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Hysterectomy and uterine fibroids; Leiomyoma; Myoma
Hysterectomy is the surgical removal of the uterus. The ovaries may also be removed, although this is not necessary for fibroid treatment. Hysterectomy is a permanent solution for fibroids, and is an option if other treatments have not worked or are not appropriate.
A woman cannot become pregnant after having a hysterectomy. If the ovaries are removed along with the uterus, hysterectomy causes immediate menopause.
Once a decision for a hysterectomy has been made, the patient should discuss with her doctor what will be removed. The common choices are:
Hysterectomy procedures include:
Abdominal Hysterectomy. Abdominal hysterectomy is the standard procedure. It is best suited for women with large fibroids, when the ovaries need to be removed, or when cancer or pelvic disease is present. The surgeon makes a 5-inch to 7-inch incision in the lower part of the belly. The cut may either be vertical, or it may go horizontally across the abdomen, just above the pubic hair (a bikini cut). The bikini cut incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases. The patient may need to remain in the hospital for 3 - 4 days, and recuperation at home takes about 4 - 6 weeks.
Vaginal Hysterectomy, LAVH, and Laparoscopic Hysterectomy. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. The vaginal incision is closed with stitches.
A variation of the vaginal approach is called laparoscopic-assisted vaginal hysterectomy (LAVH). It uses several small abdominal incisions through which the surgeon severs the attachments to the uterus and, if needed, ovaries. In LAVH, the uterus (and ovaries) are then removed through the vaginal incision, as in the standard vaginal approach. In laparoscopic hysterectomy, they are removed in small pieces through the abdomen.
Recovery times for vaginal hysterectomy and LAVH are shorter than those for abdominal hysterectomy. However, hospital stays may be longer and costs are greater with LAVH than with standard vaginal hysterectomy. Some doctors question whether LAVH adds any significant benefits compared to the standard vaginal procedure.
Robotic Hysterectomy. Robotic hysterectomy is like laparoscopic hysterectomy, but a special machine is used. This approach is most often used when a patient has cancer or is very overweight and vaginal surgery is not safe.
Minor complications after hysterectomy are very common. About half of women develop minor and treatable urinary tract infections. There is usually mild pain and light vaginal bleeding post operation. More serious complications are uncommon but can include infection and blood clots.
The patient should ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:
Patients who have had abdominal hysterectomies should discuss with their doctors when exercise programs more intense than walking can be started. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may have an on-going feeling of overall weakness, for some time. Some women do not feel completely well for as long as a year while others may recover in only a few weeks.
If a woman has had her cervix removed, she no longer needs annual Pap smears. However, women who have had any type of hysterectomy should continue to receive routine pelvic and breast exams, and mammograms.
After hysterectomy, women may have hot flashes, a symptom of menopause, even if they retain their ovaries. However, women who have a hysterectomy are less likely to have hot flashes than women who have a natural menopause. Surgery may have temporarily blocked blood flow to the ovaries, therefore suppressing estrogen release. If both ovaries have been removed in premenopausal women, the procedure causes premature menopause. Other menopausal symptoms include vaginal dryness and irritation, insomnia, and weight gain.
The most important complications occur in women who have had their ovaries removed. This causes estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease and stroke. A number of drugs are available that can help protect both bones and heart. [For more information, see In-Depth Reports #40: Menopause and #18: Osteoporosis.]
In premenopausal women, the ovaries will usually continue to function and secrete hormones even after the uterus is removed, but the lifespan of the ovaries is reduced by an average of 3 - 5 years. In rare cases, complete ovarian failure occurs right after hysterectomy, presumably because the surgery has permanently cut off the ovaries' blood supply.
Sexual intercourse may resume 4 - 6 weeks following surgery. The effect of hysterectomy on sexuality varies among women. Some women note a change in their orgasmic response because they no longer experience uterine contractions. Other women report increased sexual drive and pleasure because they are free from the problems that prompted hysterectomy.
Patients who have both ovaries removed may be at higher risk for loss of sexuality, and experience sexual problems such as vaginal dryness. A vaginal gel or lubricant can help reduce vaginal dryness.
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