A hysterectomy is an operation to remove the uterus (womb). Most hysterectomies are not emergency operations, so you have time to think about your options.

WHAT IS A HYSTERECTOMY?
A hysterectomy is the surgical removal of the uterus. Surgical removal of the ovaries (called an oophorectomy) is often performed at the same time as a hysterectomy. However, for many women undergoing a hysterectomy, there is no need to remove the ovaries. As with all decisions about surgery, the decision to have a hysterectomy (or oophorectomy), as well as the type of hysterectomy that might be most appropriate for your condition, should be discussed with your doctor
Function of the uterus and ovaries
The uterus cradles and nourishes a fetus from conception to birth, and aids in the delivery of the baby. It also produces the monthly menstrual flow, or period.
The ovaries have two major functions. One is the production of eggs or ova, which permit childbearing. The second is the production of hormones or chemicals which regulate menstruation and other aspects of health and well-being, including sexual well-being.
If the egg that is released during a woman's normal monthly cycle is not fertilized, the lining of the uterus is shed by bleeding (menstruation).
After a hysterectomy, a woman can no longer have children and menstruation stops. The ovaries generally continue to produce hormones, although in some cases they may have reduced activity.
Some hysterectomies also include removal of the ovaries, so the supply of essential female hormones is greatly reduced. This can have various effects, as discussed later.

WHY DOES A WOMAN HAVE A HYSTERECTOMY?
Hysterectomy is one treatment for a number of diseases and conditions. If you have cancer of the uterus or ovaries or hemorrhage (uncontrollable bleeding) of the uterus, this operation may save your life.
In most other cases, a hysterectomy is an elective procedure. The operation is done to improve the quality of life: to relieve pain, heavy bleeding or other chronic conditions and discomfort.
The following describe the more common reasons for recommending hysterectomies.
• CANCER OF THE UTERUS OR OVARY
Cancerous organs and, in some cases, adjoining organs and structures, are removed in order to stop the spread of this life-threatening disease.
• FIBROIDS
These are common non-cancerous (benign) tumors of the uterus and they are the most frequent reason for recommending a hysterectomy. They grow from the muscular wall of the uterus and are made up of muscle and fibrous tissue. Many women over 35 have fibroids, but usually have no symptoms.
In some women, however, fibroids (myomas) may cause heavy bleeding, pelvic discomfort and pain and occasionally pressure on other organs. These symptoms may require treatment, but not always a hysterectomy. There are promising new experimental drugs that may temporarily shrink the tumors; however, these drugs may have serious side effects. They are generally very costly. There is a type of abdominal surgery (myomectomy) that removes the myoma without removing the uterus (see Alternatives for additional information). These treatments may be sufficient or they may offer temporary relief and enable a woman to postpone having a hysterectomy, especially if she still wishes to bear children.
Some women choose to do nothing since fibroids will often shrink in size as a woman goes through menopause.
• ENDOMETRIOSIS
Another common reason for recommending a hysterectomy is endometriosis. This is a noncancerous condition in which cells from the uterine lining grow like islands outside of the uterus. This growth occurs most commonly on the ovaries, fallopian tubes, bladder, bowel and other pelvic structures, including the uterine wall. These cells may cause pain and discomfort by bleeding at the time of menstruation. Endometriosis may also cause scarring, adhesions and infertility.
Symptoms can vary greatly and some women choose to do nothing, or find that drug therapy, pain relief medication or more localized surgery are effective. When these are not effective, hysterectomy may be the treatment of choice.
• PROLAPSE
As a woman ages, the vaginal supports begin to lose their muscle tone and sag downward (prolapse). With prolapse, the bladder and/or rectum may be pulled downward with the uterus. This happens to most women to some degree. For the vast majority, the sagging is minor and symptoms are not severe.
If the prolapse worsens, some women experience a heavy or dragging feeling in the pelvic area, problems controlling bladder and/or bowel function, and occasionally, protrusion of one of the organs through the vaginal opening.
Some women get relief from these symptoms by doing special exercises ("Kegels") to strengthen the pelvic muscles, by taking hormone therapy or by using a plastic or metal ring (pessary) which may help to hold the uterus in place. None of these treats the underlying problem.
A hysterectomy with repair of supporting structures is usually recommended in more serious cases. A woman has to decide for herself if the discomfort is great enough to have a hysterectomy.
• CANCER OF THE CERVIX
Precancerous changes in the cervix are often found on routine Pap smears. These lesions or abnormalities must be treated, but rarely with a hysterectomy. When detected early and treated effectively, most of these conditions do not progress to invasive, life-threatening cancer. they can be treated conservatively, usually on an outpatient basis.
It is only in the case of invasive cancer of the cervix that hysterectomy may be the treatment of choice.
• PRE-CANCER OF THE UTERUS
A pre-cancerous change can occur when the lining of the uterus (endometrium) overgrows. "Hyperplasia of the endometrium" means an overgrowth of the lining of the uterus. It causes irregular and/or excessive bleeding. The overgrown lining can usually be treated with hormone therapy and/or a "D & C" (dilation and curettage) a simple outpatient procedure to clean out overgrown tissue. In more severe cases or cases that do not respond to treatment, hyperplasia of the endometrium may lead to cancer of the uterus. Upon diagnosis of cancer, a hysterectomy would be the treatment of choice.
• PELVIC ADHESIONS
Irritation of the lining of the abdomen may cause adhesions (scarring) which bind affected organs to each other. The adhesions can result from endometriosis, infection or injury. The symptoms may include severe pain, bowel and bladder problems and infertility.
Pain relief medication or less drastic surgery, such as laser therapy, can be effective in some cases. In very serious cases, hysterectomy may be recommended. However, a hysterectomy itself can cause adhesions.
• UNUSUALLY HEAVY BLEEDING
It is normal for the amount and length of menstrual flow to vary from woman to woman. There may also be differences in menstrual flow from one cycle to the next. If bleeding that is unusually heavy or frequent for you occurs, this may be due to a variety of causes. The most common causes are fibroids and hormonal changes.
Because there can be many reasons for unusually heavy bleeding, getting an accurate diagnosis is vital before deciding on a course of treatment. Depending on the diagnosis, drug therapy or minor surgery may be indicated. Rarely, there can be hemorrhage of the uterus in which case a hysterectomy can be life saving.
• PELVIC PAIN
This is a common symptom. As with heavy bleeding, there can be a number of causes for pelvic (lower belly) pain. These include endometriosis, fibroids, ovarian cysts, infection or scar tissue. Pain in the pelvic area may not be related to the uterus.
Therefore, a careful diagnosis is essential before considering whether to have a hysterectomy.

BENEFITS AND RISKS
A hysterectomy may be life-saving in the case of cancer. It can relieve the symptoms of bleeding or discomfort related to fibroids, severe endometriosis or uterine prolapse. On the other hand, for these non-cancerous conditions, you may prefer to seek alternatives to surgery for these symptoms or other problems related to the uterus and pelvic organs.
Symptoms like pelvic pain or unusual bleeding may not necessarily be related to the uterus. An accurate diagnosis will help you to determine the potential benefits and risks of a hysterectomy.
The risks of hysterectomy include the risks of any major operation, although its surgical risks are among the lowest of any major operation.
Hysterectomy patients may have a fever during recovery, and some may develop a mild bladder infection or wound infection. If an infection occurs, it can usually be treated with antibiotics. Less often, women may require a blood transfusion before surgery because of anemia or during surgery for blood loss. Complications related to anesthesia might also occur, especially for women who smoke, are obese, or have serious heart or lung disease.
As with any major abdominal or pelvic operation, serious complications such as blood clots, severe infection, adhesions, postoperative (after surgery) hemorrhage, bowel obstruction or injury to the urinary tract can happen. Rarely, even death can occur.
In addition to the direct surgical risks, there may be longer-term physical and psychological effects, potentially including depression and loss of sexual pleasure. If the ovaries are removed along with the uterus prior to menopause (change of life), there is an increased risk of osteoporosis and heart disease as well. These will be discussed later along with possible treatments.
In making a decision, you should also consider that a hysterectomy is not reversible. After a hysterectomy, you will no longer be able to bear children and you will no longer menstruate. You need to think about the impact these changes would have on you.

SEXUALITY
Every person reacts differently, and reactions are a combination of emotional and physical responses. We still have much to learn about the effects of hysterectomy on sexual function.
Some women say they enjoy sex more after a hysterectomy, particularly if they had a lot of bleeding and pain beforehand. Some women feel more relaxed not worrying about getting pregnant.
Some women who have hysterectomies experience lower sexual enjoyment. There may be a number of reasons for this which are only partially understood.
For some women, uterine contractions and pressure against the cervix add to sexual pleasure. Others may feel less pleasure or reduced desire due to loss of certain hormones if ovaries were removed. Loss of hormones can cause vaginal dryness and make sex uncomfortable. Hormone replacement therapy may relieve some of these symptoms. A vaginal gel or lubricant can reduce vaginal dryness. For some women, reduction in sexual pleasure is temporary while they and their partners adjust. Because sexual feelings are so individual, it may be difficult to predict exactly how a hysterectomy will affect your feelings.

EMOTIONAL EFFECTS
Some women report having a strong emotional reaction, or feeling down, after a hysterectomy. Most feel better after a few weeks, but some women do feel depressed for a long time. Other women experience a feeling of relief after a hysterectomy.
No longer being able to bear children can cause emotional problems for some women. Some women feel changed or feel they have suffered a loss. Talking things over with your doctor, your partner, a friend or a counselor often helps. It may help to talk with a friend or another woman who has had a hysterectomy before and after your operation.

DIFFERENT TYPE OF HYSTERECTOMIES
All hysterectomies are major operations involving removal of at least the uterus. Some types of hysterectomies involve removing other organs as well. It is important to talk with your doctor about the kind of hysterectomy recommended for you.
• SUBTOTAL HYSTERECTOMY
In this operation, only the upper part of the uterus is removed, but the cervix is not. Tubes and ovaries may or may not be removed. This procedure is always done through the abdomen. Leaving the cervix may help with later sexual enjoyment. After this operation, a woman still needs to have regular Pap smears to prevent cervical cancer.
• TOTAL HYSTERECTOMY
This operation involves removing both the body of the uterus and the cervix, which is the lower part of the uterus. Hysterectomy can sometimes be done through the vagina (vaginal hysterectomy); at other times, a surgical incision in the lower belly (abdominal hysterectomy) is preferable. For example, if you have large fibroid tumors, it is difficult to safely remove the uterus through the vagina.
Vaginal hysterectomy, when it can safely be performed, generally involves fewer complications, a shorter recovery period and no visible scar.
"Complete hysterectomy" is a common non-medical term that usually means a total hysterectomy plus removal of the ovaries and fallopian tubes.
• RADICAL HYSTERECTOMY
This procedure is reserved for serious disease such as cancer. The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen. Since cancer is unpredictable, other organs or parts of other systems are sometimes removed as well.

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