INTRODUCTION — Hysterectomy (surgical removal of the uterus) is the most
commonly performed gynecological surgical procedure. In 2003 to 2004, over
600,000 hysterectomies were performed annually in the United States, of which
approximately 90 percent were done for benign conditions . The distributions of
abdominal and vaginal hysterectomy were similar; 12 percent of all hysterectomies
were performed laparoscopically. Six percent of all hysterectomies were
supracervical. However, the prevalence of hysterectomy appears to be decreasing,
possibly due to the advent less invasive therapies for management of conditions
previously treated with hysterectomy, and in recent years vaginal hysterectomy has
become more common .
Once the decision has been made to proceed with hysterectomy, the physician and
patient must decide whether the procedure will be performed abdominally, vaginally,
or with laparoscopic assistance. The optimal surgical approach is unclear because
there are few data from large, well-designed randomized trials on which to base a
recommendation. The route chosen depends upon the woman's clinical
circumstances and the surgeon's technical expertise; the surgeon's personal
preference also plays a major role.
INDICATIONS — There are five broad diagnostic categories of indications for
Pelvic organ prolapse
Pelvic pain or infection (eg, endometriosis, pelvic inflammatory diseases)
Abnormal uterine bleeding
Malignant and premalignant disease
The reason for the hysterectomy, risks and benefits of the procedure, alternatives,
and expectations for outcome should be discussed with the woman in detail. Since a
number of the indications for hysterectomy are based more upon opinion than
evidence from well-designed studies, informed consent with thorough exploration of
patient preferences and expectations is particularly important . In the absence of
a life-threatening emergency (eg, uterine hemorrhage), the decision to proceed with
hysterectomy is made mutually by the woman and her physician based upon her
functional impairment, childbearing plans, response to medical therapy, discussion of
alternatives, and perception that the risks of the procedure are outweighed by the
TREATMENT ALTERNATIVES — Medical and surgical alternatives to hysterectomy
depend upon the underlying disorder. As an example:
Uterine artery embolization and myomectomy may be used to treat
symptomatic leiomyoma. (See "Interventional radiology in management of
obstetrical and gynecological disorders" and see "Myomectomy").
Pain control services may be able to return patients with intractable pelvic
pain to a functional status without surgery. (See "Causes of chronic pelvic pain in
Endometrial ablation may be an effective therapy for excessive uterine
bleeding. (See "Endometrial ablation").
Medical therapy using GnRH analogs can help reduce discomfort associated
with endometriosis. (See "Overview of the treatment of endometriosis").
Endometrial hyperplasia can sometimes be treated medically with progestins.
(See "Endometrial hyperplasia").
Conization (eg, cold knife, loop electrosurgical excision procedure) may be
adequate therapy for some women with high grade cervical intraepithelial
neoplasia/carcinoma in situ. (See "Cervical intraepithelial neoplasia: Management"
and see "Cervical intraepithelial neoplasia: Procedures for cervical conization").
Additional medical and surgical options for management of conditions treated by
hysterectomy are discussed in individual topic reviews on each subject. A comparison
of outcome after hysterectomy versus medical therapy for abnormal uterine bleeding
can be found separately. (See "Menorrhagia" section on Medical versus surgical
PREOPERATIVE ISSUES — An overview of issues pertaining to preoperative
preparation and assessment can be found separately. (See "Preoperative evaluation
and preparation of women for gynecologic surgery", section on Preoperative
preparation and section on Informed consent, and section on Antibiotic prophylaxis).
Women should be provided with clear information about what to expect during their
hospitalization and regarding return to normal activities. Education during the
preoperative office visits will enhance the patient's acceptance and compliance
during the immediate postoperative period and may help to shorten hospital stay.
Surgical approach — Hyterectomy may be performed using one or a combination
of the following approaches, including:
The choice of surgical approach depends upon the indications for the procedure,
concomitant procedures, surgical outcomes of each approach, surgeon experience,
and patient preference.
In general, a surgeon should choose the procedure which maximizes patient safety
and best achieves the goal of the operation. Recent developments in gynecologic
surgery have expanded the minimally invasive options for hysterectomy. Less
invasive procedures, when possible, are typically preferrable to more invasive
Abdominal versus vaginal hysterectomy — Most studies (randomized and
observational) have concluded that vaginal hysterectomy should be the preferred
route of hysterectomy because it is associated with fewer complications, shorter
length of hospitalization, and lower hospital charges than abdominal hysterectomy
(show table 1) [4-6], although a large Finnish study reported discordant findings .
Data from observational studies must be interpreted with caution as the route of
hysterectomy is likely to have been influenced by the severity of underlying disease
and complexity of the procedure.
Historically, abdominal hysterectomy has been designated as the appropriate route
for more serious conditions believed to necessitate a more thorough abdominopelvic
exploration, as well as procedures deemed too difficult to perform through the vagina
[8-10]. This opinion was the result of poorly defined, but traditionally accepted,
contraindications to the vaginal route, including: uterine enlargement (uterine weight
estimated <280 g [a normal uterus weighs 70 to 125 g] or uterine size less than 12
weeks); vagina deemed "too narrow" (eg, vagina narrower than 2 finger-breadths,
especially at the apex); lack of uterine descensus and mobility; presence of adnexal
disease; prior pelvic surgery; malignancy; contracted pelvis; and need to explore the
upper abdomen . However, these traditional indications for laparotomy have been
challenged [9,11-14]. There are no randomized trials examining these factors.
Examples of evidence from observational series supporting fewer exclusions to the
vaginal approach are presented below:
Uterine mobility — While greater uterine mobility is typically associated with
prior vaginal delivery, vaginal hysterectomy is not contraindicated in nulliparous
women . A prospective study attempted to determine the importance traditional
factors in route of hysterectomy by encouraging a vaginal approach in all cases .
All patients without prolapse undergoing hysterectomy for benign conditions were
included, except those with adnexal/tuboovarian disease, evidence of extensive
endometriosis with associated uterine immobility, disease outside the pelvis
necessitating abdominal exploration, and uterine size estimated at greater than 16
weeks. There were 97 abdominal and 175 vaginal procedures, with no significant
differences in patient characteristics (eg, nulliparity, prior cesarean). Over the five
years of the study, the proportion of abdominal hysterectomies fell from 68 to 5
percent. The frequency of complications was low and similar in both groups. Most
associated oophorectomies at the fifth year were also performed at the time of
vaginal hysterectomy with no associated increase in morbidity.
These results suggest that lack of prolapse/descensus may not be valid reason for an
abdominal approach, even in nulliparous women and those with a prior cesarean
delivery. However, lack of descensus due to normal pelvic support should be
differentiated from uterine immobility due to dense adhesive disease. If the patient's
history suggests the latter, an abdominal or laparoscopic approach is indicated.
Uterine size — A prospective study evaluated vaginal hysterectomy outcome
in 204 consecutive women with a myomatous uterus weighing 280 to 2000 g and/or
one or more of the commonly considered contraindications to a vaginal approach
(eg, prior pelvic surgery, history of pelvic inflammatory disorder, moderate or severe
endometriosis, concomitant adnexal mass, nulliparity, limited vaginal access) .
Vaginal morcellation was performed in all cases and no patient had uterovaginal
prolapse. Four patients underwent conversion to a laparoscopic procedure for the
completion of the hysterectomy, but two of these ultimately required laparotomy.
Adnexectomy was successfully performed vaginally in 90.6 percent of patients in
whom it was indicated.
These findings suggest that traditional uterine weight criteria for exclusion of the
vaginal approach may not be valid.
Prior cesarean delivery — Surgeons have been reluctant to perform vaginal
hysterectomy in woman with a prior cesarean delivery due to concerns about
scarring in the lower uterine segment leading to bladder trauma, excessive bleeding,
and eventual failure of the vaginal route. These issues were evaluated in a
retrospective review that compared vaginal hysterectomy outcome of 220 women
with prior cesarean deliver (one or more) to 200 patients with no previous pelvic
surgery . Only three of the 220 patients had inadvertent urological trauma
intraoperatively. Factors favoring a successful vaginal approach were only one
previous cesarean, a freely mobile uterus, previous vaginal delivery, uterus not
exceeding 10 to 12 weeks size, and absence of adnexal pathology. Infection
following the previous cesarean was an unfavorable prognostic factor due to an
increased risk of dense adhesions between the bladder and cervix.
Another retrospective study compared vaginal hysterectomy outcome of women with
a history of cesarean (n = 35) to those without this history (n = 186) . Surgical
indications, number of complications, perioperative hemoglobin change, operative
time, adjuvant use of laparoscopy, and length of postoperative hospitalization were
determined for each group. Total complications in the two groups did not differ
significantly and laparoscopy was only required on the rare occasions in which the
uterus was adherent to the abdominal wall.
These studies suggest that a prior cesarean delivery should not be considered a
contraindication to vaginal hysterectomy.
Nulliparity — Vaginal hysterectomy outcome in 52 nulliparous and 293
primiparous or multiparous women was compared prospectively . The mean
operative time was significantly longer in nulliparous patients (95 versus 80
minutes), the overall complication rate was significantly higher (13 versus 4
percent), as was the hemorrhage rate (7.7 versus 1.7 percent). Nevertheless,
vaginal hysterectomy was successfully performed in 50/52 of the nulliparous and
292/293 of the parous patients. This suggests that nulliparous women can be
considered candidates for vaginal hysterectomy.
Need for oophorectomy — Multiple clinical trials have shown that as many as
95 percent of ovaries can be removed vaginally, with or without laparoscopic
assistance [16-23]. Therefore, oophorectomy is not a contraindication to the vaginal
Obesity — Exposure of the operative field can be difficult in obese women,
whether an abdominal or vagina route is taken. The vaginal approach is suggested
for obese women requiring hysterectomy because it can be successfully performed
in this population and is associated with lower postoperative morbidity than
abdominal hysterectomy [24-26].
Summary — In 1999, the Society of Pelvic Reconstructive Surgeons issued
systematic guidelines for selection of hysterectomy route, and excluded some of the
traditional tenets described above (show table 2) . After these guidelines were
issued, a shift to procedures performed by the vaginal route occurred, with
reductions in complications, hospital days, and costs [28,29]. Others have also found
that a policy of encouraging a vaginal approach to hysterectomy results in a high
proportion of hysterectomies successfully performed by this route .
We recommend vaginal hysterectomy as the route of choice in most women. This
approach is associated with a more rapid return to normal function compared to
abdominal hysterectomy. In cases with potential extrauterine co-pathology (eg,
endometriosis, pelvic inflammatory disease, adnexal pathology, chronic pelvic pain),
laparoscopy can help to evaluate the abdomen/pelvis and assist in accomplishing
vaginal hysterectomy with or without oophorectomy (see "Laparoscopic assisted
vaginal hysterectomy" below).
However, not all hysterectomies can be or should be approached vaginally. The
tables list contraindications to the vaginal (show table 3) or laparoscopically assisted
vaginal approach (show table 4). Although no specific uterine size is included, the
surgeon must judge whether the access to the blood supply is limited by the uterine
size or pelvic structure.
Laparoscopic assisted vaginal hysterectomy — The use of laparoscopy to
perform hysterectomy is the subject of ongoing debate. Analyzing the role of
laparoscopy is complicated because varying degrees of laparoscopic assistance are
utilized in uterine removal. Surgical procedures described as laparoscopic assisted
vaginal hysterectomy (LAVH) range from a simple diagnostic laparoscopy to rule out
pelvic pathology prior to performing a vaginal hysterectomy to hysterectomy
performed entirely with laparoscopic instruments . The procedure is discussed in
detail separately. (See "Laparoscopic approach to hysterectomy").
The major benefit of laparoscopy prior to hysterectomy is that it provides direct,
panoramic, magnified visualization of the pelvis so the surgeon can assess the
severity of extrauterine pathology (show table 5). The surgeon can use this
information to decide whether this pathology is likely to preclude a vaginal approach
to hysterectomy under any circumstances or whether additional laparoscopic surgery
would facilitate vaginal hysterectomy. The surgeon can then proceed vaginally or
abdominally or perform a vaginal procedure with laparoscopic assistance .
As an example, if laparoscopy reveals moderate adhesions or endometriosis but an
accessible cul de sac is visualized, the extrauterine impediments can be removed
laparoscopically prior to proceeding with vaginal hysterectomy [8,32-34]. Additional
procedures that can be completed laparoscopically to facilitate vaginal hysterectomy
are management of uterine leiomyomata to facilitate uterine removal and ligation of
infundibulopelvic ligaments to facilitate difficult ovary removal. In the hands of the
surgeon facile with laparoscopy, LAVH can used to treat most pathologies, benign
and malignant, thus making a difficult vaginal hysterectomy easier and avoiding the
need for open laparotomy .
In addition, laparoscopy is a good option in patients with severe arthritis that
prohibits proper positioning to allow for adequate vaginal exposure. It allows for an
appropriate placement of the extremities without patient compromise, while
providing a minimally invasive approach to hysterectomy .
The laparoscopic route is increasingly being used in management of gynecological
cancers so these patients may avoid open laparotomy [32,33,36-38]. A vaginal
approach alone does not allow for evaluation of the abdominal peritoneal surfaces or
the retroperitoneal lymph nodes to assess for evidence of metastatic disease, but the
addition of the laparoscopic component overcomes these shortcoming. (See
"Laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers").
Contraindications — Contraindications to LAVH are similar to those for
laparoscopic hysterectomy (show table 4) . A general discussion of the
contraindications and complications of laparoscopic surgery can be found separately.
(See "Overview of gynecologic laparoscopic surgery").
The upper limit of uterine size that would preclude laparoscopic hysterectomy
depends primarily on the experience of the surgeon, just as with vaginal
hysterectomy. The ability to access the uterine arteries, rather than an absolute size,
is another important consideration. In a clinical trial comparing laparoscopic with
abdominal hysterectomy in patients with leiomyomatous uteri determined to be
greater than 14 weeks of gestation in size, morbidity was similar for both approaches
except the laparoscopy group had longer operative times .
High body mass index (BMI) was previously considered a relative contraindication
due to difficulties in establishing and maintaining the pneumoperitoneum, as well as
ventilatory challenges with larger women . However, a retrospective study of
330 patients who underwent total laparoscopic hysterectomy reported that no
conversions to laparotomy were required on the basis of BMI .
Abdominal versus vaginal versus laparoscopic hysterectomy
Systematic review — A Cochrane review assessed the most appropriate
approach to hysterectomy for benign gynecological disease . The review included
27 randomized trials with a total of 3643 patients. The major findings are listed in
the table (show table 6); there were wide differences in the reported effects among
the trials. The authors concluded vaginal hysterectomy should be performed in
preference to abdominal hysterectomy where possible. When vaginal hysterectomy
is not possible, they suggested that a laparoscopic approach might avoid the need
for abdominal hysterectomy; however, the length of the surgery increases as the
scope of the surgery performed laparoscopically increases and these procedures
require greater surgical expertise.
More research needs to be done given the variations in study design, differences in
outcomes evaluated and surgical expertise, multiple studies with small sample sizes,
and lack of long-term postoperative evaluation.
eVALuate trial — The eVALuate trial was a concurrent pair of multicenter
randomized controlled trials that evaluated the relative roles of vaginal, abdominal,
and laparoscopic hysterectomy in routine gynecological practice . This trial is the
largest randomized trial comparing these procedures, and was included in the
Cochrane review discussed above. The method of randomization was that patients
were scheduled for abdominal hysterectomy and then randomly assigned to
laparoscopic or abdominal hysterectomy or else they were scheduled for vaginal
hysterectomy and then randomly assigned to laparoscopic or vaginal hysterectomy.
All had benign disease. Women were excluded from participation if they had 2nd or
3rd degree prolapse, a uterus greater than 12 week size, a medical disorder
precluding laparoscopic surgery, or if they required bladder or pelvic support
surgery. The laparoscopic arm included various approaches, including hysterectomy
where all steps were performed laparoscopically to hysterectomies with vaginal
The major findings from this trial are shown in the table (show table 7). Although
major composite surgical complications (including conversion to laparotomy)
occurred more frequently in laparoscopic than abdominal hysterectomy, it should be
noted that "conversion to laparotomy" cannot be a complication of abdominal
hysterectomy. Furthermore, conversion to laparotomy is not necessarily a
complication of laparoscopy, but rather a surgical judgment. If only unintended
laparotomies due to a major complication were included in the laparoscopic
hysterectomy group, then the rate of major complications would have been
equivalent for both the abdominal and laparoscopic approaches (7.8 versus 6.2
percent). Another concern regarding these findings are that the surgeons had less
experience with the laparoscopic than the abdominal procedure.
Laparoscopic hysterectomy took longer to perform than abdominal or vaginal
hysterectomy (median time 72 to 84, 50, and 39 minutes, respectively), but was
associated with less postoperative pain than abdominal hysterectomy, as well as a
shorter length of hospitalization (three versus four days), quicker recovery, and
better quality of life six weeks postoperatively.
Results from the vaginal hysterectomy arm were generally favorable, but the sample
size was not large enough to show statistically significant differences between
groups, except for shortest duration of surgery.
A separate cost analysis found that laparoscopic hysterectomy was not cost effective
relative to vaginal hysterectomy, and had comparable cost effectiveness to
abdominal hysterectomy . Observational studies in the United States and Canada
have documented cost effectiveness of laparoscopic hysterectomy as compared to
abdominal hysterectomy based predominately on decreased duration of
hospitalization and quicker return to work [42,43].
Summary — Laparoscopic hysterectomy offers no clinical or economic advantage
over vaginal hysterectomy. It does offer less postoperative pain, shorter hospital
stay and faster convalescence compared to abdominal hysterectomy. It may be
associated with higher risk of urinary tract injury and increased costs. Based on the
discussion above, we suggest vaginal hysterectomy be performed in preference to
abdominal hysterectomy whenever possible because of shorter recovery period and
fewer postoperative infectious complications. We suggest LAVH in patients who
might otherwise require an abdominal hysterectomy. Women whose history and
physical examination suggest that vaginal hysterectomy will be uncomplicated do not
need laparoscopy prior to or during vaginal hysterectomy.
Total versus subtotal (supracervical) — Some women desire to retain the cervix
believing that it may affect sexual satisfaction after hysterectomy. It has been
postulated, without data, that removal of the cervix causes excessive neurologic and
anatomic disruption, thereby leading to increased operative and postoperative
morbidity, vaginal shortening, subsequent vault prolapse, abnormal cuff
granulations, and the potential for fallopian tube prolapse. These issues were
addressed in a systematic review of total versus subtotal hysterectomy for benign
gynecological conditions, which reported the following findings :
There was no difference in the rates of incontinence, constipation or
measures of sexual function (sexual satisfaction, dyspareunia).
Length of surgery and amount of blood lost during surgery were significantly
reduced during subtotal hysterectomy compared to total hysterectomy, but there
was no difference in transfusion rates.
Febrile morbidity was less likely and ongoing cyclical vaginal bleeding one
year after surgery was more likely after subtotal 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 [45,46].
However, no trials have addressed the risk of pelvic organ prolapse many years after
surgery, which may differ after total versus supracervical hysterectomy.
Advantages to supracervical hysterectomy include shorter operative time than total
abdominal hysterectomy, decreased length of hospital stay if performed
laparoscopically, and possibly faster convalescence [44-50]. There may also be fewer
injuries to the urinary tract because the procedure does not dissect as close to the
cervix or as deep into the pelvis as total hysterectomy. However, clinical trials have
not been sufficiently powered to demonstrate this clinical observation.
Other differences include post-hysterectomy body image and health status. In a
randomized, nonblinded study of women undergoing total abdominal versus subtotal
hysterectomy, the patients completed questionnaires regarding postoperative quality
of life, body image, and sexual activity. Women in the subtotal versus the total
hysterectomy group reported significantly improved body image and health-related
quality of life . Both groups reported improvements in sexual satisfaction.
The only absolute contraindication to subtotal hysterectomy is the presence of a
malignant or premalignant condition of the uterine corpus or cervix. Extensive
endometriosis is a relative contraindication as these women may have persistence of
dyspareunia if the cervix is retained.
The risks and benefits of retaining the cervix should be included as part of the
preoperative informed consent. We suggest that women should be informed that
retaining the cervix does not appear to confer any medical or sexual benefits.
Although the vagina receives some part of its lubrication from the cervical glands (in
addition to transudate through the vaginal walls), there is no evidence that total
versus subtotal hysterectomy adversely effects vaginal lubrication or leads to
dyspareunia [44,52]. Disadvantages of conserving the cervix includecyclic vaginal
bleeding in some patients (7 to 11 percent [45,53]), the need for routine screening
for cervical cancer, and the potential need for subsequent trachelectomy (eg,
because of bleeding, prolapse, or precancer/cancer) . Thus, on balance, there is
no compelling reason to retain the cervix if it can be easily removed with the corpus.
Elective supracervical hysterectomy should be preceded by cervical cytology
confirming absence of cervical intraepithelial neoplasia. Women who have had a
supracervical hysterectomy should be screened for cervical cancer according to
standard guidelines for their age and risk status. In women with abnormal uterine
bleeding, endometrial cancer should be excluded prior to performing a supracervical
Supracervical hysterectomy is indicated for select patients who choose this
procedure after appropriate counseling, and occasionally in surgical emergencies.
Supracervical hysterectomy should not be done because of the surgeon's lack of
comfort with removing the cervix. Instead, assistance from more skilled surgeons
should be sought.
Elective oophorectomy — The risks and benefits of elective oophorectomy at the
time of hysterectomy are discussed in detail elsewhere. (See "Oophorectomy and
ovarian cystectomy" section on Oophorectomy at the time of hysterectomy).
OUTCOME — The outcome of hysterectomy can be assessed in terms of relief of
symptoms, psychosexual issues, and patient satisfaction.
Relief of symptoms — The most common symptoms prior to surgery include
problematic vaginal bleeding, pelvic or back pain, limitation of activity, sleep
disturbance, fatigue, urinary incontinence, and bloating. One multicenter study of
1299 women who underwent hysterectomy in Maryland found that at least one of
these symptoms was present and considered severe in 20 to 70 percent of patients
preoperatively, but most achieved relief by 24 months postoperatively (show table 8)
. Ninety-nine percent of patients indicated the surgery had somewhat or
completely resolved the problems that they had prior to surgery , although 8
percent reported no improvement when surveyed about the specific symptoms
described in the table .
Psychosexual issues — The majority of retrospective studies on the psychological
effects of hysterectomy showed an adverse outcome . By comparison,
prospective studies have found therapeutic effects of hysterectomy, including
improvement of mood and quality of life. Multiple studies have shown that
hysterectomy, with or without oophorectomy, appears to have few, if any, effects on
sexual functioning [52,57-60].
The Maine Women's Health Study of 418 women showed hysterectomy led to
marked relief of pelvic pain and vaginal bleeding. There were also modest
improvements in self-reported feelings of depression, fatigue, sexual dysfunction,
and other symptoms associated with nonmalignant conditions of the uterus . A
limited number of women reported new problems such as hot flashes (13 percent),
weight gain (12 percent), depression (8 percent), anxiety (6 percent), and lack of
interest in sex (7 percent).
The Maryland study (discussed above) also noted improvement in the
proportion of patients reporting depression or anxiety before and after surgery
(depression 28 versus 12 percent, anxiety 65 versus 25 percent, before and after
hysterectomy respectively) . In addition, 48 percent of patients described
limited physical function and 23 percent described limited social function before
surgery compared to 23 and 5 percent, respectively, 24 months after surgery.
This study also assessed measures of sexual functioning prior to hysterectomy and at
6, 12, 18, and 24 months after the procedure . The percentage of women who
engaged in sexual relations increased from approximately 71 percent before
hysterectomy to 77 percent at 12 and 24 months after hysterectomy; the rate of
frequent dyspareunia dropped from 19 to 4 percent; the rate of experiencing
orgasms increased from 92 to 95 percent; and libido increased. Overall, the
frequency of sexual activity increased and problems with sexual functioning
A multicenter study from the Netherlands noted no difference in sexual
function by hysterectomy procedure (abdominal, vaginal, or subtotal) . There
was a significant increase in sexual pleasure after each of the three procedures.
A number of confounding factors with the potential to have either a positive or
negative impact on sexuality, independent of hysterectomy, must be taken into
account when studying the psychosocial effect of this surgery [62-64]. As an
example, women with prior psychiatric illness and those with personality and
psychosocial problems are unlikely to improve after surgery . Other preoperative
factors reported to increase a woman's emotional distress following hysterectomy
include a desire to maintain fertility, a high investment in motherhood, and the
patient who has not dealt well with a previous loss .
Early detection of ovarian failure after hysterectomy and initiation of estrogen
therapy immediately after surgery in premenopausal women undergoing
oophorectomy appear to improve the psychological outcome.
Patient satisfaction — A post-hysterectomy survey in which women were asked to
what extent the surgical procedure solved their prehysterectomy problems found
that 85 percent of women were completely satisfied, 11 percent mostly satisfied, 3
percent somewhat satisfied, and less than one percent were not satisfied .
Overall approximately 70 percent reported much better health after the surgery.
However, some regret at loss of fertility is common .
Earlier menopause — Hysterectomy appears to impair ovarian function over the
long-term, at least in some women. One randomized study and several observational
series have shown that women who undergo hysterectomy develop menopausal
symptoms earlier than controls not exposed to this surgery, possibly due to
impairment of the ovarian blood supply [66-71]. In one study, menopause (defined
as FSH >40) occurred approximately four years earlier in premenopausal women
who underwent hysterectomy (both ovaries retained) compared to matched controls
without hysterectomy . Hysterectomy with unilateral oophorectomy was
associated with an even earlier onset of the menopause.
COMPLICATIONS — In an Australian population-based study of almost 80,000
hysterectomies performed for benign indications, the most common complications for
all surgical approaches combined were: hemorrhage (2.4 percent), genitourinary
disorders (eg, pelvic organ prolapse, urinary retention, renal or ureteral injury) (1.9
percent), urinary tract infection (1.6 percent), and infection other than in the urinary
tract (1.6 percent) .
General complications of hysterectomy are discussed here. Procedure-specific
complications are discussed separately in the topic reviews on each type of
hysterectomy. (See "Abdominal hysterectomy", see "Vaginal hysterectomy", and see
"Laparoscopic approach to hysterectomy").
Urinary incontinence — Hysterectomy may result in damage to the nerve supply
or supportive tissues of the pelvic floor, which may lead to subsequent pelvic floor
dysfunction. The role of hysterectomy in urinary incontinence is controversial [73-
78]. In one large retrospective cohort study (n = 644,766), hysterectomy was
associated with a two-fold increase in risk of subsequent surgery for stress
incontinence compared to women who had not undergone hysterectomy (hazard
ratio 2.4, 95% CI 2.3-2.5). This difference was present regardless of the surgical
approach used for the hysterectomy; women who had previous surgery for stress
urinary incontinence, or for whom the indication for hysterectomy was pelvic organ
prolapse, were excluded . However, this study was limited by the absence of
data on the prevalence of preexisting urinary incontinence symptoms.
Pelvic organ prolapse — Studies have reported discordant findings regarding the
effect of hysterectomy on the development of pelvic organ prolapse [79-82]. The risk
may depend on age, whether prolapse is present at the time of hysterectomy, and
on the surgical approach. However, it is unclear if the increased association of
vaginal hysterectomy with subsequent pelvic organ prolapse is due to selection bias
in performing vaginal hysterectomy or whether the surgical technique is more prone
to cause surgical trauma to the vaginal support tissues.
Potential mechanisms for post-hysterectomy prolapse include alteration in connective
tissue or surgical injury to the innervation and vascularization of the pelvic floor
In a large population-based study with the longest period of follow-up (38 years),
the likelihood of undergoing a future pelvic floor repair was significantly higher in
women who had prolapse at the time of hysterectomy (even if a concomitant
prolapse repair was performed) compared with women without prolapse (hazard
ratio 2.5, 95% CI 1.9-3.3) . In addition, for women with prolapse at the time of
hysterectomy, there was a risk of subsequent pelvic floor repair in those who
underwent vaginal, but not abdominal, hysterectomy.
In a longitudinal study, more than 160,000 women who underwent hysterectomy for
benign indications were compared with population-based controls and found to have
a higher risk of subsequent pelvic organ prolapse surgery . Multiparous women
who underwent vaginal hysterectomy had the highest rate of subsequent prolapse
surgery, with this risk most evident within five years of hysterectomy.
INFORMATION FOR PATIENTS — Educational materials on this topic are available
for patients. (See "Patient information: Abdominal hysterectomy" and see "Patient
information: Vaginal hysterectomy"). We encourage you to print or e-mail these
topic reviews, or to refer patients to our public web site,
www.uptodate.com/patients, which includes these and other topics.
SUMMARY AND RECOMMENDATIONS
We recommend a vaginal approach to hysterectomy for most patients
(Grade 1B). Compared to other routes of hysterectomy, it is less invasive, more
cosmetic, and associated with fewer complications, shorter hospital stay, lower cost,
and faster return to normal activity. (See "Abdominal versus vaginal versus
laparoscopic hysterectomy" above).
We suggest laparoscopic assisted vaginal hysterectomy in patients in whom
laparoscopic visualization of the pelvis and laparoscopic surgery are likely to allow
performance of vaginal hysterectomy and negate the need for laparotomy (Grade
2B). (See "Laparoscopic assisted vaginal hysterectomy" above).
We suggest performing total abdominal hysterectomy rather than
supracervical hysterectomy (Grade 2B). There are no proven medical or surgical
benefits of performing supracervical or subtotal hysterectomy if the cervix can be
easily removed with the corpus. We recommend that women who have had a
supracervical hysterectomy be screened for cervical cancer according to standard
guidelines for their age and risk status (Grade 1A). (See "Total versus subtotal
After hysterectomy, most women report relief of symptoms, improved quality
of life, no adverse effect on sexual function, and satisfaction with their surgery. (See