Surgical removal of uterus or hysterectomy

The purpose of this leaflet is to provide the patient with information about the nature of the hysterectomy, its indications, surgical methods and the risks that may be associated with the operation. In addition, it provides information about the effects of hysterectomy on a woman's life in the future.

A hysterectomy is the surgical removal of the uterus, after which a woman will not be able to become pregnant or give birth again.

Indications for surgery

Surgical removal of the uterus is indicated in the following cases:

• benign tumours of the uterus

• malignancies of the uterus, cervix or ovaries

• severe inflammatory disease of the female reproductive organs

• large-scale, frequent vaginal bleeding that does not respond to medication

Surgical removal of uterus

Surgical removal of the uterus may be partial or complete. The extent of the operation is decided by the operating surgeon based on the patient's illness and state of health.

Partial removal of the uterus or uterine amputation is the removal of the upper body of the uterus. In this case, the cervix remains intact.

In the case of complete removal of uterus, the cervix is removed along with the uterus.

When dealing with malignancies, the uterus is removed along with the cervix and the surrounding tissues, including the ovaries, fallopian tubes and pelvic lymph nodes.

In the case of a benign tumour, the doctor will decide whether removing the ovaries and fallopian tubes is necessary or not.

Before surgery

If you have chronic illnesses (e.g. high blood pressure, cardiac arrhythmia, diabetes, asthma), the surgery may involve a greater health risk. Thus, the patient needs to see an anaesthesiologist before the surgery.

It is important to tell your doctor about the illnesses you have suffered and about the medications you are taking on daily basis. Special attention is paid to so-called blood thinners, which must not be taken for some time before surgery or must be switched to another medication for the time of the surgery in order to reduce the risk of bleeding during surgery. There may also be a need to change the dose of diabetes medications. This will be decided by your treating doctor.

All medications taken on a daily basis should be taken with the patient to the hospital.

Preparation for surgery

Take a shower in the early morning on the day of the surgery. To avoid anaesthesia complications, you must not eat for at least six hours before surgery or drink for at least four hours before surgery. Do not smoke or chew gum for six hours before surgery. Exposure of acidic stomach contents (undigested food or drink) to the lungs during anaesthesia can be life-threatening. Everyday medications can be taken with a little bit of water.

To reduce the risk of complications, please inform your doctor before the surgery about:

• your state of health

• all of your diseases

• the medications you take on daily basis

• any known hypersensitivity to medications

Operation description

The surgery is performed by a gynaecologist.

The uterus can be removed using three methods:

• open surgery of the abdomen

• vaginally

• laparoscopically

In the case of open surgery of the abdomen, a vertical or transverse incision is made on the abdomen through the abdominal wall and the uterus is removed through that incision. With this surgery, the patient must stay in hospital for up to five days and there will be a visible scar after healing.

In the case of vaginal surgery, an incision is made in the vagina which enables entering the abdominal cavity. The uterus is removed though the vaginal incision. After the surgery, the wound is closed with sutures and there will be no visible scars on the abdomen.

When using the laparoscopic method, a small incision is made in the umbilical region on the anterior abdominal wall, the abdominal cavity is filled with carbon dioxide using a special needle and a laparoscope is entered into the abdominal cavity for visualisation. Another 1-3 small incisions will be made in the anterior abdominal wall to insert the surgical instruments. The uterus can be removed from the abdomen in several pieces through the small incisions that have been made previously or though the vagina. After the removal of the uterus, surgical instruments are removed and the gas is cleared out from the abdominal cavity, the wounds are closed with sutures.

Advantages of laparoscopy

With laparoscopy, post-operative recovery is faster, hospital stays are shorter and surgical trauma is smaller. Patients experience less post-operative pain and the risk of inflammation is lower compared with open surgery of the abdominal cavity. With laparoscopy, the patients can return to their normal physical activity within 3-4 weeks and with open surgery of the abdomen this recovery time is ca 2 months.

Effects of uterus removal on a woman's future life

The changes taking place in the body after surgery depend largely on your age and the extent to which the uterus has been removed.

Pain is quite expected in the few days following the surgery. You will be given medication to relieve the pain.

There may be a small amount of blood secreting or smearing from the vagina for several weeks after the surgery. Constipation is normal; this can be prevented with diet and intestinal emollients. Some women may have temporary difficulties with urinating or emptying the bladder.

It is important to follow your doctor's advice when recovering from surgery. It is important to get sufficient rest and to move around as much as possible. At the start, take shorter walks and gradually extend them as you get better.

For 4 weeks after surgery:

• do not put anything into the vagina (including not using tampons and vaginal medicines).

For 6-8 weeks after surgery:

• do not lift weights over 5 kg; and

• do not have sex.

In some women who have undergone partial removal of the uterus and the cervix has remained intact, menstrual bleeding may continue in a mild form due to the small amount of uterine mucosal tissue remaining in the cervix.

If you are of fertile age and did not have your ovaries removed along with your uterus, hormonal regulation will be maintained as usual and the ovaries will continue to function: the follicles will mature, ovulation will occur and often premenstrual syndrome will persist, even though the menstruation itself no longer occurs. Menopause then occurs at the time it would have occurred without surgery, usually in your 50s.

If the uterus is removed with the ovaries before the time of natural menopause, this results in a decrease in the production of female hormones and thus menopause, which can manifest as unpleasant transition symptoms such as night sweats, hot flushes, mood swings and sleep disturbances. Dryness and thinning of the skin and mucous membranes may also occur over time. If these symptoms affect your quality of life and your health condition allows it, your doctor may prescribe you hormone replacement therapy.

In woman who are already in menopause, removal of the uterus does cause any significant new symptoms.

The presence of the uterus does not determine a person's libido or interest in sex. Libido is affected by androgenic hormones, which are formed in adrenal glands and in small amounts in the ovaries as well. Therefore, sexuality after removal of the uterus remains exactly the same as it was before the surgery.

Possible complications

Removal of the uterus has a small risk of serious complications:

• heavy bleeding during surgery

• bleeding after surgery

• increased blood clotting and formation of clots in blood vessels

• postoperative inflammation

• bladder, ureter or intestinal injury

• intestinal obstruction

• severe life-threatening reaction to anaesthetic medications

After removal of the uterus, the following may occur:

• urinary incontinence

• pelvic organ prolapse

• chronic pain

• vaginal fistula between the bladder and the rectum

ITK1025

Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 24.03.2021 (protocol no. 5-21)