1. Max Brinsmead MB BS PhD May 2015
Hysterectomy
Max Brinsmead MB BS PhD
May 2015

2. Indications for Hysterectomy
Fibroids
Menstrual dysfunction
Prolapse
Endometriosis
Adenomyosis
Pelvic Inflammatory Disease
Cancer
Cervix
Uterus
Ovaries

3. Alternatives to Hysterectomy
Medical treatment of bleeding problems or endometriosis
Endometrial resection for menorrhagia
Myomectomy and uterine artery embolisation for fibroids
Radiotherapy for Ca cervix
A number of RCT’s and systematic analyses compare these alternatives
So clinician-guided and informed patient choice is an important component of best practice

4. Types of Hysterectomy Subtotal Hysterectomy Total Hysterectomy
Uterine body only
Total Hysterectomy
Uterine body and cervix (not ovaries!)
Hysterectomy with BSO
Uterus with bilateral salpingo oophorectomy
Radical (or Wertheim) Hysterectomy
Total hysterectomy with pelvic lymph nodes, paracervical tissue and upper 1/3 vagina

5. Routes for Hysterectomy
Abdominal Hysterectomy (AH)
Total
Subtotal
Vaginal Hysterectomy (VH)
Laparoscopic Hysterectomy
Laparoscopically-assisted vaginal (LAVH)
Totally laparoscopic hysterectomy

6. Which Route is Best? Abdominal Hysterectomy Vaginal Hysterectomy
Results in greatest mean blood loss
Has the highest incidence of febrile morbidity
And abdominal wound infection (obviously)
Longest hospitalisation
And slowest to recover
Vaginal Hysterectomy
Is the preferred route when technically possible
Laparoscopic Hysterectomy
Requires training and equipment
Longest operating time
But shortest hospitalisation and recovery
But has the greatest overall risk of complications
There is debate about its cost effectiveness

7. Complications of Hysterectomy
Infection
Abdominal incision
Vaginal vault and pelvic
Infected haematoma
Blood loss and anaemia
Bladder dysfunction or Cystitis
Bowel dysfunction
Damage to:
Bladder
Bowel
Ureters
Depression or Sexual Dysfunction
Longer Term
Prolapse
Wound pain
Earlier menopause

8. “Ball-Park” Risks with Hysterectomy
30 – 40% minor complication rate
1:10 risk of “unpleasant” complication
1:20 risk of transfusion
1:50 risk of serious complication
But <1:100 with ongoing problems
1-3:1000 risk of death
Complications are some 1.5-fold more common if there are fibroids

9. Hysterectomy complication rates from long-term cohort studies

10. Hysterectomy complications from Cochrane RCT’s

11. It is not treatment of 1st choice but recommended when…
NICE recommendations concerning Hysterectomy for Heavy Menstrual Bleeding
It is not treatment of 1st choice but recommended when…
Women who have no wish for future fertility
Desires amenorrhoea
And is fully informed
Information required…
Implications of the surgery
Sex & psychological functions
Risks and complications in some detail
Bladder function
Need for further surgery
Pros and cons of oophorectomy

12. NICE recommendations concerning route of Hysterectomy
Factors that influence this decision include…
Nature of any gynaecological disease
Presence/Size of any fibroids
Mobility and descent of the uterus
Shape and size of vagina
History of any previous surgery
Vaginal hysterectomy (VH) is the route of 1st choice
If oophorectomy is required then Laparoscopically-assisted VH is best
If abdominal hysterectomy (AH) is performed then subtotal (leaving the cervix) is an option

13. Removal of the Cervix Is only an option during abdominal hysterectomy
Technically more difficult
So operative time and blood loss is increased
So leave the cervix when things are going badly
Some evidence for more bladder problems when it is left (about 2-fold)
Sometimes “mini periods” if it is left (about 7%)
2% risk of cervical prolapse when it is left
Main argument for removal is risk of CIN and Ca
But the cervix does not have any sexual function
Confirmed by RCTs

14. Bilateral Oophorectomy during Hysterectomy?
1:80 lifetime risk of ovarian cancer
Bilateral oophorectomy reduces the risk of breast Ca
Is more important for the woman at risk
e.g. those with BRAC1&2 mutations
Up to 1:10 pre menopausal women undergoing hysterectomy return for surgery to remaining ovaries
This can be technically difficult
And PMT-symptoms can be a major problem for a few women
Oophorectomy may be important if there is peritoneal endometriosis
Adds little to operative time and risk during AH
But may be quite difficult in up to 30% during VH

15. Bilateral Oophorectomy during Hysterectomy 2?
The major problem is that of premature menopause
And symptoms from a surgical menopause seem to be more severe
Many women feel very strongly about ovarian removal
There is a dearth of information about any endocrine role for postmenopausal ovaries
They continue to produce androgens
Which may have a role in well-being and libido
And are converted to oestrone by fat cells
Age is one factor that has a major role in deciding about bilateral oophorectomy
Below the age of 45 – aim for preservation
Above the age of 65 – balance tips in favour of removal

16. NICE recommendations concerning Oophorectomy during Hysterectomy
Healthy ovaries should not be routinely removed
Oophorectomy should only be performed with a woman’s expressed wishes and consent
If ovarian cycling is thought to be contributing to symptoms then a trial of GnRH for 3-4 months before hysterectomy may be useful
Women who elect to have or require bilateral oophorectomy need advice about…
Impact on the risks of ovarian & breast Ca
Pros and cons of oestrogen hormone therapy (ERT)

17. After Hysterectomy Most women don’t need Pap smears
Except those who had previous CIN >2 , Ca Cervix or Ca corpus uterus
Oestrogen only HRT (ERT) is an option
Except when BSO was performed for oestrogen responsive cancer or severe endometriosis
Symptoms control in these patients can be a real problem
Current research suggests that ERT has many benefits and few risks

18. Any Questions or Comments?
Please leave a note on the Welcome Page to this website