By Heather Guidone
(surgical removal of the uterus) is the second
most frequently performed surgical procedure
among reproductive aged women in the U.S., with
approximately 600,000 hysterectomies performed
each year at an estimated cost of $5 billion.
most common diagnoses associated with hysterectomy
are fibroids, uterine prolapse, cervical dysplasia,
and endometriosis. In fact, among women aged
30-34 years, the leading cause of hysterectomy
to the old school of thought, hysterectomy would
cure endometriosis. Today, of course, we know
this is untrue - a hysterectomy is no more curative
than pregnancy (another common fallacy). However,
women with endometriosis who have elected to
undergo a hysterectomy have found relief following
is a hysterectomy the right answer for you?
Maybe, maybe not.
Ask your surgeon; what's involved? What can
I expect following a hysterectomy? Will it alleviate
all my pain? Will I need HRT? Are there alternatives?
What are your treatment goals? Are you hoping
strictly for pain relief, or is fertility your
primary concern? What treatments have you not
a hysterectomy can provide significant symptomatic
relief in many cases, it is not a definitive
cure for the disease. For example: in an 18-month
study conducted by Johns Hopkins, 138 women
with endometriosis underwent hysterectomies.
In the group of those who kept their ovaries,
31% had recurrence of disease. Of those who
had their ovaries removed, 10% had recurrence(2).
A hysterectomy can be performed either vaginally
or abdominally. The U.S. Centers for Disease
Control compared the risks of vaginal versus
abdominal hysterectomy, and found that the risk
of one or more post-surgical complications (such
as uncontrolled bleeding and fever) was 1.7
times higher for abdominal hysterectomy than
for vaginal hysterectomy(3).
a vaginal hysterectomy, the uterus is removed
through the vagina. This requires no abdominal
incision, so recovery and hospital stays are
often shorter. This method, however, can interfere
with sexual function because the vagina may
be tightened or shortened during the surgery.
(laparoscopic assisted vaginal hysterectomy)
is similar to the vaginal hysterectomy, but
the surgeon is assisted with the aid of the
laparoscope. The uterus is cut and removed in
sections through the scope or vaginally. Though
the surgery takes longer, hospital stay and
recovery time are often shortened.
an abdominal hysterectomy, an incision is made
in the abdomen either vertically below the belly
button or horizontally above the pubic hairline.
The incision is generally about 6 to 8 inches
long. Organs are then removed through the incision.
Subtotal (or Supracervical) - the uterus
is removed, but the cervix remains intact.
Total (or complete) - uterus, cervix, and
fundus are removed, but the ovaries and
fallopian tubes remain intact. As with subtotal
hysterectomy, pre-menopausal women who undergo
this procedure will still ovulate, but will
not experience any menstrual flow.
Hysterectomy with bilateral salpingo-oophorectomy:
uterus, cervix, fallopian tubes, and ovaries
are removed. If one ovary is left because
it is not diseased, this procedure is called
a unilateral salpingo-oophorectomy.
hysterectomy: uterus, cervix, fallopian tubes,
ovaries, part of the vagina, and sometimes
pelvic lymph nodes are removed. Generally,
this procedure is reserved to treat widespread
women opt for "prophylactic oophorectomy"
- preventative removal of the ovaries. This
is sometimes performed during the hysterectomy
in order to reduce a patient's chance of ovarian
cancer and the need for future surgery.
sure to discuss what type of hysterectomy you
will be having and express your wishes very
clearly to your surgeon.
time following hysterectomy varies from patient
to patient. Reported times have been from 3-10
weeks.(4) Many women may be depressed or concerned
about sexual relations following their hysterectomy.
Do not hesitate to address these concerns with
your physician, and seek the assistance of a
licensed therapist if the need arises.
groups can also be extremely helpful in aiding
a patient through this difficult time. For more
information on this and other post-hysterectomy
support needs, visit Hystersisters online
the patient can expect not to have sex for up
to 6 weeks after surgery. Mentally, a study
has shown that 25-45% of women over the age
of 45 who have undergone hysterectomy (with
or without ovary removal) have experienced a
loss in libido.(5)
HRT or Not to HRT
Hormone Replacement Therapy (HRT) is usually
necessary for most women who have undergone
a hysterectomy. However, HRT is a particularly
thorny issue for endometriosis patients. Some
professionals believe that any amount of estrogen
replacement will spur a recurrence of disease;
others feel that it is important to have estrogen
in small enough doses where it will not stimulate
any remaining endometriosis, but will offer
protective factors to the woman's bones, heart,
others believe that HRT should be offered to
the patient, but only after 6 months to a year.
Work with your physician to find out what is
right for your needs.
Some members of the endometriosis community
have reported that their menopausal symptoms
decreased while taking the following supplements
or herbs: Vitamin C, Vitamin A, Vitamin E, Calcium,
Vitamin D, Ginseng, Black Cohosh (estrogenic),
Chamomile, Natural Soy (contains progesterone)
and Belladonna derivatives.
with any course of therapy, you should consult
an appropriate, licensed healthcare professional
for advisement before undertaking any regimen(s).
is hysterectomy not the right answer?
A hysterectomy may not be your best choice of
treatment for several reasons, not the least
of which is preservation of fertility. If your
main goal in treating your disease is to restore
or preserve your fertility, see a reproductive
endocrinologist specializing in endometriosis
and discuss the situation with him/her prior
to deciding on hysterectomy.
of the best sites I've ever seen regarding Endometriosis
and infertility is Dr. Mark Perloe's online
information resource, www.IVF.com
your disease is not confined to the uterus,
cul-de-sac or ovaries, a hysterectomy will not
likely relieve all of your pain. Endometriosis
located on or around the bowel, for instance,
may not be rendered inactive simply with the
removal of your uterus. Extrapelvic disease,
such as thoracic or sciatic endometriosis, it
will not likely be affected by hysterectomy
thorough excision of all disease from all locations
has been shown to have the most effective success
in disease management.
should never consider hysterectomy if you have
not tried any other treatments for your endometriosis
(i.e. surgical removal, medical therapy, alternative
therapies). If you were diagnosed (but no disease
was removed) at the time of your laparoscopy
and your doctor's only suggestion to you for
treatment is a hysterectomy, please consider
a second - and third - opinion.
treatments for endometriosis
There are other treatment options for endometriosis,
endometrial ablation - usually an outpatient
procedure where electricity is used to burn
away the lining of the uterus. This is done
via hysteroscope, an instrument placed through
the natural opening in the cervix (no incisions
thermal balloon - placement of a plastic
balloon into the uterus through the cervix.
The balloon is then filled with sterile
water and heated to very high temperatures,
destroying the lining of the uterus.
uterine artery embolization - a procedure
that uses angiographic techniques to place
a catheter into the uterine arteries. Small
particles are injected into the arteries,
resulting in the blockage of the arteries.
Generally used, with success, for the treatment
medical therapy - you may wish to try a course
of GnRH or other medical therapy to achieve
possible symptomatic relief. Lupron, Abarelix,
Synarel and Zoladex are examples of medical
alternative therapies - see "Alternative
Approaches to Endometriosis Relief"
for more information.
excision surgery - eradication of all disease
through surgical excision. For in-depth discussions
of this technique, please visit Dr.
David Redwine's website and the Center
for Endometriosis Care's website.
experience with hysterectomy
Unfortunately, even though I benefited greatly
from excision surgery for my endometriosis,
I eventually needed to undergo a hysterectomy
for the treatment of several fibroids and adenomyosis,
both of which had begun to debilitate me.
the time of my hysterectomy, no endometriosis
was discovered (my excision surgery had taken
place a year before). I had removal of the uterus,
both ovaries, both tubes and cervix, and my
after-affects have been mild compared to that
of the previous endometriosis/adenomyosis/leiomyoma
do not take HRT (by choice), but do take lots
of calcium. I do not regret my decision, but
recognize that it is not an option for everyone;
nor would I advise any endometriosis patient
to undergo hysterectomy without exhausting every
other medical and surgical option first.
is not the only, or the most, effective treatment
for endometriosis. Research all of your options
and make an educated decision before undergoing
this irreversible procedure. Your best approach
to managing your endometriosis is teaming up
with an endometriosis specialist and deciding
what is right for your own needs.
(1) "Hysterectomy in the United States,
1980 - 1993;" Centers for Disease Control
and Prevention/National Center for Chronic Disease
Prevention and Health Promotion-Division of
Reproductive Health. 4770 Buford Hwy NE, Mail
Stop K20, Atlanta, GA 30341-3717
(2) Hysterectomy-Novak's Gynecology, Jonathan
S. Berek et al 1996
(3) CDC Division of Reproductive Health, 4770
Buford Hwy NE, Atlanta, GA 30341-3717
(4) Hysterectomy in the US, 1988-1990, L.S.
Wilcox, et al.
(5) Journal of Obstetrics & Gynecology,
C. Guidone is a freelance writer
and researcher with a special interest in women's
health. She has served as the Director of Operations
and an Executive Board Member of the Endometriosis
Research Center, a 501(c)3 non-profit organization
for education, research facilitation and support
since the organization was founded. She is a
member of the American Medical Writer's Association
and the World Endometriosis Society. Heather
resides outside NYC with her family. For more
information, visit: www.hcgresources.com/endoindex.html