Monday, November 19, 2012

Surgical Removal of Uterus and Menopause

The hysterectomy, an operation to remove the uterus, is the second most frequent major surgical procedure among reproductive-aged women, after cesarean section. Approximately 600,000 hysterectomies are performed each year in the United States — and one in three women will have had one by the age of 60.

The hysterectomy procedure may or may not include a bilateral oophorectomy -- the removal of both ovaries. Only if a woman has her ovaries removed she will go through menopause. Removal of the uterus alone does not automatically trigger menopause because the ovaries will continue to make hormones. However, since the uterus is removed, the woman will no longer have her periods and cannot get pregnant. She might have hot flashes because the surgery can sometimes affect the blood supply to the ovaries. Later on, she might have natural menopause a year or two earlier than expected.

Some women decide to remove their ovaries and fallopian tubes at the same time as their uterus because she has a real or perceived vulnerability to ovarian cancer. This is a personal decision usually based on age, health and doctor's recommendation.

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Hysterectomy: Is It Right for You?

There are some urban myths in the female community that hysterectomy might help to relieve or totally eliminate the often-distressing side effects of menopause. A hysterectomy, however, will not be able to relieve menopausal symptoms; to the contrary, in some cases, it can actually cause the body to undergo menopause prematurely.

In addition, a hysterectomy is major surgery, and its associated drawbacks make this an option solely for those who have valid medical concerns that need to be addressed. Risks associated with a hysterectomy can be serious, including the following:
*   Blood clots
*   Infection
*   Excessive bleeding
*   An adverse reaction to anesthesia
*   Damage to the urinary tract, bladder, or rectum during surgery
*   Premature menopause
*   Bowel blockage
*   Death, in rare instances

"No one should have a hysterectomy — or any surgery — if it's not necessary," says Jerry Nosanchuk, a Michigan-based osteopathic physician who specializes in treating menopausal women after a hysterectomy. "You need to be vigilant and consider the benefits and potential consequences of hysterectomy before making the decision to have one. On the other hand, there are instances when surgery is a reasonable decision."

Conditions when Hysterectomy is Recommended

For some conditions, a hysterectomy is the only true cure. Women who might benefit from a hysterectomy include those suffering from the following conditions:
*   Premalignancies, cell changes signaling possible uterine, ovarian, or cervical cancers
*   Endometriosis, a condition in which the tissue that usually lines the uterus develops outside the organ instead
*   Adenomyosis, a very painful condition in which tissue that usually lines the uterus grows deep inside the uterine muscle wall
*   Prolapsed uterus, a situation in which the uterus sags into the vagina because of stretching or lack of muscular support
*   Excessive uterine fibroids, or benign tumors in the uterus
*   Chronic pelvic pain

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What Happens in a Hysterectomy?

A hysterectomy can be performed in several different ways, through the vagina or through the abdominal wall, using traditional or laparoscopic techniques. While the term hysterectomy refers to the removal of the uterus, this procedure may also include the removal of the cervix, one or both ovaries, and/or the fallopian tubes. Women should educate themselves and discuss these options carefully with their doctor if they are considering the surgery.

"Removal of the ovaries would be recommended if ovarian tumors are present [or there is a] family history of breast or ovarian cancer or simply to prevent future cancer of the ovary," says Dr. Pinkerton.

Prophylactic, or preventative, surgery to remove the ovaries is also sometimes recommended for women who have inherited genetic mutations that put them at higher risk of breast and ovarian cancers and who no longer want to have children.

Abdominal Approach

If your uterus is large, or if the surgeon wants to physically inspect other organs during the procedure, you might be recommended an abdominal approach to hysterectomy. Using the traditional abdominal approach, the surgeon makes a single large incision through the wall of the lower abdomen to access the uterus. The incision can run vertically, from just below your navel to the level of the pubic bone, or horizontally across the bikini line. The direction of the incision depends on factors such as the presence of other scars on the abdomen, the reason for the hysterectomy, and the need to look at other organs. With abdominal laparoscopic surgery, the doctor makes a few smaller incisions and inserts special surgical instruments through those access points.

With any surgical procedure, the patient risks a bad reaction to anesthesia, blood loss during or after the procedure, and blood clotting after the procedure. Hysterectomy risks also include possible damage to other organs in the pelvis such as the bladder and urinary tract. Compared to abdominal laparoscopic surgery, the traditional approach using a single large incision incurs a greater risk of post-surgical infection, and healing takes longer--about six to eight weeks.

Vaginal Approach

In the vaginal approach, instead of reaching the uterus through an incision in the abdomen, the surgeon passes special instruments up through the vagina. She makes an incision through the wall of the vagina to reach the uterus, cutting it away from the fallopian tubes and connective tissue before removing it through the vaginal incision. With the vaginal approach, the patient has the option of using regional anesthesia to numb the lower half of the body, rather than using general anesthesia. For patients with risk factors for general anesthesia, this might be a good option.

Compared to the abdominal approach, vaginal hysterectomy allows faster recovery and less hospital time. Patients can expect to stay in the hospital for a day or two following the surgery, and full recovery generally takes one to two weeks.

Alternatives to Hysterectomy

Hormonal Therapy

Various types of hormonal therapy may be potentially effective alternatives to hysterectomy for some women with noncancerous uterine problems. Hormone injections, birth control pills or hormone-secreting intrauterine devices may help control abnormally heavy or prolonged uterine bleeding, reports the American Congress of Obstetricians and Gynecologists.

In a 2006 study published by the "Cochrane Database of Systematic Reviews," Dr. Jane Marjoribanks and colleagues report that hormone-secreting intrauterine devices prove as effective as surgery in improving quality of life among women with abnormally heavy uterine bleeding. Hormone-based treatment may also help relieve symptoms associated with uterine leiomyomas and endometriosis.

Uterus-Preserving Surgery

Surgery to correct a uterine problem rather than removing the uterus may be an alternative for some women with noncancerous gynecological conditions. Gynecological surgeons can often remove leiomyomas from the uterus with a procedure called a myomectomy. The American Congress of Obstetricians and Gynecologists reports that the leiomyomas do not grow back after a myomectomy. New fibroids, however, may develop in some women. A myomectomy typically preserves the option for future childbearing.

A uterine suspension procedure can reposition the uterus with a sling-like device to relieve symptoms associated with uterine prolapse, reports the Cleveland Clinic. Women with endometriosis may elect to have the areas of abnormal endometrial tissue removed, leaving the uterus intact. Endometriosis may recur after this surgical procedure, notes the American Congress of Obstetricians and Gynecologists.

Endometrial Ablation

An endometrial ablation procedure destroys the uterine lining tissue, or endometrium. The endometrium is the tissue involved in menstrual bleeding; destruction of this tissue typically eliminates or significantly reduces menstrual bleeding. Endometrial ablation may effectively relieve symptoms associated with abnormally heavy uterine bleeding and small uterine leiomyomas, reports the American Congress of Obstetricians and Gynecologists. The procedure may be an alternative to hysterectomy for women with these conditions who do not desire future childbearing.

Doctors use different techniques to perform endometrial ablation, including freezing, heat application, and microwave, radiowave or electrical energy. Endometrial ablation is performed as an outpatient procedure. The doctor inserts the instruments into the uterus through the cervix; the procedure does not require surgical incisions.

After Hysterectomy

After the operation, you will need to stay a few days in the hospital to recover. The time spent depends on the type of operation you had and your progress. Your doctor might prescribe antibiotics to prevent infections, as well as pain medication.

Complete recovery from abdominal hysterectomy usually takes 6-8 weeks. During this time, you can slowly increase the level of your activities but don't overdo it! Listen to your body and do everything in moderation.

Get plenty of rest and avoid lifting during the first two weeks. You can then begin to do light chores, some driving, and even return to work as long as your job does not involve too much physical activity. Once the bleeding, pain and abdominal pressure have stopped, you can resume normal activities. Around the sixth week following the operation, you can take baths and resume sexual activity, but demanding exercises should be put off until 3 months after your operation.

Women who have had a vaginal hysterectomy generally recover more quickly and are able to resume their activities earlier than women who have undergone an abdominal hysterectomy.

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What Will Change?

For pre-menopausal woman, the periods will stop after the hysterectomy. She can no longer get pregnant. If the ovaries are removed, she might go through distressing menopausal symptoms (hot flashes, mood swings, sleep disturbance, vaginal dryness etc). This may cause even more severe symptoms than a natural menopause.

Some women have also reported a decrease in sexual pleasure with the removal of the cervix but this has not been scientifically proven. In fact, most women report either an increase in sexual pleasure or no change at all.

Sources and Additional Information:

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