A patient recently asked me if I thought she should get a hysterectomy. At first blush, this seems an odd question to ask your endocrinologist. I am not a gynecologic surgeon, so I don’t have hands-on experience. But she correctly noted that I see a lot of women in their 40s and 50s and that some of them must have had hysterectomies and, in the course of our conversations, shared their experience.
This patient had been diagnosed with uterine prolapse — a condition in which the uterus is not adequately supported by the muscles and ligaments of the pelvic floor and sags down into the vagina. She felt pressure in her vagina and on her bladder when she was standing. Her symptoms were getting worse despite pelvic floor therapy and she had been offered a few options, one of which was a hysterectomy.
Opting for surgery of any kind is a big choice. Opting for a surgery that permanently removes a part of you that has reminded you of its presence regularly since you were 12 and perhaps allowed another human — or two, or more — to grow can feel very fraught.
Today we are going to discuss what the data can tell us about life after a hysterectomy. My hope is that this will help you think through your options and guide what questions you might ask your doctor when making a decision.
What exactly is a hysterectomy?
At the most basic level, a hysterectomy is the surgical removal of the uterus. The uterus can be removed with the cervix — a total hysterectomy — or without the cervix — a partial hysterectomy. The fallopian tubes may also be removed. Fallopian tube removal has been shown to reduce the risk of ovarian cancer by as much as 80%, so it is often a recommended part of the surgery for that reason. And, depending on why you are having a hysterectomy, the ovaries may be left in place or removed.
You should be sure to understand exactly what anatomy your surgeon plans to remove during the procedure. And you should confirm after the procedure what was removed. There are good reasons the two lists might be different, and this can have implications for your recovery and future health.
There are three main ways the surgeon can approach a hysterectomy. They can go through the vagina — this is called a vaginal hysterectomy. They can go through a small incision near your belly button, with a few smaller incisions for cameras and instruments, called a laparoscopic hysterectomy. The surgeon can also remove the uterus via a larger incision like the one used for a C-section; this is called an abdominal hysterectomy.
Your surgeon will have reasons for choosing each approach, but the guidelines from the American College of Obstetricians and Gynecologists recommend using a minimally invasive technique — either vaginal or laparoscopic — whenever feasible. Still, more than half of hysterectomies in the U.S. are performed abdominally. There are several possible reasons for this, including inadequate training for doctors on minimally invasive techniques, and issues surrounding insurance reimbursement.
The technique used has impacts on how long patients remain in the hospital, recovery times, and possible complications, so understanding what approach will be used is key to your experience.
A simple way to start that conversation is just to ask, “What type of hysterectomy do you think is the best approach for me, and why?”
If a minimally invasive technique is recommended, consider following up by asking, “What do you estimate the chances are that you will need to change to an abdominal hysterectomy during the procedure?” There is always a chance, even if it is small, that the surgeon may need to change approaches mid-surgery, and understanding how likely this is in your particular case may decrease your chances of being surprised, disappointed, or upset if this happens to you.
Who gets a hysterectomy?
There are 600,000 hysterectomies performed in the U.S. each year, but the rate of hysterectomies being performed peaked in 1975 at 10.6 per 1,000 women and has been falling. In 2035, the rate is expected to fall to 3.5 per 1,000 women. This is likely due to improvements over the past couple of decades in more conservative treatment options for managing issues such as heavy uterine bleeding, as well as improvements in preventing, screening for, and treating cervical cancer.
Indications for having a hysterectomy include fibroids, abnormal bleeding, pelvic organ prolapse, pain due to endometriosis or previous infection, and cancerous and precancerous changes in the uterus or uterine lining. With the exception of cancerous and precancerous conditions, hysterectomy is typically considered only when other treatments, such as pelvic floor therapy, medications, or progestin-eluting IUDs, have not worked well.
Are women satisfied with the results?
There are several studies of patient satisfaction after hysterectomy. Some, like this 2000 study, look at patients undergoing all different procedures. The authors found that 24 months after surgery, 96% of patients reported that the symptoms for which they had had the hysterectomy had completely resolved. Nearly 94% reported that the results were what they were expecting or better at 24 months. Having complications that required them to be readmitted to the hospital was the most significant factor associated with dissatisfaction.
More recent studies look at how satisfied patients are after hysterectomy based on which surgical technique was used. This study comparing conventional laparoscopic hysterectomy with robotic-assisted hysterectomy found no difference in satisfaction between the two groups.
Another consideration if you are still in your reproductive years is that some patients do report that they regret the loss of their fertility.
What are the potential downsides of hysterectomy?
Certainly, as referenced above, if you are still in your reproductive years, the loss of fertility may be a significant one, especially if you were hoping for a pregnancy in the future.
In the short term, all surgeries have some risk of complications. A huge population-based study of almost 80,000 hysterectomies found that complications were not common. The most frequent complications were hemorrhage, pelvic organ prolapse, damage to the bladder or ureters — the tubes that carry urine from the kidneys to the bladder — and infection. Hemorrhage and infection are risks of nearly every type of surgery. The best way to avoid surgical complications is to choose an experienced surgeon who performs the specific type of surgery you are having very frequently.
Longer-term, even when the ovaries are left in place, there is some evidence that women who have a hysterectomy may experience menopause 1.5 to 6 years earlier than women who do not have a hysterectomy. What is unclear is whether this earlier menopause is due to the hysterectomy or to the conditions that made the hysterectomy necessary.
Similarly, some women experience prolapse after hysterectomy. In this study of nearly 3,600 women who underwent hysterectomy, 2.6% of the participants had symptoms that led to seeing a physician for evaluation in the 10 years after hysterectomy. Another 1.6% had surgery for prolapse within the 10 years after hysterectomy. History of pelvic organ prolapse does appear to be a risk factor for experiencing prolapse after hysterectomy.
Observational studies suggest that there is a small increase in cardiovascular risk in women who have undergone hysterectomy compared with women who do not have hysterectomy. This is especially pronounced in women who have their hysterectomy prior to age 35. However, this is an association; a causal relationship between hysterectomy and cardiovascular risk has not been established.
Overall, the risks associated with hysterectomy are small, but you should always consider the risks associated with any procedure against the benefits you are hoping to receive.
Questions you might ask to understand the risks and benefits in your particular case might include:
- “How likely is it that my symptoms will be resolved with a hysterectomy?”
- “How likely is it that my prolapse will recur after my hysterectomy, and what will my treatment options be then?”
Before any procedure, it is reasonable to ask the surgeon:
- “How many laparoscopic hysterectomies do you perform each year?”
- “How often do you need to switch from a laparoscopic to abdominal hysterectomy?”
- “What is your complication rate with this particular surgery?”
For many women, hysterectomy can be an excellent option to manage both cancer and non-cancerous problems such as heavy uterine bleeding, fibroids, and pelvic organ prolapse.
The bottom line
- Hysterectomy is the surgical removal of the uterus. There are a number of surgical techniques that can be used, including vaginal, laparoscopic, and abdominal approaches.
- Most women who undergo hysterectomy report that the symptoms for which they had the hysterectomy were resolved with the procedure, and they report high levels of satisfaction.
- Hysterectomies are safe, but as with any surgery, there is a small chance of complications.
- Hysterectomies have been associated with earlier age at menopause, pelvic organ prolapse, and increased risk for cardiovascular disease, but none of these relationships have been shown to be causal.
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