HYSTERECTOMY

Hysterectomy is defined as the surgical removal of the uterus.

There are two types of hysterectomy:

• A Total Hysterectomy is the removal of the uterus and cervix.
• A Subtotal or Supracervical Hysterectomy is the removal of only the uterus.

Whether or not to remove the cervix is a discussion between the woman and the surgeon.  A woman with cervical pathology, history of abnormal pap smears or has deep endometriosis near the cervix may be encouraged to have the cervix removed.  The removal of the cervix does not seem to interfere with sexual satisfaction for a majority of women.  If the cervix remains intact, routine pap smear screening is still recommended even with no history of abnormal pap smears.

Removing the ovaries and tubes is referred to as a Salpingo-oophorectomy.  This is not recommended to all women undergoing a hysterectomy and should be discussed with your surgeon about the risks and benefits to undergo removal versus preserving the ovaries and tubes.

Fibroid symptoms vary from woman to woman, but they include:

• Heavy menstrual bleeding (normal menses last up to 7 days).
• Pelvic or abdominal pain.
• Pelvic pressure on the bladder which can cause the bladder to feel full with little urine or require frequent urination.
• Pressure on the rectum, and in some can cause constipation or difficulty with bowel movements.
• Lower back pain.
• Pain during sexual intercourse.
• Difficulty achieving pregnancy.
• Pelvic or abdominal swelling or bloating.
• Potential complications during pregnancy, including
  • Preterm labor or preterm Contractions.
  • Fetus in breech presentation requiring cesarean section.

DIAGNOSIS

• Sometimes fibroids can be palpated on pelvic or abdominal exam as large, firm masses.
• Fibroids can be seen on Ultrasound, CT Scan and MRI.
• Sometimes we will also perform a fluid-filled ultrasound (Hysterosonogram/Sonohysterogram) to better identify the location and number of all of the fibroids, especially if they are located inside the uterus.

TREATMENT

Treatment depends on the symptoms that you are experiencing, whether they are bleeding symptoms or symptoms associated to the bulk effect of fibroids.

 If your main symptom is bleeding, there are some medication options including:

• Non-steroidal Anti-inflammatory (Ibuprofen etc)
• Tranexamic Acid
• Birth Control Pills, Ring, Patch
• Birth Control Shot
• Intrauterine Device
• GnRH Agonist, also known as Lupron
• GnRH Antagonist (Oriahnn)

Surgical procedures can resolve bleeding and bulk symptoms. Options vary depending upon whether you desire future pregnancy.

Myomectomy, or surgical removal of the fibroids and preserves the uterus. Depending upon the location, number and size, this procedure may be performed via different routes.

• Hysteroscopy (only for fibroid located within the uterus): fibroids removed via a camera placed through the cervix (no incisions are made).
• Laparoscopy: fibroids removed via 3-4 small incisions made on the abdomen.
• Robotic: Fibroids removed again with 3-4 small incisions with the assistance of a surgical robot.
• Laparotomy: Fibroids removed via a larger incision on the abdomen.
• Radiofrequency Fibroid Ablation (shrinks the fibroids and preserves the uterus).
  • Accessa- Performed via 3-4 abdominal incisions.
  • Sonata (link)- Performed via a handpiece placed through the cervix. This is an incision-free treatment that shrinks fibroids to reduce symptoms. Charles E. Miller, MD & Associates is the only team in Chicago that offers the Sonata Treatment through Lutheran General Hospital.
• MRI guided High Intensity Focused Ultrasound: Uses high intensity ultrasound waves to shrink the fibroids. It is only available at certain centers in the United States.
• Uterine Fibroid Embolization (UFE): Performed by an interventional radiologist to block the blood vessels that feed the fibroid and cause them to shrink over time.
• Hysterectomy: Removal of the uterus and fibroids.
  • Resolves current symptoms and risk of future fibroid growth. At Charles E. Miller, MD & Associates, we perform these procedures almost entirely laparoscopically (through 3-4 small abdominal incisions approximately 1cm each).

What are the reasons to have a Hysterectomy?

Hysterectomy is the most common gynecologic procedure performed in the United States. However, the numbers of cases seem to be decreasing due to advances in medicine allowing patients less invasive options.

If these less invasive options fail or are not recommended on an individual basis, women may be offered a hysterectomy for:

• uterine fibroids
• pelvic pain
• endometriosis
• pelvic adhesions
• abnormal uterine bleeding
• uterine prolapse
• pre-cancerous/cancerous disease. 

A hysterectomy is rarely performed on an emergent basis and the decision to proceed with this surgery should be mutually agreed upon by the woman and her surgeon after discussing hysterectomy risks and benefits, alternatives, fertility desires and expectations after the surgery.

What are the risks/benefits to a Hysterectomy?

Please refer to the link Surgical Risks on the home page.

The benefit to having a hysterectomy is that it is allows for complete resolution of any symptoms caused by the uterus without the risk of the symptoms coming back. It is a definitive approach to managing symptoms if other treatment options have failed or a woman is not a candidate for other therapies.

Are there different ways to perform a Hysterectomy?

There are three different approaches to a hysterectomy:

Abdominal incision. The most traditional technique is through a single, approximately 4-6 inch, abdominal incision. If the indication for surgery is non-cancerous or the uterus is not too large, the incision is made horizontally about 2 finger-breadths above the pubic bone, also known as the “bikini incision”, otherwise, a midline, vertical incision may be recommended.

The hospital stay is about 2 to 4 days long and the recovery is about 6 to 8 weeks long.  This technique can be applied to both total and subtotal hysterectomies.

Vaginal approach. There are no abdominal incisions, however, only a total hysterectomy can be performed. The uterus also has to be mobile and small enough to fit through the vaginal canal.  The hospital stay is usually one night. The postoperative pain is significantly less than an abdominal hysterectomy.

However, recovery is still about 6 weeks long so that the vaginal cuff, where the cervix once use to be, can heal from the sutures. Most women resume daily activities, other than intercourse at about 2 weeks.

 Laparoscopic approach.  This technique involves 3 to 4, less than ½ an inch skin incisions to perform.  The patient may go home the same day or stay overnight. Postoperative pain is significantly less than the abdominal approach.

The recovery is about 2 weeks long if a subtotal hysterectomy is performed. If a total hysterectomy is performed, 6 weeks of no intercourse is recommended if the cervix is removed so that the vaginal cuff can heal. Most women resume other daily activities within 2 weeks.

Advantages of the laparoscopic approach versus the vaginal approach

Large uteri can be removed as well as other abdominal pathology, such as endometriosis, ovarian cysts, etc.  Laparoscopy is a newer approach to hysterectomy and involves a surgeon skilled in this technique.  In our practice, our surgeons are well trained in laparoscopy and can safely perform simple and difficult hysterectomies using this approach.