very thick uterine lining or uterine fibroids. uterine fibroids further information: uterine fibroids levonorgestrel intrauterine devices are highly effective in limiting menstrual blood flow and improving other symptoms. side effects are typically very moderate because the levonorgestrel (a progestin) is released in low concentration locally. there is now substantial evidence that levongestrel-iuds provide good symptomatic relief for women with fibroids. uterine fibroids may be removed and the uterus reconstructed in a procedure called "myomectomy". a myomectomy may be performed through an open incision, laparoscopically, or through the vagina (hysteroscopy). uterine artery embolization (uae) is a minimally invasive procedure for treatment of uterine fibroids. under local anesthesia a catheter is introduced into the femoral artery at the groin and advanced under radiographic control into the uterine artery. a mass of microspheres or polyvinyl alcohol (pva) material (an embolus) is injected into the uterine arteries in order to block the flow of blood through those vessels. the restriction in blood supply usually results in significant reduction of fibroids and improvement of heavy bleeding tendency. the 2012 cochrane review comparing hysterectomy and uae did not find any major advantage for either procedure. while uae is associated with shorter hospital stay and a more rapid return to normal daily activities, it was also associated with a higher risk for minor complications later on. there were no differences between uae and hysterectomy with regards to major complications. uterine fibroids can be removed with a non-invasive procedure called magnetic resonance guided focused ultrasound (mrgfus). uterine prolapse prolapse may also be corrected surgically without removal of the uterus. there are several strategies that can be utilized to help strengthen pelvic floor muscles and prevent the worsening of prolapse. these include, but are not limited to, use of "kegel exercises", vaginal pessary, constipation relief, weight management, and care when lifting heavy objects. types schematic drawing of types of hysterectomy hysterectomy, in the literal sense of the word, means merely removal of the uterus. however other organs such as ovaries, fallopian tubes, and the cervix are very frequently removed as part of the surgery. radical hysterectomy: complete removal of the uterus, cervix, upper vagina, and parametrium. indicated for cancer. lymph nodes, ovaries, and fallopian tubes are also usually removed in this situation, such as in wertheim's hysterectomy. total hysterectomy: complete removal of the uterus and cervix, with or without oophorectomy. subtotal hysterectomy: removal of the uterus, leaving the cervix in situ. subtotal (supracervical) hysterectomy was originally proposed with the expectation that it may improve sexual functioning after hysterectomy, it has been postulated that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. these theoretical advantages were not confirmed in practice, but other advantages over total hysterectomy emerged. the principal disadvantage is that risk of cervical cancer is not eliminated and women may continue cyclical bleeding (although substantially less than before the surgery). these issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings: there was no difference in the rates of incontinence, constipation, measures of sexual function, or alleviation of pre-surgery symptoms. length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates. febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy. there was no difference in the rates of other complications, recovery from surgery, or readmission rates. in the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse. supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact and may be contraindicated in women with increased risk of this cancer; regular pap smears to check for cervical dysplasia or cancer are still needed. technique hysterectomy can be performed in different ways. the oldest known technique is vaginal hysterectomy. the first planned hysterectomy was performed by konrad langenbeck - surgeon general of the hannovarian army, although there are records of vaginal hysterectomy for prolapse going back as far as 50bc. the first abdominal hysterectomy recorded was by ephraim mcdowell. he performed the procedure in 1809 for a mother of five for a large ovarian mass on her kitchen table. in modern medicine today, laparoscopic vaginal (with additional instruments passing through ports in small abdominal incisions, close or in the navel) and total laparoscopic techniques have been developed. abdominal hysterectomy most hysterectomies in the united states are done via laparotomy (abdominal incision, not to be confused with laparoscopy). a transverse (pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. this technique allows physicians the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. the recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. historically, the biggest problem with this technique was infections, but infection rates are well-controlled and not a major concern in modern medical practice. an open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. before the refinement of the vaginal and laparoscopic vaginal techniques, it was also the only possibility to achieve subtotal hysterectomy; meanwhile, the vaginal route is the preferable technique in most circumstances. vaginal hysterectomy vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected, or surgical exploration is required. laparoscopic-assisted vaginal hysterectomy with the development of laparoscopic techniques in the 1970s and 1980s, the "laparoscopic-assisted vaginal hysterectomy" (lavh) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. it also allows better exploration and slightly more complicated surgeries than the vaginal procedure. lavh begins with laparoscopy and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. thus, lavh is also a total hysterectomy; the cervix is removed with the uterus. if the cervix is removed along with the uterus, the upper portion of the vagina is sutured together and called the vaginal cuff. laparoscopic-assisted supracervical hysterectomy the "laparoscopic-assisted supracervical hysterectomy" (lash) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. total laparoscopic hysterectomy total laparoscopic hysterectomy (tlh) was developed in the early 90s by prabhat k. ahluwalia in upstate new york. tlh is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus, typically with a uterine manipulator. the entire uterus is disconnected from its attachments using long thin instruments through the "ports". then all tissue to be removed is passed through the small abdominal incisions. other techniques supracervical (subtotal) laparoscopic hysterectomy (lsh) is performed similar to the total laparoscopic surgery but the uterus is amputated between the cervix and fundus. dual-port laparoscopy is a form of laparoscopic surgery using two 5 mm midline incisions: the uterus is detached through the two ports and removed through the vagina. "robotic hysterectomy" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision. uterus prior to hysterectomy laparoscopical hysterectomy cervical stump (white) after removal of the uterine corpus at laparoscopic supracervical hysterectomy transvaginal extraction of the uterus in total laparoscopical hysterectomy end of a laparoscopical hysterectomy comparison of techniques patient characteristics such as the reason for needing a hysterectomy, uterine size, descent of the uterus, presence of diseased tissues surrounding the uterus, previous surgery in the pelvic region, obesity, history of pregnancy, the possibility of endometriosis, or the need for an oophorectomy, will influence a surgeon's surgical approach when performing a hysterectomy. vaginal hysterectomy is recommended over other variants where possible for women with benign diseases. vaginal hysterectomy was shown to be superior to lavh and some types of laparoscopic surgery causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. laparoscopic surgery offers certain advantages when vaginal surgery is not possible but also has the disadvantage of significantly longer time required for the surgery. in one 2004 study conducted in the uk comparing abdominal (laparotomic) and laparoscopic techniques, laparoscopic surgery was found to cause longer operation time and a higher rate of major complications while offering much quicker healing. in another study conducted in 2014, laparoscopy was found to be "a safe alternative to laparotomy" in patients receiving total hysterectomy for endometrial cancer. researchers concluded the procedure "offers markedly improved perioperative outcomes with a lower reoperation rate and fewer postoperative complications when the standard of care shifts from open surgery to laparoscopy in a university hospital". the abdominal technique is very often applied in difficult circumstances or when complications are expected. given these circumstances the complication rate and time required for surgery compares very favorably with other techniques, however time required for healing is much longer. hysterectomy by abdominal laparotomy is correlated with much higher incidence of intestinal adhesions than other techniques. time required for completion of surgery in the eval trial is reported as follows: abdominal 55.2 minutes average, range 19–155 vaginal 46.6 minutes average, range 14–168 laparoscopic (all variants) 82.5 minutes average, range 10–325 (combined data from both trial arms) morcellation has been widely used especially in laparoscopic techniques and sometimes for the vaginal technique, but now appears to be associated with a considerable risk of spreading benign or malignant tumors. in april 2014, the fda issued a memo alerting medical practitioners to the risks of power morcellation. robotic assisted surgery is presently used in several countries for hysterectomies. additional research is required to determine the benefits and risks involved, compared to conventional laparoscopic surgery. a 2014 cochrane review found that robotic assisted surgery may have a similar complication rate when compared to conventional laparoscopic surgery. in addition, there is evidence to suggest that although the surgery make take longer, robotic assisted surgery may result in shorter hospital stays. more research is necessary to determine if robotic assisted hysterectomies are beneficial for people with cancer. previously reported marginal advantages of robotic assisted surgery could not be confirmed; only differences in hospital stay and cost remain statistically significant. in addition, concerns over widespread misleading marketing claims have been raised. summary—advantages and disadvantages of different hysterectomy techniques technique benefits disadvantages abdominal hysterectomy no limitation by the size of the uterus combination with reduction and incontinence surgery possible no increase in post-surgical complications compared with vaginal longest recovery period and return to normal activities may have a higher risk of bleeding compared with laparoscopic surgery vaginal or laparoscopic technique preferred for people who are obese vaginal hysterectomy shortest operation time short recovery period and discharge from hospital less pain medication and lower hospital costs compared with laparoscopic technique lowest cost limited by the size of the uterus and previous surgery limited ability to evaluate the fallopian tubes and ovaries laparoscopic supracervical hysterectomy (subtotal hysterectomy) unclear if subtotal approach leads to a reduction in pelvic organ prolapse in the long-term no evidence that this technique improves sexual function or reduces operative risk of urinary or bowel damage faster return to normal activities women must have regular cervical cancer screening following surgery possibility of cyclical bleeding following subtotal approach laparoscopic-assisted vaginal hysterectomy (lavh) possible with a larger uterus, depending on the surgeon's skills combination with reduction operations are possible higher cost than vaginal approach malignancies can only be removed by this approach if they are intact not suggested for people with cardiopulmonary disease total laparoscopic hysterectomy short inpatient treatment duration compared with abdominal allows the possibility to diagnose and treat other pelvic diseases quicker return