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Abstract

Hysterectomy is the most frequently performed major surgical intervention in gynecology. Although surgically removing the uterus is invasive, it represents the most definitive treatment option for heavy menstrual bleeding. In this article, we will discuss the indications for hysterectomy as a treatment for heavy menstrual bleeding, the different approaches to perform the hysterectomy, the complications which may occur during and after this procedure and finally the outcomes in comparison with other treatment options.

Keywords

abdominal hysterectomy laparoscopic hysterectomy oophorectomy robot-assisted hysterectomy salpingectomy subtotal or supravaginal hysterectomy total hysterectomy vaginal hysterectomy

Indications

Hysterectomy is an effective treatment for heavy menstrual bleeding (HMB) but is a major surgical treatment option associated with physical and emotional complications as well as social and economic costs [1]. Recognition of the potential morbidities allied with the availability of less invasive surgical and medical treatment options has resulted in a reduction in rates of hysterectomy for HMB compared with the 1980s, where in the UK, 60% of all secondary care referrals for HMB resulted in hysterectomy [2,3].

Hysterectomy is indicated where there is serious endometrial disease found in association with HMB, namely endometrial hyperplasia with atypia or endometrial cancer. However, most causes of HMB are benign. Thus, hysterectomy is generally reserved as a final, definitive treatment for HMB when medical and uterine sparing surgical options have failed or are contra-indicated.

The decision to perform a hysterectomy should be made in conjunction with the patient, based upon the degree of functional impairment and its impact on her health-related quality of life; response to previous evidence-based medical or surgical therapies; an appreciation of remaining treatment alternatives; plans for future childbearing and a consideration of the relative risk:benefit ratio, which is especially important where surgical risk factors such as obesity and previous abdominal surgery are present or there are other medical co-morbidities.

Technique

Once the decision has been made to proceed with hysterectomy, the gynecologist has to choose together with the patient the most appropriate surgical technique to remove the uterus. There are four different surgical approaches namely an abdominal hysterectomy, a vaginal hysterectomy, a laparoscopic hysterectomy and robot-assisted laparoscopic hysterectomy. In addition to the surgical approach, the patient and her gynecologist need to consider whether to retain the cervix and/or her tubes and ovaries. The characteristics, risks and benefits of each procedure will be discussed in turn.

Abdominal hysterectomy

Definition

The abdominal approach involves a hysterectomy through either a transverse or midline incision in the lower abdomen. The technique is considered the most invasive form of hysterectomy because of the postoperative morbidity associated with a large abdominal incision and prolonged recovery time.

Indications

When it is clear that HMB has a benign cause, the reasons to remove the uterus by the abdominal approach include [4]:

The presence of other pathology in the pelvic area (such as endometriosis or adhesions);

An enlarged uterus limiting surgical access to safely complete a less invasive laparoscopic or vaginal hysterectomy.

Vaginal hysterectomy

Definition

The vaginal approach involves a hysterectomy through the vagina, without an abdominal incision. The first elective hysterectomy in history was one performed through a vaginal approach in 1863 [5].

Contra-indications

Absolute contra-indications for the vaginal approach include [6]:

A suspected malignancy in the pelvic area (except endometrial carcinoma);

Pelvic adhesions;

An inability to properly position the patient for vaginal access (e.g., in severe arthritis).

Historically there have been additional contraindications described for the vaginal approach to hysterectomy, but recent studies do not support these any longer. The first one is the lack of uterine prolapse or descent, for example, in nulliparous women [7,8]. Even though operation time in such women is increased and the complication rate is higher, successful removal without the need for conversion to other approaches is similar for vaginal hysterectomies in nulliparous and multiparous women [8]. However, lack of mobility due to normal pelvic support should be distinguished from uterine immobility due to dense adhesive disease, the latter being a definite contra-indication to the vaginal route [6]. Uterine size and weight should also not be a criterion for avoiding the vaginal approach since vaginal morcellation is an effective option to facilitate surgical access [9]. However, vaginal hysterectomy is not possible when access to the uterine arteries is limited by the size of the uterus relative to that of the pelvis and the operating surgeon should make this assessment.

It is often suggested that previous surgery in the pelvic area, for example, a previous cesarean section, should be a contra-indication for vaginal hysterectomy because of concerns about scarring in the lower uterine segment leading to an increased risk of bladder trauma and excessive bleeding. However, this contention is not supported by the available evidence [4,10 –12]. Thus, only in the rare case of dense adhesion between bladder and cervix, for example, due to infection after surgery, will the vaginal route be contra-indicated. Similarly, the vaginal route should not be considered contra-indicated where oophorectomy is required. Several clinical trials have shown that as many as 95% of ovaries can be removed vaginally, although laparoscopic assistance may be required in some instances [8,13 –15].

Comparison with other approaches

Most important benefits of the vaginal hysterectomy compared with the abdominal approach are the quicker return to normal activities, shorter stay in hospital, fewer infections and less risk of injury to the ureter [4,16]. In obese patients requiring hysterectomy, the vaginal route is the preferred approach, because it is associated with lower postoperative morbidity compared with abdominal hysterectomy [17 –19]. A disadvantage of this procedure is the greater risk of bladder or bowel injury in comparison with the abdominal hysterectomy [4,16], although the rate of these complications is also influenced by the surgeon's experience.

Laparoscopic hysterectomy

Definition

The laparoscopic approach involves a hysterectomy via ‘keyhole surgery’ utilizing small incisions in the abdominal wall. A laparoscope is inserted most commonly through the umbilicus to provide visualization and the uterus is removed using surgical instruments inserted through two or three additional small incisions. More recently, single-port laparoscopic hysterectomy has been described where the hysterectomy is performed via a single umbilical incision using specialized access ports and often specially adapted hand instruments [20]. The laparoscopic route to achieve hysterectomy is becoming more popular with advances in instrumentation and proficiency in endoscopic surgical skills [21].

The laparoscopic hysterectomy has further subdivisions depending on the part of the procedure performed laparoscopically [4,22]:

Total laparoscopic hysterectomy (TLH) where the entire operation is performed laparoscopically. The first TLH was carried out in 1993;

Laparoscopically assisted vaginal hysterectomy (LAVH) where part of the procedure is undertaken laparoscopically and the rest by way of the vaginal approach. The first LAVH was performed in 1989 [23,24]. Some surgeons term an LAVH a laparoscopic hysterectomy (LH) when the laparoscopic contribution to the hysterectomy includes ligation of the uterine vessels. It has not been substantiated which one of the laparoscopic methods is preferred [4,22].

Contra-indications

Contra-indications for the laparoscopic approach include [24]:

Medical conditions that do not permit a pneumoperitoneum;

A uterine size or shape which makes it impossible to access the uterine arteries;

Extensive pelvic-abdominal adhesions.

Comparison with other approaches

Compared with abdominal hysterectomy, the laparoscopic hysterectomy leads to quicker return to normal activities, causes less blood loss and a smaller drop in blood count, a shorter stay in the hospital and fewer wound infections. However, the main disadvantage is the greater risk of damaging the bladder or ureter. Operating times are also longer with the laparoscopic approach [4].

Comparison of TLH with the vaginal approach shows almost similar outcomes. However, operating times are longer with laparoscopic surgery [4,25]. Differences in postoperative pain are unclear; some literature points at less postoperative pain in the laparoscopic approach [25,26] but there is also evidence for the contrary [4]. There is also an increased rate of urinary tract injury after TLH compared with vaginal hysterectomy [4].

Robot-assisted laparoscopic hysterectomy

In the past few years, interest has increased in robotically assisted laparoscopic hysterectomy (RH). Currently, there is no evidence pointing toward RH rather than LH. Robotic surgery involves higher costs [27] and it seems to be associated with an increased risk of vaginal cuff dehiscence [28].

Selecting the optimal technique

The optimal technique for hysterectomy in HMB is unclear because there are few data from large, randomized controlled trials (RCTs). In general, vaginal hysterectomy is the preferred method for removal of the uterus because this route is associated with fewer complications, shorter length of hospitalization, more rapid return to normal function and lower social economic costs than abdominal hysterectomy [4,29]. However, vaginal hysterectomy is not always technically feasible or desirable for example when vaginal access or uterine descent is limited; where bilateral oophorectomy is required; adnexal masses are present; the uterus is large and adhesions or other pelvic pathologies are apparent. Laparoscopic hysterectomy with or without robotic assistance can overcome some of these obstacles and failing that recourse to conventional abdominal hysterectomy.

In scrutinizing trends in hysterectomy between surgeons, hospitals, health regions and countries, it is clear that specific patient characteristics and the risks and benefits of particular types of hysterectomy are not the only factors determining the route of hysterectomy. The surgeon's experience and preference for the different techniques is important as is the type of health service gynecologists practice in [4].

Type

When the gynecologist together with the patient has decided to perform a hysterectomy, they have to decide three more things; will the cervix be removed – subtotal versus total hysterectomy; will a bilateral oophorectomy be required and will a bilateral salpingectomy be required?

Subtotal versus total hysterectomy

The uterus consists of two parts: the uterine body and the cervix. A total hysterectomy involves the removal of both the uterine body and the cervix whereas a subtotal or supracervical hysterectomy involves the removal of the uterine body only [30]. The proposed benefits of subtotal hysterectomy are improved outcomes for sexual, urinary or bowel function, because by retaining the cervix the supporting structures of the uterus and vagina, in other words, the cardinal and uterosacral ligaments and their innervation, remain intact. This may translate into a reduction in the risk of uterine prolapse and fewer urinary, bowel and sexual symptoms in the long term. However, the evidence for this contention is lacking. Proven benefits of subtotal hysterectomy include a significantly shorter operation time and reduced blood loss although there does not appear to be a reduction in the requirement for blood transfusions [30].

A decision to leave the cervix in situ should only be made after a review of the woman's cervical screening history and confirmation that she has no symptoms or signs of cervical abnormality. The risk of developing stump carcinoma of the cervix is estimated to be around 0.3% [31]. Women undergoing subtotal hysterectomy must be fully aware of the need for on-going compliance with the existing cervical screening program [30]. They also need to be aware of the possibility of cyclical vaginal bleeding after surgery, which is estimated to affect 7% [32].

Hysterectomy with or without oophorectomy

Prior to hysterectomy it is important that women have made an informed decision about whether or not to undergo a bilateral salpingo-oophorectomy (BSO). Removal of the ovaries has significant ramifications for women of reproductive age because of the consequences of estrogen deficiency or subsequent ovarian malignancy.

In women undergoing a hysterectomy for HMB, a BSO is generally performed when malignant ovarian disease is suspected and this should have been anticipated after diagnostic work up and discussed with the woman prior to surgery. However, most women undergoing BSO at the time of hysterectomy have normal ovaries. In this situation, the main reason for BSO is to decrease the risk of ovarian cancer [33,34], given the fact that approximately 1.43% of women will develop ovarian cancer in their lifetime [34,35], with an associated mortality of 0.47% by age 80 [34,36]. Out of those, 4–14% had had prior hysterectomies in which the fallopian tubes and ovaries were retained in their medical history [34,35], representing a potential missed opportunity for disease prevention. Another reason to choose BSO is to prevent possible future surgical interventions for ovarian cysts, most of which are benign. It has been reported that retention of the ovaries during hysterectomy contributes to re-surgery because of adnexal pathology in 2.75–5% of women [34,37–38].

Removing the ovaries can of course have adverse effects. Estrogen deficiency causes troublesome vasomotor and urogenital symptoms which can reduce health-related quality of life. A BSO in women of reproductive age also eliminates the beneficial effect of estradiol on bone metabolism and the cardiovascular system [33,34]. While the implications of a BSO in postmenopausal women are reduced, the ovaries still produce a small amount of testosterone which will be converted into estrogen in fat, muscles and other peripheral tissues [34,39]. The clinical significance of this androgen production is unclear. Estrogen replacement therapy can be prescribed but controversy continues about the potential harms to women including venous thromboembolism, ischemic stroke and cardiovascular disease [34,40]. Thus, when making a decision for BSO, risk factors for potential complications should be taken into account and these include breast and ovarian cancer, coronary heart disease, osteoporotic hip fracture, noncompliance to hormone replacement therapy [34]. In addition, patient characteristics should be considered in decision making such as the woman's age, presence of menopausal symptoms, associated gynecological conditions (e.g. endometriosis, chronic pelvic pain, history of ovarian cysts) and family history of gynecological malignancies.

Hysterectomy with or without salpingectomy

Another option is to combine hysterectomy with bilateral salpingectomy. Reason is to prevent re-intervention for malignant or benign fallopian tube pathologies. Literature showed that the incidence of benign adnexal pathologies is higher after hysterectomy without salpingectomy compared with hysterectmy in combination with salpingectomy (26.9 vs 13.9%; p = 0.02). This also leads to a higher surgical re-intervention rate, namely 12.56 vs 4.16%; p = 0.04 [41].

There is also literature which shows that the fallopian tube epithelium which implants on the ovary might be the source of low- and high-grade serous carcinoma. This suggests that bilateral salpingectomy possibly might reduce the risk of low- and high-grade serous carcinoma of the ovaries [42].

Until now there has been no evidence that prophylactic salpingectomy reduces the incidence of neoplasm of the ovaries or fallopian tubes [41].

Outcomes

Hysterectomy provides permanent relief from HMB in contrast to uterine sparing surgery such as endometrial ablation where up to 38% required further treatment because of ongoing excessive bleeding [43,44]. The effectiveness of hysterectomy in alleviating HMB translates into high satisfaction rates which are generally around 95% up to 3 years following surgery [44 –46]. An individual patient data meta-analysis using both direct and indirect comparisons of patient satisfaction outcomes at 12 months compared hysterectomy with the levonorgesterol-releasing intrauterine system (LNG-IUS) and first- and second-generation endometrial destructive techniques for HMB. This literature review found hysterectomy to be more effective [46]. Moreover, while hysterectomy is the more expensive and necessitates prolonged recovery compared with these less invasive medical and surgical therapies, it avoids the need for re-treatment over the longer term because of on-going HMB symptoms. This observation and the higher reported rates of patient satisfaction goes some way to explaining the greater cost–effectiveness of hysterectomy compared with the LNG-IUS and endometrial ablation which was found following a model-based economic analysis using individual patient data obtained from a systematic review of the literature [46,47].

However, In comparison to less invasive interventions for HMB, namely medical treatments, hysteroscopic surgery and endometrial ablation, hysterectomy has a relatively high incidence of short-term complications, such as hemorrhage, infection and wound healing problems [44]. A large population-based study of almost 80,000 hysterectomies performed for benign indications showed the following complications: hemorrhage (2.4%), genitourinary disorders (pelvic organ prolapse, urinary retention or ureteral injury) (1.9%), urinary tract infection (1.6%) and other infections (1.6%) [48]. Short-term complications such as hemorrhage and infection are also associated with hysteroscopic surgery such as endometrial resection but the overall incidence is lower at around 4% [49]. Another disadvantage of hysterectomy is the relationship with early ovarian failure. A prospective cohort study showed an association between hysterectomy with or without unilateral oophorectomy and an earlier onset of the menopause in comparison with woman who had no hysterectomy [44,50]. There have been suggestions that there is probably a relation between hysterectomy and cardiovascular function, but there is no strong evidence for this.

Conclusion

Hysterectomy is indicated for women who have no future fertility requirement and have HMB caused by benign pathologies where other treatment options have failed or are contra-indicated. Recovery times are longer and short-term complications greater post-hysterectomy compared with medical and intrauterine surgery. However, hysterectomy represents the most effective and potentially cost-effective treatment option for HMB. Vaginal hysterectomy should be the default route for hysterectomy, but laparoscopic and abdominal approaches are preferable in many cases according to pelvic pathology, individual patient factors, the experience of the surgeon and preferences of both patients and surgeons. There appear to be no proven benefits for performing subtotal hysterectomy compared with total hysterectomy. The decision to provide a prophylactic bilateral salpingectomy or BSO at the time of hysterectomy should be discussed with the patient in advance balancing the perceived risks and benefits of these additional procedures.

Executive summary

Hysterectomy as a treatment option for heavy menstrual bleeding is an invasive procedure which has to be reserved for women for whom other treatment options have failed or are contra-indicated.

Hysterectomy can be performed in four different surgical approaches; abdominal, vaginal, laparoscopic and robot-assisted.

Vaginal hysterectomy should be the default route for hysterectomy, but laparoscopic and abdominal approaches are preferable in many cases according to pelvic pathology, individual patient factors, the experience of the surgeon and preferences of both patients and surgeons.

There appear to be no proven benefits for performing subtotal hysterectomy compared with total hysterectomy.

Risks and benefits to provide a prophylactic bilateral salpingectomy or bilateral salpingo-oophorectomy at the time of hysterectomy should be discussed with the patient in advance.

Footnotes

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

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Hysterectomy for Heavy Menstrual Bleeding

Abstract

Keywords

Indications

Technique

Abdominal hysterectomy

Definition

Indications

Vaginal hysterectomy

Definition

Contra-indications

Comparison with other approaches

Laparoscopic hysterectomy

Definition

Contra-indications

Comparison with other approaches

Robot-assisted laparoscopic hysterectomy

Selecting the optimal technique

Type

Subtotal versus total hysterectomy

Hysterectomy with or without oophorectomy

Hysterectomy with or without salpingectomy

Outcomes

Conclusion

Footnotes

References