Hysterectomy

Max Brinsmead MB BS PhD

May 2015

Indications for Hysterectomy

Fibroids Menstrual dysfunction Prolapse Endometriosis Adenomyosis Pelvic Inflammatory Disease Cancer

Cervix Uterus Ovaries

Alternatives to Hysterectomy

Medical treatment of bleeding problems or endometriosis

Endometrial resection for menorrhagia Myomectomy and uterine artery embolisation

for fibroids Radiotherapy for Ca cervix

A number of RCT’s and systematic analyses compare these alternatives

So clinician-guided and informed patient choice is an important component of best practice

Types of Hysterectomy

Subtotal Hysterectomy Uterine body only

Total Hysterectomy Uterine body and cervix (not ovaries!)

Hysterectomy with BSO Uterus with bilateral salpingo oophorectomy

Radical (or Wertheim) Hysterectomy Total hysterectomy with pelvic lymph nodes,

paracervical tissue and upper 1/3 vagina

Routes for Hysterectomy

Abdominal Hysterectomy (AH) Total Subtotal

Vaginal Hysterectomy (VH)

Laparoscopic Hysterectomy Laparoscopically-assisted vaginal (LAVH) Totally laparoscopic hysterectomy

Which Route is Best? Abdominal Hysterectomy

Results in greatest mean blood loss Has the highest incidence of febrile morbidity And abdominal wound infection (obviously) Longest hospitalisation And slowest to recover

Vaginal Hysterectomy Is the preferred route when technically possible

Laparoscopic Hysterectomy Requires training and equipment Longest operating time But shortest hospitalisation and recovery But has the greatest overall risk of complications There is debate about its cost effectiveness

Complications of Hysterectomy

Infection Abdominal incision Vaginal vault and pelvic Infected haematoma

Blood loss and anaemia Bladder dysfunction or Cystitis Bowel dysfunction Damage to:

Bladder Bowel Ureters

Depression or Sexual Dysfunction Longer Term

Prolapse Wound pain Earlier menopause

“Ball-Park” Risks with Hysterectomy

30 – 40% minor complication rate 1:10 risk of “unpleasant” complication 1:20 risk of transfusion 1:50 risk of serious complication But <1:100 with ongoing problems 1-3:1000 risk of death

Complications are some 1.5-fold more common if there are fibroids

Hysterectomy complication rates from long-term cohort studies

Hysterectomy complications from Cochrane RCT’s

NICE recommendations concerning Hysterectomy for Heavy Menstrual Bleeding

It is not treatment of 1st choice but recommended when… Women who have no wish for future fertility Desires amenorrhoea And is fully informed

Information required… Implications of the surgery Sex & psychological functions Risks and complications in some detail Bladder function Need for further surgery Pros and cons of oophorectomy

NICE recommendations concerning route of Hysterectomy

Factors that influence this decision include… Nature of any gynaecological disease Presence/Size of any fibroids Mobility and descent of the uterus Shape and size of vagina History of any previous surgery

Vaginal hysterectomy (VH) is the route of 1st choice

If oophorectomy is required then Laparoscopically-assisted VH is best

If abdominal hysterectomy (AH) is performed then subtotal (leaving the cervix) is an option

Removal of the Cervix

Is only an option during abdominal hysterectomy Technically more difficult So operative time and blood loss is increased So leave the cervix when things are going badly Some evidence for more bladder problems when

it is left (about 2-fold) Sometimes “mini periods” if it is left (about 7%) 2% risk of cervical prolapse when it is left Main argument for removal is risk of CIN and Ca But the cervix does not have any sexual function

Confirmed by RCTs

Bilateral Oophorectomy during Hysterectomy?

1:80 lifetime risk of ovarian cancer Bilateral oophorectomy reduces the risk of breast Ca Is more important for the woman at risk

e.g. those with BRAC1&2 mutations Up to 1:10 pre menopausal women undergoing

hysterectomy return for surgery to remaining ovaries This can be technically difficult

And PMT-symptoms can be a major problem for a few women

Oophorectomy may be important if there is peritoneal endometriosis

Adds little to operative time and risk during AH But may be quite difficult in up to 30% during VH

Bilateral Oophorectomy during Hysterectomy 2?

The major problem is that of premature menopause And symptoms from a surgical menopause seem to

be more severe Many women feel very strongly about ovarian

removal There is a dearth of information about any endocrine

role for postmenopausal ovaries They continue to produce androgens Which may have a role in well-being and libido And are converted to oestrone by fat cells

Age is one factor that has a major role in deciding about bilateral oophorectomy Below the age of 45 – aim for preservation Above the age of 65 – balance tips in favour of removal

NICE recommendations concerning Oophorectomy during Hysterectomy

Healthy ovaries should not be routinely removed

Oophorectomy should only be performed with a woman’s expressed wishes and consent

If ovarian cycling is thought to be contributing to symptoms then a trial of GnRH for 3-4 months before hysterectomy may be useful

Women who elect to have or require bilateral oophorectomy need advice about… Impact on the risks of ovarian & breast Ca Pros and cons of oestrogen hormone therapy

(ERT)

After Hysterectomy

Most women don’t need Pap smears Except those who had previous CIN >2 , Ca

Cervix or Ca corpus uterus

Oestrogen only HRT (ERT) is an option Except when BSO was performed for oestrogen

responsive cancer or severe endometriosis Symptoms control in these patients can be a real

problem Current research suggests that ERT has many

benefits and few risks

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