UNDERSTANDING HYSTERECTOMY

Why Do I Need a Hysterectomy?
FIBROIDS
Troublesome fibroids are the most common indication for hysterectomy. They may be as small as a pea or as large as a grapefruit, but they don't always produce symptoms. In fact, you may not know you have fibroids until your doctor feels them during a routine pelvic exam.

It is not necessary to remove a fibroid just because it is there. Estrogen appears to stimulate the growth of some fibroids, and many stop growing or shrink after menopause. However, when they cause pain, or profuse or prolonged menstrual bleeding, put pressure on your bladder or rectum, or begin to grow rapidly, they should be taken out. Although nearly all fibroids are benign - noncancerous - on rare occasions such rapid growth may indicate a malignant change.

All fibroid tumors are composed of connective tissue and muscle fiber and arise from the muscular layer of the uterus. From here, they can grow in three directions: subserous fibroids stick out from the surface of the uterus into the pelvic cavity; intramural fibroids are buried inside the wall of the uterus; and submucosal fibroids protrude from the endometrial lining into the uterine cavity.

Removal of the uterus will solve the problem of troublesome fibroids. If you are a young woman who may want to have children and your fibroids are not too large or numerous, you may be able to have a myomectomy, an operation in which the fibroids are removed and the uterus is left in place. This may not be a cure, however, because in some cases new fibroids will grow, making further surgery necessary.


ENDOMETRIOSIS
Endometriosis occurs when tiny islands of cells that behave like endometrial tissue begin growing in various places outside the uterus. These "implants" attach themselves to the ovaries, tubes, bladder, rectum, or other parts of the abdominal cavity, where they act just as if they were the lining of the uterus - thickening and bleeding each month according to your ovarian cycle.

Always benign, these implants may grow between one organ and another, sticking them together with tight bonds called adhesions. When endometriosis occurs in the ovaries, blood-filled cysts often form and can cause considerable sudden pain and tenderness. Other symptoms of endometriosis include premenstrual and menstrual pain, prolonged or heavy periods, tenderness in the lower abdomen, sharp stabbing pain during intercourse, and lower back pain.

Because endometriosis is connected to hormone production, interruption of the ovarian cycle may cure the symptoms. For this reason, pregnancy often relieves symptoms of early endometriosis in young women, as does menopause in older women. Various types of hormone therapy may also help in mild cases.

If your doctor suspects endometriosis, the diagnosis can be confirmed with laparoscopy, which lets the doctor see the affected areas by looking through a thin, lighted tube inserted into the pelvic cavity through a small incision in your abdomen. If your doctor found evidence of ovarian cysts or extensive endometriosis during the pelvic exam, a laparotomy - exploratory abdominal surgery - may be performed.

Because endometriosis is so closely tied to the ovarian cycle, an absolute cure involves the removal of the uterus and both tubes and ovaries. Depending on your age and the spread of the disease, less extensive surgery may be performed. If there are not too many implants, it may be possible to remove them and leave the reproductive organs in place. But as long as the ovaries continue to function, new areas of endometriosis can arise.


ADENOMYOSIS
If you have been having prolonged periods with heavy bleeding, or pelvic or abdominal pain and tenderness before, during, and after your period, your doctor may suspect adenomyosis to be the cause. In this condition, most common in women in their 40's, endometrial-like tissue grows inside the wall of the uterus, making it soft, enlarged, and tender

The presence of adenomyosis can be confirmed only after the uterus is removed and tissue from the wall is examined under a microscope. The only effective treatment for adenomyosis is removal of the uterus.


ENDOMETRIAL HYPERPLASIA AND ADENOMATOUS HYPERPLASIA
Endometrial hyperplasia is an abnormal change in the inner lining of the uterus that occurs most often to women who are experiencing change of life, when there is prolonged production of estrogen. Although endometrial hyperplasia is benign, it may progress to a stage called adenomatous hyperplasia. If you have this condition, your chances of developing uterine cancer are increased.

Your doctor may suspect adenomatous hyperplasia if you have experienced heavy or irregular bleeding, especially if you have skipped several menstrual periods. The diagnosis can be confirmed by endometrial biopsy, which is done in the office, or by dilatation and curettage, commonly called a D & C. In either procedure, the doctor scrapes tissue from the lining of the uterus, which is then examined under a microscope by a pathologist.

If the tissue is found to be precancerous, removal of the uterus will probably be recommended in order to prevent the development of cancer at a later time.

Some women experience prolonged periods of heavy bleeding even though there are no apparent changes to the lining of the uterus. This condition is called menorrhagia. If their bleeding cannot be reduced through D & C and hormonal treatments, hysterectomy is often recommended.


PELVIC INFLAMMATORY DISEASE (P.I.D.)
Pelvic inflammatory disease (P.I.D.) may be caused by any one of a number of bacterial infections, including gonorrhea. When acute infections of the tubes and/or ovaries cause abnormal pain and tenderness, fever, and a vaginal discharge, they are usually treated with antibiotics and bed rest. If the infection responds to treatment, the tubes will usually recover. But if the infection was treated too late, or did not respond to antibiotics, abcesses may arise that can rupture into the abdominal cavity, causing peritonitis. This condition can be life-threatening, and emergency removal of both tubes and ovaries as well as the uterus may be necessary.

If your doctor has told you that you have chronic P.I.D., this means that you probably had a moderaterly severe infection that responded to antibiotics, yet left you with permanently closed tubes or adhesions in and around the tubes. You may have had pelvic and abdominal pain and painful intercourse.

Depending on the extent of the disease, it might be necessary to remove both tubes and ovaries, as well as the uterus.


CERVICAL CANCER
Early cervical cancer, increasingly common among young women, affects the surface of the cervix. Called cancer in situ in its early stages, it is slow-growing and may take 3 or 4 years to spread. Although there are no symptoms in this early stage, advanced cervical cancer may cause spotting or a foul-smelling, bloody discharge.

Your doctor may suspect early cervical cancer from the results of a Pap smear, which shows the presence of abnormal cells. This diagnosis must be confirmed with a biopsy, in this case conization, which is usually done in the hospital. In this procedure, a cone-shaped piece of tissue is removed from the affected area and examined under a microscope. An office procedure called colposcopy, where the doctor looks at the cervix through a magnifying lens and takes biopsies, is valuable in diagnosing cancer in situ and may eliminate the need for conization.

Fortunately, removal of the uterus cures nearly 100 percent of early cervical cancers. If you want to preserve the ability to have children, it may be possible to remove only the affected tissue at the time of conization, and leave the uterus in place. Of course, this does not guarantee a cure, and there is always a chance that the cancer may occur again.

Ovarian Cancer
Ovarian cancer is less common, and is usually found in older women. This type of cancer is considered the most dangerous, however, because it is fast-growing and the symptoms are often so vague that they are overlooked. The result is that the disease is often not caught in its early stages.

Your doctor may discover an enlarged ovary during a pelvic exam, or you may have noticed bleeding between periods, heavy or prolonged periods, or vague but persistent lower abdominal gas pains. Some ovarian tumors may produce fluid that can accumulate in the abdominal cavity, causing it to become swollen and uncomfortable. Your doctor may decide to order a sonogram, a sound-wave technique used to check for suspected tumors. If the tumor is found to be over a certain size, it will require further diagnosis by laparoscopy or by laparotomy.

Ovarian cancer is treated by removing one or both ovaries and tubes, and usually the uterus, depending on the type of tumor. In some cases, radiation and chemotherapy may also be indicated.


ENDOMETRIAL CANCER
This is a malignancy of the lining of the uterus, which tends to occur in women over 40. In women past menopause, endometrial cancer may produce a watery, bloody discharge or bleeding, while women who have not gone through change of life may notice abnormal periods or spotting between periods.

If your symptoms suggest endometrial cancer, your doctor may get more information from the results of a Pap smear, or by collecting some endometrial cells for observation. An endometrial biopsy often can be done in the office. The presence of endometrial cancer is usually confirmed by D & C.

Treatment depends on the extent of the malignancy. It can involve the removal of the uterus, and both tubes and ovaries. The tubes and ovaries are sometimes removed because they are the first organs to be involved if the cancer spreads, and because estrogen production may stimulate residual cancer cells to grow. In some cases, surgery may be combined with pre- and post-operative radiation treatment.


PROLAPSED UTERUS AND RELATED CONDITIONS
When the ligaments that hold your uterus in place are weakened by childbearing or loss of elasticity due to aging, they allow the uterus to drop from its normal position down into and even through the vaginal opening. This is called uterine prolapse or (descensus).

Similarly, the supportive tissues of the vaginal walls may also lose their elasticity. Since these walls help to hold the rectum and bladder in place, relaxation of support can allow these organs to bulge out under the vagina. When the bladder and urethra are involved, the condition is called cysto-urethrocele; if the rectum "balloons" into the vagina, it is called rectocele.

All three conditions may give you the uneasy feeling that "something is falling out." You may also experience a dragging sensation in your lower abdomen or have lower back pains. If the affected organ blocks the vaginal opening, your partner may notice this during intercourse. Because the angle of the dropped bladder allows some urine to be retained, cysto-urethrocele may give you the sensation of having to urinate even though you just emptied your bladder. You may also lose urine while coughing or during other abdominal stress, and you may have an increased number of bladder infections. Rectocele can cause constipation by allowing the stool to "pack" in the pouch formed by the bulging rectum.

By having you strain down during a pelvic exam, your doctor can see the bulging of the vagina and how far down the vagina the uterus has fallen. Another diagnostic method is to place an instrument called a tenaculum on the cervix when you are lying down. By tugging on it gently, your doctor can simulate the pressure that would be exerted if you were standing up.

Cysto-urethrocele and rectocele may be treated by surgical repair that restores support to the vaginal wall. If surgery is not desired because of the patient's age or general condition, a ring-like device called a pessary can be used to hold the organs inside the body, although many women find this uncomfortable and troublesome.

Uterine prolapse can be treated by removal of the uterus, and any associated repair to the vaginal wall can also be done at this time. Frequently, the uterus is removed if there is a partial prolapse and the woman desires to be sterilized.


WHAT WILL MY HYSTERECTOMY INVOLVE?

Now that you've had a chance to read about your particular problem, you should have a better idea as to why your doctor has suggested surgery. The next step is for you to understand exactly what a hysterectomy and its related surgeries involve. Of course, your doctor will explain which procedure is recommended for you.


Total Hysterectomy
If you have a total hysterectomy, your uterus - and nothing else - will be removed. Because the ovaries release their hormones directly into the bloodstream, you should not have change of life symptoms with this surgery.

Salpingo-oophorectomy
In this procedure, one or both tubes and ovaries are removed. Because the uterus serves no purpose without the ovaries and is subject to problems like abnormal bleeding or cancer, your doctor may suggest that your uterus also be removed.

Total Hysterectomy + Salpingo-oophorectomy
If only one ovary is removed, you should not have any change of life symptoms. If both ovaries are removed, most women can be started on estrogen replacement therapy soon after surgery to counteract any menopausal symptoms. If you are around the menopause, your doctor may suggest removing your ovaries at the time of hysterectomy to prevent any chance of ovarian cysts or cancer. But if you have already gone through change of life, you should not notice any physical changes after your ovaries are removed.

Abdominal Hysterectomy
Most hysterectomies are performed abdominally. This procedure is used if the tubes or ovaries must be removed, if the uterus is quite large, or if there are other abdominal problems such as endometriosis or adhesions. Your doctor may suggest removing your appendix during abdominal hysterectomy because it is easily done and prevents the possibility of future appendicitis.

Vaginal Hysterectomy
In a vaginal hysterectomy, the uterus is removed through the vaginal opening, and the only incision is made internally. For a vaginal hysterectomy to be performed, your doctor should be able to remove the uterus easily - a prolapsed uterus that has dropped down or into the vagina is a perfect candidate. Vaginal repair is often combined with a vaginal hysterectomy (but it may be done as a separate procedure). If the ligaments that hold the uterus in place are still firm, if your vagina is too narrow, or if your uterus is enlarged by a tumor, it may be more difficult for the uterus to be removed through the vagina.

If you have an abdominal hysterectomy, your incision will be about 6 to 8 inches long. It will be either horizontal in your lower abdomen (a "bikini" incision), or vertical. Although a horizontal incision is less noticeable, a vertical incision may be necessary in order to give the surgeon enough room to operate.

Graphics and Text from Krames Communications brochures