Symptoms of needing a hysterectomy

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When is a Hysterectomy Needed?

The United States has the highest hysterectomy rate in the industrialized world. Statistics from 2004 indicate that about one-third of all U.S. women have had a hysterectomy by the age of 60. Today, about 90 percent of hysterectomies are done by choice and not as an emergency or lifesaving procedure. Various studies have concluded that anywhere from 10 percent to 90 percent of those operations were not really needed, but many physicians continue to recommend them.

In certain circumstances, hysterectomies save lives and restore health. However, as major surgery, hysterectomies can have long-term effects on women’s health, sexuality, and life expectancy. There is increasing understanding that a woman’s uterus and ovaries have value during midlife and beyond, so the view of a woman’s uterus and ovaries as “expendable” during later periods in our lives is now obsolete.

Because of the controversy over high hysterectomy rates, many insurance plans now require a second opinion from another physician before agreeing to pay for the procedures. Because some surgeons recommend hysterectomy routinely, women need to understand when the surgery is truly necessary.

When is it necessary?

Hysterectomy may be recommended for several life-threatening conditions. If you have any of the following conditions, hysterectomy may save your life and also free you from significant pain and discomfort.

  • Invasive cancer of the uterus, cervix, vagina, fallopian tubes, and/or ovaries. Only 8 to 12 percent of hysterectomies are performed to treat cancer.
  • Severe, uncontrollable pelvic inflammatory disease (PID)
  • Severe, uncontrollable uterine bleeding (rare, usually associated with childbirth)
  • Rare but serious complications during childbirth, including rupture of the uterus

Hysterectomy may be justified as treatment for some conditions that are not life-threatening, but these usually can be treated without resorting to major surgery:

  • Precancerous changes of the endometrium, called hyperplasia. (Remember, however, that hyperplasia can often be reversed with medication.)
  • Extensive endometriosis causing debilitating pain and/or involving other organs. (More conservative surgery and/or medication is usually an effective treatment in these circumstances.)
  • Fibroid tumors that are extensive, are large, involve other organs, or cause debilitating bleeding. (However, fibroids usually can be removed by myomectomy, thereby preserving the uterus.)
  • Pelvic relaxation (uterine prolapse) that is causing severe symptoms. (Another treatment option in this case is uterine suspension surgery or a pessary.)
  • Severe bleeding leading to anemia and not correctable with iron supplementation. (Birth control pills, the Mirena IUD, and endometrial ablation are alternative treatments that can be used before resorting to hysterectomy.)

Hysterectomies should not be performed for mild abnormal uterine bleeding, fibroids without symptoms, and pelvic congestion (menstrual irregularities and low back pain). These problems typically respond to safer alternatives.

Fortunately, diagnostic and therapeutic techniques such as sonography, Pap tests, hysteroscopy, endometrial ablation, and laparoscopy make it possible to avoid or delay many hysterectomies that might have been done in the past. It is important to consider and utilize these techniques before resorting to major surgeries.

For information on types of hysterectomies and what to expect if you do need a hysterectomy, see Hysterectomy. For information on when, if you do need a hysterectomy, it might be possible to retain your ovaries, see Hysterectomy and Ovarian Conservation.

Symptoms and Conditions That May Be Treated With Hysterectomy

Fibroids, endometriosis, and other conditions that may involve pelvic pain are sometimes treated with hysterectomy or removal of the uterus.

Hysterectomy (removal of the uterus) is a treatment option for a calcified fibroid, seen in this pelvic X-ray. Getty Images

Of the approximately 600,000 hysterectomies performed each year, the majority are performed in the treatment of fibroids. (1)

A hysterectomy is a surgical operation to remove the uterus or womb, an organ located in the female pelvis.

Attached to the uterus on either side is a fallopian tube and an ovary.

During pregnancy, a fertilized egg implants itself in the lining of the uterus where the developing fetus is nourished before birth.

After undergoing hysterectomy, a woman cannot become pregnant.

Fibroids Are a Condition That May Be Treated With Hysterectomy

What are fibroids?

Fibroids, also known as leiomyomas or myomas, are the most common tumors of the female reproductive system. These tumors are benign (noncancerous) and they never develop into cancer. (2)

Uterine leiomyosarcomas are extremely rare cancerous growths that resemble fibroids and look like them on imaging tests. Only about 6 women in 1 million women in the United States will be diagnosed with this form of cancer each year, but it tends to be aggressive. Treatment includes surgery, chemotherapy, and radiation.

Fibroids are very common; most women have these noncancerous growths.

It’s estimated that up to 80 percent of all women develop fibroids during their childbearing years. (3) Because they often cause no symptoms, they are usually detected incidentally during a pelvic exam or a prenatal ultrasound.

Fibroid size varies dramatically.

Fibroids can be microscopic or can grow to be eight inches across or more. (4) Fibroids may grow as a single tumor or grow in a cluster. They can grow and expand the uterus just like a pregnancy. In cases of large fibroids, health professionals may describe their size by comparing them to different stages of pregnancy. For example, your doctor may tell you that your fibroid is similar in size to a uterus carrying a 20-week pregnancy. (5)

Fibroids can grow slowly or rapidly or remain the same size. They can go through growth spurts or shrink on their own. Sometimes fibroids present during pregnancy shrink or completely disappear after pregnancy. (2)

What causes uterine fibroids to grow?

Doctors don’t know the cause of uterine fibroids, but it’s believed that they develop from a stem cell in the smooth muscular tissue of the uterus (myometrium). Genetic changes, hormones, and other growth factors all appear to play roles in their development. (2)

While a woman can develop fibroids at any time after puberty, they most commonly appear during the reproductive years. Symptoms most commonly affect women in their thirties and forties.

African-American women are more likely to have fibroids and are also more likely to develop problems with them at a younger age. (6)

Common signs and symptoms of uterine fibroids

In most cases fibroids do not cause any pain or any other symptoms. But if they reach a certain size or are in certain locations they may cause symptoms including heavy menstrual bleeding, prolonged menstrual periods (lasting more than a week), pelvic pain, frequent urination, low back pain, or painful intercourse.

What treatments for fibroids are available?

While symptoms often respond to medications or nonsurgical treatment, sometimes the symptoms are severe enough for the woman and her doctor to consider hysterectomy. Hysterectomy is the only permanent solution for uterine fibroids.

Conditions That May Be Treated With Hysterectomy: Endometriosis

What is endometriosis?

Endometriosis is a disease in which tissue similar to the lining of the uterus grows in other places in the body. This often painful condition affects about 10 percent of all women of childbearing age. (7) Most often endometriosis is found on the ovaries, fallopian tubes, and the peritoneum (pelvic side wall). It can also appear in the bowel and bladder. Rarely, it appears in other parts of the body such as the lungs. (8)

What causes endometriosis?

The cause of endometriosis is unknown. Possible causes include problems with menstrual period flow, genetic factors, hormones, or faulty immune systems.

Common signs and symptoms of endometriosis

Symptoms include very painful menstrual cramps, chronic pain in the lower back and pelvis, intestinal pain, bleeding or spotting between periods, and digestive problems including diarrhea, constipation, or nausea, especially when you are menstruating.

What endometriosis treatments are available?

Hormone therapy and pain medication may help alleviate pain. Minimally invasive procedures may be performed to remove disease, but often lesions return within a year or two. Sometimes after repeated surgical treatments to remove the disease or instances where hormonal therapy has failed to keep the disease at bay, women may opt for a hysterectomy, which is generally considered a last resort.

Conditions That May Be Treated With Hysterectomy: Pelvic Support Problems

What are pelvic support problems?

Pregnancy, vaginal childbirth, and aging can weaken or stretch a woman’s pelvic supporting tissues and ligaments. Menopause and heavy lifting can also contribute to these problems. In some cases, the pelvic organs including the uterus can lower or sag into the vagina. Women with pelvic organ prolapse may experience pelvic pressure, urinary incontinence, or difficulty making a bowel movement. (9)

A hysterectomy, along with repair, can relieve these symptoms.

Conditions That May Be Treated With Hysterectomy: Abnormal Uterine Bleeding

What is abnormal uterine bleeding?

Heavy bleeding during your period is one example of abnormal uterine bleeding. Other instances include: bleeding and spotting between periods, bleeding or spotting after sex, menstrual cycles that last longer than 38 days or shorter than 24 days, and bleeding after menopause.

What causes abnormal uterine bleeding?

Benign growths in the uterus, either polyps or fibroids, are common causes. Medications are often the first line of treatment. If medications fail to reduce the bleeding, surgical procedures like endometrial ablation or uterine artery embolization may be suggested.

Sometimes when all other treatments have failed, a woman may opt for a hysterectomy.

Conditions That May Be Treated With Hysterectomy: Chronic Pelvic Pain

What is chronic pelvic pain?

Chronic pelvic pain is pain in the pelvic area that lasts six months or longer. Most chronic pelvic pain is attributed to endometriosis. Other conditions that can lead to chronic pelvic pain include fibroids, ovarian cysts, irritable bowel syndrome, or interstitial cystitis (painful bladder syndrome). Any of the organ systems in the pelvis can contribute to these pains. Bladder conditions, diseases of the digestive tract, musculoskeletal and nerve-related pain conditions can also cause pelvic pain. (10)

What treatments are available for chronic pelvic pain?

Depending on the condition causing the pain, treatment can include medication, physical therapy or biofeedback, or minimally invasive procedures such as trigger point injections or peripheral nerve blocks. As a last resort, hysterectomy may be suggested for chronic pelvic pain that hasn’t responded to any other treatment. (10)

Conditions That May Be Treated With Hysterectomy: Adenomyosis

What is adenomyosis?

Adenomyosis is a condition in which the tissue that lines the uterus grows inside the walls of the uterus where it doesn’t belong. The displaced tissue continues to act normally — thickening, breaking down, and bleeding — during each menstrual cycle. An enlarged uterus and painful, heavy periods can result. The disease usually resolves after menopause. The condition is treated in the same way that endometriosis is treated. Sometimes hormonal treatments can help. Hysterectomy is the definitive cure for adenomyosis. (11)

Conditions That May Be Treated With Hysterectomy: Cancer

What types of cancer can be treated with hysterectomy?

About 10 percent of hysterectomies are performed to treat cancer. (12) Hysterectomy is the main treatment for endometrial cancer, which is the most common gynecologic cancer. Physicians consider the surgery the best option in many cases.

Why is endometrial cancer treated with hysterectomy?

Endometrial cancer is often detected at an early stage because of symptoms like abnormal vaginal bleeding, which may precipitate a doctor visit. According to the American Cancer Society, endometrial cancer is uncommon in women younger than 45, and the average age of diagnosis is 60. Hysterectomy can often cure the cancer.

Does ovarian cancer treatment include hysterectomy?

Sometimes ovarian cancer is treated with hysterectomy. Unlike endometrial cancer, which is often caught in earlier stages, ovarian cancer, which begins in the ovaries, often goes undetected because it may have no symptoms until it has spread within the pelvis and abdomen. According to the American Cancer Society, about half of the women diagnosed with ovarian cancer are age 63 or older. Treatment for ovarian cancer usually involves a combination of surgery and chemotherapy. The surgery may involve hysterectomy, especially if the cancer is extensive.

Hysterectomy is also the most common treatment for early stage cervical cancers, which begin in the cells lining the cervix — the lower part of the uterus.

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Dr. Jacqueline Gerhart: Hysterectomy and Menopause

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Madison, Wisconsin – UW Health Family Medicine physician Jacqueline Gerhart writes a column that appears weekly on madison.com and in the Wisconsin State Journal. Columns are re-published here with permission.

Dear Dr. Gerhart: I think I’m going through menopause because I have hot flashes. But I’m not sure because I’ve had a hysterectomy. How do I know?

Dear Reader: Menopause is defined as the loss of your period (or absence of menstruation) for 12 months. Since you have had your uterus removed, you no longer have periods. So you can’t use that as a guide to when you are going through menopause. Because of this, you need to look for other signs and symptoms associated with menopause, and sometimes may need further testing to rule out other disorders.

Almost on a daily basis I have patients come in to ask me about testing for menopause. Usually, they ask me to test their hormone levels in hopes of determining if they are menopausal, and “how far into menopause” they are. Unfortunately, hormone testing won’t be able to tell you that.

Menopause is a clinical diagnosis, meaning we define it based on your age, your symptoms and the absence of other disorders. Lab tests for “female hormones” such as estrogen and progesterone vary throughout the month.

In other words, if you are still having a period or if you are still ovulating (releasing an egg each month), every single day will result in a different hormone level, depending on where you are in your cycle. So the range for your hormone tests varies widely to include all parts of your cycle.

The “precursor” hormones to estrogen and progesterone are LH and FSH. These are other hormones that patients often ask to be tested. Unfortunately, these also vary depending on the time of your cycle. They only reach a more “steady state” once you have gone through menopause. So we can’t accurately tell where you are in the process of menopause using simple blood tests.

Women usually go through menopause in their 40s and 50s. The average age of menopause (or the cessation of periods) is 51. Usually, women will start having irregular periods (like one every two to four months) about one or two years before “official menopause.” Other “pre-menopause” or “peri-menopause” symptoms are vaginal dryness, mood changes, weight gain, slowed metabolism, night sweats and hot flashes.

A hysterectomy that removes your uterus but not your ovaries doesn’t cause menopause at the time of surgery. This is because your ovaries still release eggs and produce estrogen and progesterone. But a surgery that removes your ovaries will cause menopause right after surgery. Your periods will stop immediately and you likely will have hot flashes and possibly severe menopause symptoms, since these changes occur abruptly rather than over time.

Also, about 1 percent of women will experience “premature menopause” before age 40 due to “primary ovarian insufficiency,” which is when the ovaries stop producing the normal levels of reproductive hormones. For these women, we may recommend hormone treatment until the natural age of menopause to help protect them from heart or bone disease.

For information on non-hormonal ways to manage menopause, check out this UW Integrative Medicine patient handout: Supplements for Hot Flashes during Menopause (pdf)

This column provides general health information and is not specific advice intended for any particular individual(s). It is not a professional medical opinion or a diagnosis. Always consult your personal health care provider about your concerns. No ongoing relationship of any sort (including but not limited to any form of professional relationship) is implied or offered by Dr. Gerhart to people submitting questions.

Date Published: 07/03/2013
News tag(s): jacqueline l gerhart

One in three women have a hysterectomy by age 60. Unsplash/Thomas Kelley

Each year, up to 500,000 women in the United States have a hysterectomy, meaning a surgical removal of the uterus and sometimes the cervix and supporting tissues. Once a woman has this procedure, she is no longer able to get pregnant. It is the most common non-pregnancy-related major surgery performed on women in the United States. One in three women have a hysterectomy by age 60.

Generally, most hysterectomies are not emergency operations, so a woman will have time to discuss with her doctor and time to think about her options.

There are many reasons why a woman may be recommended by her doctor to have a hysterectomy.

Reasons why a woman may need a hysterectomy:

There are three categories as to why a woman may be recommended or required to have a hysterectomy:

  • To save her life
  • To correct a serious problem that is interfering with normal functioning
  • To improve the quality of her life

Here are the specific causes why a woman may need this procedure:

  • Uterine fibroids

The most common reason why hysterectomies are done is because of fibroids in the uterus. Fibroids are common, benign tumors that grow in the muscles of the uterus. Many women may not even know they have them, but they can cause significant heavy bleeding or pain in others.

  • Endometriosis

Endometriosis is a benign condition that affects the uterus and is the second most common reason why a woman may need a hysterectomy. Endometriosis occurs when endometrial tissue, which is the inside lining of the uterus, begins to grow on the outside of the uterus and on nearby organs. This condition may cause painful menstrual periods, abnormal vaginal bleeding, and loss of fertility.

  • Cancer

Cancer found within the female reproductive organs accounts for about 10 percent of all hysterectomies. Endometrial cancer, uterine sarcoma, cervical cancer, and cancer of the ovaries or fallopian tubes often require a hysterectomy. Depending on the type and extent of cancer, other kinds of treatment such as radiation or hormonal therapy may be used as well.

  • Uterine prolapse

This is a benign condition in which the uterus moves from its usual place down into the vagina. Uterine prolapse is due to weak and stretched pelvic ligaments and tissues, and can lead to urinary problems, pelvic pressure, or difficulty with bowel movements. Childbirth, obesity, and loss of estrogen also contribute to the problem.

  • Hyperplasia

Hyperplasia is when the lining of the uterus becomes too thick and causes abnormal bleeding. It is believed to be caused by too much estrogen.

  • Pelvic pain

This is a common symptom for many women who are recommended to have a hysterectomy. There can be a number of causes of pelvic pain including endometriosis, fibroids, ovarian cysts, infection and scar tissue.

General considerations before having a hysterectomy

Like with any major surgery, a woman should make sure her physician has done a careful diagnosis that follows the protocol for recommending a hysterectomy. The risks of hysterectomy include the risks of any major operation, although its surgical risks are among the lowest of all major surgeries. A woman should thoroughly discuss with her physician the pros and cons of this procedure and have a thorough understanding of what to expect before, during and after the operation. The more a woman has done her research on why she needs a hysterectomy, the more likely she will have a good outcome after it is done.

Dr. Samadi is a board-certified urologic oncologist trained in open and traditional and laparoscopic surgery and is an expert in robotic prostate surgery. He is chairman of urology, chief of robotic surgery at Lenox Hill Hospital. He is a medical correspondent for the Fox News Channel’s Medical A-Team. Follow Dr. Samadi on Twitter, Instagram, Pintrest, SamadiMD.com and Facebook.

What is a hysterectomy?

A hysterectomy is an operation to remove the uterus (womb).

A total hysterectomy means both the uterus and the cervix are removed. A total hysterectomy does not mean the ovaries are removed. If the ovaries are removed this is a hysterectomy with oophorectomy (removal of the ovaries).

Occasionally a ‘subtotal’ hysterectomy is performed where the cervix is retained. If a hysterectomy is required due to cancer or risk of cancer it may also be recommended to take out the fallopian tubes, due to some research suggesting ovarian cancer may sometimes originate in the tube .

Having a hysterectomy is major surgery. The decision to have a hysterectomy should only be made after you have been given adequate information about why you need one, how the surgery will be performed, what will happen to your body and what the consequences may be. It is also important to think about how you may feel about losing your uterus and whether you need help and support coping with those feelings.

Why a hysterectomy might be performed

Cancer of the cervix, uterus, ovaries or tubes

This diagnosis means the hysterectomy must happen as soon as possible.

Uncontrollable continuous uterine bleeding

This is rare but also makes a hysterectomy important to do as soon as possible.

Heavy or persistent bleeding

Various causes of heavy bleeding can result in a woman needing a hysterectomy.

Severe chronic pelvic pain

Various causes such as infection, endometriosis and adenomyosis can mean a hysterectomy is the best treatment.

Endometriosis

If severe, a hysterectomy may be the best treatment, often with removal of ovaries and tubes to prevent reoccurrence.

Pelvic inflammatory disease (PID)

Sometimes caused by chronic infection of the fallopian tubes and pelvis, PID can mean hysterectomy is the appropriate treatment.

Fibroids

A hysterectomy may be necessary if there are multiple fibroids, the uterus is enlarged or fibroids are growing rapidly.

Adenomyosis

A condition where cells that usually line the uterus are found in the muscle layer of the uterus causing heavy bleeding and pain.

Ways to perform a hysterectomy

There are four ways a hysterectomy may be performed:

Method How it is performed
Abdominal technique

An incision is made:

  • horizontally across the lower abdomen
  • vertically down the midline of the abdomen
Vaginal The surgery is performed via the vagina.
Total laparoscopic or The surgery is keyhole surgery.
Laparoscopic assisted vaginal The surgery is keyhole surgery in combination with the vaginal approach.

The decision as to which method of hysterectomy is most appropriate depends on:

  • the reason for the hysterectomy
  • the facilities/equipment available in the local/regional hospital
  • the surgeon’s skill in laparoscopic hysterectomy

Should you have a hysterectomy?

If you are unsure about having a hysterectomy, you should seek a second opinion.

Sometimes it is appropriate to take time making the decision except when there is cancer or uncontrollable life threatening bleeding.

For many women, hysterectomy relieves the symptoms and improves quality of life. Often women say, ‘I wish I had done this years ago’.

A small number of women take time to recover following hysterectomy. This may be for many reasons including:

  • complications following the operation such as infection or bleeding which prolongs recovery
  • adjusting to the loss of the uterus and the ability to have a child, particularly if a woman does not have children and wanted children
  • concerns about femininity and sexuality, particularly if the ovaries were also removed
  • becoming menopausal if the ovaries were removed before periods had stopped
  • feeling unhappy about the doctor and/or the hospital staff’s treatment

You may like to consider the following questions when thinking about whether or not to have a hysterectomy:

Last updated 26 September 2018 — Last reviewed 24 February 2014

** Currently under review **

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at February 2014.

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