hysterectomy hysterectomy hysterectomy is the partial or total surgical removal of the uterus. it may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. partial hysterectomies allow for hormone regulation while total hysterectomies do not. not to be confused with hysterotomy. hysterectomydiagram showing what is removed with a radical hysterectomyspecialtygynaecologyicd-9-cm68.9meshd007044medlineplus002915 usually performed by a gynecologist, a hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body while leaving the cervix intact; also called "supracervical"). removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. it is the second most commonly performed gynecological surgical procedure, after cesarean section, in the united states. nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. it is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options. medical uses hysterectomy hysterectomy is a major surgical procedure that has risks and benefits. it affects the hormonal balance and overall health of patients. because of this, hysterectomy is normally recommended as a last resort after pharmaceutical or other surgical options have been exhausted to remedy certain intractable and severe uterine/reproductive system conditions. there may be other reasons for a hysterectomy to be requested. such conditions and/or indications include, but are not limited to: endometriosis: growth of the uterine lining outside the uterine cavity. this inappropriate tissue growth can lead to pain and bleeding. adenomyosis: a form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall musculature. this can thicken the uterine walls and also contribute to pain and bleeding. heavy menstrual bleeding: irregular or excessive menstrual bleeding for greater than a week. it can disturb regular quality of life and may be indicative of a more serious condition. uterine fibroids: benign growths on the uterus wall. these muscular noncancerous tumors can grow in single form or in clusters and can cause extreme pain and bleeding. uterine prolapse: when the uterus sags down due to weakened or stretched pelvic floor muscles potentially causing the uterus to protrude out of the vagina in more severe cases. reproductive system cancer prevention: especially if there is a strong family history of reproductive system cancers (especially breast cancer in conjunction with brca1 or brca2 mutation), or as part of recovery from such cancers. gynecologic cancer: depending on the type of hysterectomy, can aid in treatment of cancer or precancer of the endometrium, cervix, or uterus. in order to protect against or treat cancer of the ovaries, would need an oophorectomy. transgender (trans) male affirmation: aids in gender dysphoria, prevention of future gynecologic problems, and transition to obtaining new legal gender documentation. severe developmental disabilities: this treatment is controversial at best. in the united states, specific cases of sterilization due to developmental disabilities have been found by state-level supreme courts to violate the patient's constitutional and common-law rights. postpartum: to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive obstetrical haemorrhage. chronic pelvic pain: should try to obtain pain etiology, although may have no known cause. risks and adverse effects in 1995, the short-term mortality (within 40 days of surgery) was reported at 0.38 cases per 1000 when performed for benign causes. risks for surgical complications were presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity. the mortality rate is several times higher when performed in patients who are pregnant, have cancer or other complications. long-term effect on all case mortality is relatively small. people under the age of 45 years have a significantly increased long-term mortality that is believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy. this effect is not limited to pre-menopausal people; even people who have already entered menopause were shown to have experienced a decrease in long-term survivability post-oophorectomy. approximately 35% of people after hysterectomy undergo another related surgery within 2 years. ureteral injury is not uncommon and occurs in 0.2 per 1,000 cases of vaginal hysterectomy and 1.3 per 1,000 cases of abdominal hysterectomy. the injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as a ureter crosses below the uterine artery, often from blind clamping and ligature placement to control hemorrhage. recovery hospital stay is 3 to 5 days or more for the abdominal procedure and between 1 and 2 days (but possibly longer) for vaginal or laparoscopically assisted vaginal procedures. after the procedure, the american college of obstetricians and gynecologists recommends not inserting anything into the vagina for the first 6 weeks (including inserting tampons or having sex). unintended oophorectomy and premature ovarian failure removal of one or both ovaries is performed in a substantial number of hysterectomies that were intended to be ovary sparing. the average onset age of menopause after hysterectomy with ovarian conservation is 3.7 years earlier than average. this has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy or due to missing endocrine feedback of the uterus. the function of the remaining ovaries is significantly affected in about 40% of people, some of them even require hormone replacement therapy. surprisingly, a similar and only slightly weaker effect has been observed for endometrial ablation which is often considered as an alternative to hysterectomy. a substantial number of people develop benign ovarian cysts after a hysterectomy. effects on sexual life and pelvic pain after hysterectomy for benign indications the majority of patients report improvement in sexual life and pelvic pain. a smaller share of patients report worsening of sexual life and other problems. the picture is significantly different for hysterectomy performed for malignant reasons; the procedure is often more radical with substantial side effects. a proportion of patients who undergo a hysterectomy for chronic pelvic pain continue to have pelvic pain after a hysterectomy and develop dyspareunia (painful sexual intercourse). premature menopause and its effects estrogen levels fall sharply when the ovaries are removed, removing the protective effects of estrogen on the cardiovascular and skeletal systems. this condition is often referred to as "surgical menopause", although it is substantially different from a naturally occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce hormones even after the cessation of menstrual periods. one study showed that risk of subsequent cardiovascular disease is substantially increased for people who had hysterectomy at age 50 or younger. no association was found for women undergoing the procedure after age 50. the risk is higher when ovaries are removed but still noticeable even when ovaries are preserved. several other studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. this has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting. hysterectomies have also been linked with higher rates of heart disease and weakened bones. those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact. reduced levels of testosterone in women are predictive of height loss, which may occur as a result of reduced bone density, while increased testosterone levels in women are associated with a greater sense of sexual desire. oophorectomy before the age of 45 is associated with a fivefold mortality from neurologic and mental disorders. urinary incontinence and vaginal prolapse urinary incontinence and vaginal prolapse are well known adverse effects that develop with high frequency a very long time after the surgery. typically, those complications develop 10–20 years after the surgery. for this reason exact numbers are not known, and risk factors are poorly understood. it is also unknown if the choice of surgical technique has any effect. it has been assessed that the risk for urinary incontinence is approximately doubled within 20 years after hysterectomy. one long-term study found a 2.4 fold increased risk for surgery to correct urinary stress incontinence following hysterectomy. the risk for vaginal prolapse depends on factors such as number of vaginal deliveries, the difficulty of those deliveries, and the type of labor. overall incidence is approximately doubled after hysterectomy. adhesion formation and bowel obstruction the formation of postoperative adhesions is a particular risk after hysterectomy because of the extent of dissection involved as well as the fact the hysterectomy wound is in the most gravity-dependent part of the pelvis into which a loop of bowel may easily fall. in one review, incidence of small bowel obstruction due to intestinal adhesion was found to be 15.6% in non-laparoscopic total abdominal hysterectomies vs. 0.0% in laparoscopic hysterectomies. wound infection wound infection occurs in approximately 3% of cases of abdominal hysterectomy. the risk is increased by obesity, diabetes, immunodeficiency disorder, use of systemic corticosteroids, smoking, wound hematoma, and preexisting infection such as chorioamnionitis and pelvic inflammatory disease. such wound infections mainly take the form of either incisional abscess or wound cellulitis. typically, both confer erythema, but only an incisional abscess confers purulent drainage. the recommended treatment of an incisional abscess after hysterectomy is by incision and drainage, and then coverage by a thin layer of gauze followed by sterile dressing. the dressing should be changed and the wound irrigated with normal saline at least twice each day. in addition, it is recommended to administer an antibiotic active against staphylococci and streptococci, preferably vancomycin when there is a risk of mrsa. the wound can be allowed to close by secondary intention. alternatively, if the infection is cleared and healthy granulation tissue is evident at the base of the wound, the edges of the incision may be reapproximated, such as by using butterfly stitches, staples or sutures. sexual intercourse remains possible after hysterectomy. reconstructive surgery remains an option for people who have experienced benign and malignant conditions. : 1020–1348 other rare problems hysterectomy may cause an increased risk of the relatively rare renal cell carcinoma. the increased risk is particularly pronounced for young people; the risk was lower after vaginally performed hysterectomies. hormonal effects or injury of the ureter were considered as possible explanations. in some cases the renal cell carcinoma may be a manifestation of an undiagnosed hereditary leiomyomatosis and renal cell cancer syndrome. removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. two cases have been identified and profiled in an issue of the blackwell journal of obstetrics and gynecology; over 20 other cases have been discussed in additional medical literature. on very rare occasions, sexual intercourse after hysterectomy may cause a transvaginal evisceration of the small bowel. the vaginal cuff is the uppermost region of the vagina that has been sutured closed. a rare complication, it can dehisce and allow the evisceration of the small bowel into the vagina. alternatives myomectomy sutured uterus wound after myomectomy depending on the indication there are alternatives to hysterectomy: heavy bleeding levonorgestrel intrauterine devices are highly effective at controlling dysfunctional uterine bleeding (dub) or menorrhagia and should be considered before any surgery. menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation which is an outpatient procedure in which the lining of the uterus is destroyed with heat, mechanically or by radio frequency ablation. endometrial ablation greatly reduces or eliminates monthly bleeding in ninety percent of patients with dub. it is not effective for patients with