who are having abnormal bleeding due to an imbalance in their hormones. And that can take the form of something as simple as birth control pills or Depo-Provera injections.

There is also a very strong hormone therapy called gonadotropin-releasing hormone that essentially puts a woman into menopause, which, of course, makes her quit bleeding.

For women having abnormal bleeding caused by fibroids, endometriosis or adenomyosis, hormone therapy is only successful in maybe 50 percent to 60 percent of the cases.

What are some alternative surgeries for fibroids or heavy bleeding?
There is a surgical treatment called myomectomy, which is a surgery that removes just the fibroid and not the entire uterus.

For fibroids that grow only on the inside of the uterus there is a procedure where the fibroid is removed through a hysteroscopy, where a scope is placed inside the uterus and the fibroid is then removed.

There is also a procedure called uterine artery embolization. In this procedure, little pellets are released in the uterine artery to clog it up so that the blood supply to the fibroids is cut off. That causes the fibroids to die and thereby shrink.

And finally, there is a procedure that cauterizes or lasers the lining of the uterus so that it no longer can cycle or have normal periods. In that way, you also cut down on menstrual bleeding.

What are the benefits of these surgeries?
Both myomectomy and hysterectomy are equally invasive and have essentially the same hospital stay and recovery associated with it. But, maintaining the uterus is obviously important to women who want kids and some women just have a preference to keep all their organs as long as they can.

In terms of the uterine artery embolization procedure, the recovery from that is probably equivalent to the recovery from a simple laparoscopic or vaginal hysterectomy. It's in the two-to-three-week range. And of course, it avoids any abdominal incision or vaginal incision.

Hysteroscopy is significantly less invasive than hysterectomy. The woman usually goes home right afterwards and only requires three to five days of recovery.

What are alternative surgeries for uterine prolapse?
Most of the time what that involves is strengthening the ligaments, which form a support structure that holds the uterus up. Sometimes it involves using a graft or artificial tissue to attach to the uterus back up to the backbone.

Aside from maintaining fertility, what are the benefits of keeping the uterus?
There are three reasons to maintain the uterus. One is certainly just personal choice. As I said, some people strongly prefer to maintain their organs if at all possible. I think that needs to be respected if there is no life-threatening cause for hysterectomy.

The other two reasons are really not scientific but are certainly being discussed. I think we will have studies on them in the future. One is a theory that doing a hysterectomy may increase a woman's risk of developing vaginal prolapse in the future; that detaching the uterus from the supporting ligament, and removing the cervix, may increase her risk of vaginal prolapse.

The last reason, which has been discussed in the lay press but really has not been shown to be true in the studies that have been published in the medical journals, is the theory that orgasm may be different following hysterectomy. Some women feel contractions in their cervix or the uterus, and, if a woman's sexual response involves that, it would clearly be absent after the organ is removed.

So is sexual desire and response different following hysterectomy?
There is this common belief that after hysterectomy a woman's sexual appeal or sexual desire will go away. That's not been found to be true, particularly if there is no hormonal change associated with the procedure. Usually sexual response remains the same before and after the hysterectomy.

What do you think a woman's steps should be if she's been told that she needs a hysterectomy?
I think she should have a clear understanding of why she has been advised to have a hysterectomy. Is it because of bleeding? Is it because of a possible cancer? Is it because of a large mass? She should also have an understanding of how the surgery is going to be accomplished.

I think a woman needs to understand if, in her particular case, any of the nonsurgical options are possible, and then, she also needs to do some self-analysis as to what would give her the best outcome in terms of her lifestyle. Sometimes it sounds very attractive to do a less invasive procedure that will allow for a quick recovery because of lifestyle issues such as responsibilities to family, work scheduling, plans for travel. So sometimes a woman may choose a less invasive procedure that has a lower success rate because she can't take six weeks off to have an abdominal hysterectomy, even though, ultimately, that may be what she needs to do to resolve the problem.