Hysterectomy

When a hysterectomy may be recommended

A hysterectomy is an operation to remove the womb (uterus). Afterwards you no longer have periods and cannot become pregnant, so it is a permanent step, and a decision I never rush. It may be one option, among several, for:

• fibroids (non-cancerous growths of the muscle of the womb) that cause heavy bleeding, pain or pressure;
• adenomyosis (tissue similar to the lining of the womb growing into its muscle wall), which causes heavy, painful periods;
• heavy periods that have not improved with other treatments;
• endometriosis (similar tissue growing outside the womb) with severe symptoms, alongside removal of the endometriosis itself;
• some pre-cancerous changes, such as atypical hyperplasia (a pre-cancerous thickening of the lining of the womb).

It is only suitable if you are sure you do not want a pregnancy in the future, and it is usually considered when other treatments have not helped or are not right for you. I will give you my honest view, and the decision is yours.

Alternatives

Whether there is an alternative to a hysterectomy depends entirely on why it is being considered. For some conditions, such as pre-cancerous changes in the womb, a hysterectomy is usually the recommended treatment. For others, such as fibroids, adenomyosis, heavy periods or endometriosis, there are often treatments that keep the womb, and you can read about them on the fibroids, adenomyosis, endometriosis and hysteroscopy pages. At your consultation I will go through the options that apply to you, including waiting, before we decide together.

Choices about the cervix, tubes and ovaries

The cervix

In a total hysterectomy the womb and the cervix (the neck of the womb) are both removed; in a subtotal hysterectomy the cervix is kept. Many women ask whether keeping the cervix protects against prolapse later, or makes a difference to sex. The trials that answer this, in which women were chosen at random to keep or lose the cervix, are reassuring on both.

A Cochrane review, which brings together all of these trials, did not find any difference in sex, or in bladder or bowel function, whether the cervix was kept or removed, for up to nine years afterwards ^[1]. Another review found that sexual satisfaction was the same in both groups a year after the operation ^[2].

Prolapse was no more common after either operation in women followed for between five and fourteen years ^[3]. When women in one Danish trial were examined fourteen years later, the support of the vagina was no different between the two groups ^[4].

In the trials, keeping the cervix made the operation a little shorter, with a little less bleeding ^[1], but most of these were open operations, and the comparison does not carry over to keyhole surgery.

In a keyhole operation, a womb removed without its cervix cannot come out through the vagina, so it has to be cut into pieces inside a bag (contained morcellation, described below). That means making one of the small incisions larger for the instrument, and it carries the small risk of spreading an unexpected cancer. After a total hysterectomy, the womb can usually be removed whole through the vagina. For these reasons, I do not think keeping the cervix has a real advantage in keyhole surgery.

It also has disadvantages. In the first year, about 14 in 100 women who keep the cervix go on having light monthly bleeding, compared with about 1 in 100 after a total hysterectomy ^[2]. In the long-term studies, slightly more women who kept the cervix reported leaking urine ^[3].

About 1 in 100 women later need a second operation to remove the cervix, most often because symptoms such as bleeding or pain continue, and this is more likely in younger women and in women with endometriosis ^[5]. If you keep it, you will need to continue cervical screening.

Keeping the cervix is not usually advised after abnormal cervical screening results or pre-cancerous changes in the womb. We will weigh these together, and the choice is yours.

The fallopian tubes

The fallopian tubes carry eggs from the ovaries to the womb, so after a hysterectomy they no longer have a role. Removing them at the same operation (salpingectomy) may lower the risk of ovarian cancer, because some ovarian cancers are thought to begin in the tubes.

The ovaries

If you have not reached the menopause and your ovaries are healthy, I usually advise keeping them. They carry on producing hormones, so the menopause does not start straight away, although your periods stop. Even so, the menopause can come somewhat earlier than it otherwise would.

If the ovaries are removed before the menopause, the menopause starts straight away (a surgical menopause), whatever your age. HRT (hormone replacement therapy) is then usually advised, at least until around 51, the average age of the menopause, to ease symptoms and help protect your bones, unless there is a reason you should not take it.

Endometriosis can be found after the menopause: in a study that followed more than 80,000 American nurses for 30 years, about 1 in 100 were diagnosed with it for the first time after the menopause, most often after a surgical menopause and whether or not they took HRT, while HRT after a natural menopause did not increase the chance ^[13]. If you have endometriosis and your ovaries are removed, we will talk through the type of HRT that suits you.

Removing the ovaries may be worth considering if they are affected by disease, such as severe endometriosis, if you have a high inherited risk of ovarian cancer, or if you are close to or past the menopause.

How I carry out a hysterectomy

I usually carry out a hysterectomy by keyhole surgery, under a general anaesthetic. Keyhole surgery is either laparoscopic, in which I hold the instruments directly, or robotic, in which I control them from a console beside you using the da Vinci system. For most women, keyhole surgery means less pain, a shorter stay in hospital and a quicker return to normal life than open surgery. It is not suitable for everyone, and I will tell you honestly whether it suits you.

Through a few small incisions, I free the womb from its attachments, protecting the bladder and the ureters (the tubes that carry urine from the kidneys to the bladder), and remove it through the vagina. The top of the vagina (the vaginal vault) is then closed with stitches.

If you also have a prolapse of the womb, I can support the top of the vagina at the same operation with stitches to its own ligaments, without mesh, a technique we have published ^[6] and explain on the prolapse page.

The ureters run very close to the womb, and keeping them safe is one of the most important parts of the operation. In a complex operation, I first free the ureters from the tissue around them (ureterolysis), so that I can see them throughout. I developed this approach and published it in 2019, by which time we had used it in more than 350 operations without injuring a ureter ^[7]. I have now used it in more than a thousand.

Bleeding is the other main risk. In a complex operation, when the usual place to seal the artery to the womb is hard to reach, I seal it at its origin instead, a technique we presented in 2019 ^[10].

Larger wombs and contained morcellation

A womb too large to come out through the vagina in one piece can be cut into smaller pieces inside a protective bag, and removed through the vagina or one of the small incisions (contained morcellation).

Occasionally, a womb that appears to contain only fibroids also contains a sarcoma (a rare cancer of the muscle of the womb). According to the Royal College of Obstetricians and Gynaecologists (RCOG), the risk rises with age. For women under 50, it is between about 1 in 1,250 and 1 in 300; for women aged 50 to 59, between about 1 in 300 and 1 in 160; and for women aged 60 and over, between about 1 in 280 and 1 in 65 ^[11]. The ranges are wide because the studies behind them differ.

Scans, and sometimes a sample of the lining of the womb, help me to assess the risk, but no test before surgery can rule out every rare cancer of this kind. If a sarcoma is cut into pieces, cancer cells could spread inside the abdomen and make the cancer harder to treat.

The RCOG advises against morcellation for women over 50 or after the menopause, when an unexpected cancer is more likely ^[11]. Your age, whether you have reached the menopause and any worrying findings on your scans or tests all affect whether morcellation is suitable. If it is not, we will discuss the alternatives, such as removing the womb in one piece through a larger incision.

The bag reduces the risk of spreading tissue, although it cannot remove that risk completely. We moved early to cutting up the womb only inside a bag, around 2014, when the US Food and Drug Administration (FDA) first warned that cutting it up without a bag could spread a hidden cancer. In 2020 the FDA advised that this should only ever be done inside a bag ^[8].

In 2018 a colleague and I surveyed hospitals across the UK on how they assess and explain these risks ^[9]. We found that practice varied, which is why I take these precautions so seriously.

Open surgery

Open surgery (an abdominal hysterectomy, through a larger incision in the lower abdomen) is rarely needed in my practice, although it can be the safer choice for a very large womb. Since 2013, more than 99 in 100 of my abdominal operations have been keyhole rather than open, and around one in a thousand has needed to be changed to open surgery (about these figures).

Robotic surgery for a large or complex womb

For many straightforward hysterectomies, laparoscopic and robotic surgery give similar results, and I use both. For complex operations, the RCOG concluded in 2022 that robotic surgery can be considered safe and a more effective tool than conventional keyhole surgery, with fewer conversions to open surgery, including for women with a BMI of 30 or more ^[12].

When the womb is large or unusually shaped, when earlier operations have left scar tissue that binds organs together (adhesions), or when there is severe endometriosis, I prefer robotic surgery. In my experience it helps in three ways:

• a three-dimensional view, magnified up to ten times, so that I can see and protect the bladder, bowel and ureters;
• instruments with wrist-like joints, for precise stitching deep in the pelvis, such as closing the top of the vagina;
• a steady, comfortable position at the console, which helps during a long, complex operation.

Laparoscopic surgery remains a good option for many women, and I will explain which approach I recommend, and why. My robotic operating lists run at Spire St Anthony's Hospital in Sutton and Nuffield Health Parkside Hospital in Wimbledon.

Risks of the operation

A hysterectomy is a major operation, and all surgery carries risks. Serious complications are uncommon, and I will explain how each applies to you. The main risks are:

• bleeding, which occasionally needs a blood transfusion;
• infection of the wounds, the bladder or the top of the vagina;
• injury to the bladder, bowel or ureters;
• blood clots in the legs or lungs (venous thromboembolism), made less likely by early walking, compression stockings and, for some women, blood-thinning injections;
• the top of the vagina opening up, which is rare and usually needs an operation to repair;
• conversion to open surgery, if that becomes the safer option;
• the risks of a general anaesthetic, which your anaesthetist will discuss with you.

You will have full written information well before your operation.

Recovery

I give each patient a personal plan for recovery in writing. As a guide, after a keyhole hysterectomy:

• most women stay one night in hospital and are walking comfortably within a few days;
• I usually advise about four weeks before returning to work (light desk work from home is often possible after about two weeks if you need it), and physical work takes longer;
• heavy lifting should wait for around six weeks, and sex for around eight, while the top of the vagina heals.

Light bleeding can continue for a few weeks, and recovery after open surgery takes longer. My article recovery after a keyhole hysterectomy goes through it week by week. I will explain the results of the laboratory examination of the womb (histology). Many women feel relief after a hysterectomy, and some also feel a sense of loss, even when the decision was right for them.

If you have heavy bleeding, a fever, worsening pain, a painful or swollen calf, or difficulty passing urine after you go home, contact the hospital ward straight away, using the number on your discharge letter, or call NHS 111. In an emergency, such as chest pain or sudden breathlessness, call 999. For non-urgent questions, my practice manager, Helen, can help.

Cervical screening afterwards

Your cervical screening should be up to date before a hysterectomy. Afterwards:

• after a total hysterectomy, most women no longer need cervical screening, provided previous results were normal and no abnormal cells are found when the cervix is examined in the laboratory;
• if you have had abnormal cervical cells in recent years, or any are found after the operation, you may need tests from the top of the vagina (vault smears) for a time, which I will explain;
• if you keep your cervix, you continue routine cervical screening as before.

How I can help

At your first consultation, which lasts about 30 minutes, I will go through your symptoms and the treatments you have tried and, with your permission, examine you. I can scan you during the consultation at Parkside Hospital and the CRP Clinic; at Spire St Anthony’s and Ashtead Hospital, I arrange a scan at the hospital and see you again to go through the results.

Consultations are in English or Arabic, in person or by video. If you already have scans or reports, my practice manager, Helen, can send you a secure link to upload them. You can read about fees and insurance and where I see patients, or book an appointment.