Histerektomy indication

Hysterectomy is the most common non–pregnancy-related major surgery performed on women in the United States. This surgical procedure involves removal of the uterus and cervix, and for some conditions, the fallopian tubes and ovaries.

Reasons for choosing this operation are treatment of uterine cancer and various common noncancerous uterine conditions such as fibroids, endometriosis, prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Although this procedure is highly successful in curing the disease of concern, it is a surgical alternative with the accompanying risks, morbidity, and mortality that an operative procedure carries and it leads to sterility in women who are premenopausal. The patient may be hospitalized for several days and may require 6-12 weeks of convalescence. Complications, such as excessive bleeding, infection, and injury to adjacent organs, also may occur.

Frequency

Approximately 600,000 hysterectomies are performed annually in the United States, with a cost of approximately $5 billion per year.

The US Centers for Disease Control and Prevention (CDC) estimated 3.1 million US women had a hysterectomy from 2000-2004.

• The hysterectomy rate decreased slightly from 5.4/1000 in 2000 to 5.1/1000 in 2004.
• From 2000-2004, rates of hysterectomy differed by age. Overall rates were highest among women aged 40-44 years and lowest among women aged 15-24 years. Hysterectomy rates among women aged 50-54 years decreased significantly from 8.9/1000 in 2000 to 6.7/1000 in 2004.
• Hysterectomy rates also differed by geographic region. The overall rate was highest for women living in the South (6.3/1000) and lowest for those in the Northeast (4.3/1000). Hysterectomy rates in the Northeast decreased from 4.9/1000 in 2000 to 3.7/1000 in 2004.
• From 2000-2004, the most common medical reasons for undergoing a hysterectomy included benign fibroid tumors, endometriosis, and uterine prolapse. Uterine cancer was not as common but is an important reason for undergoing a hysterectomy.
• The proportion of hysterectomies with an indication of uterine leiomyoma decreased from 44.2% in 2003 to 38.7% in 2004.

The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13% in 1995 and then steadily declined to 3.9% in 2003 (p for trend < 0.001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (p for trend < 0.001).

Indications

Reasons for choosing hysterectomy are treatment of uterine cancer, ovarian cancer, some cases of cervical cancer, and various common noncancerous uterine conditions like fibroids, endometriosis, uterine prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress

Relevant Anatomy

Various hysterectomy procedures are available, including the following:

• Total abdominal hysterectomy involves removal of the uterus and cervix through an abdominal incision.
• Supracervical or subtotal hysterectomy is removal of the uterus through an abdominal incision, while sparing the cervix.
• Radical hysterectomy is extensive surgery that, in addition to removal of the uterus and cervix, might include removal of lymph nodes, loose areolar tissue near major blood vessels, upper vagina, and omentum.
• Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical removal of the ovary and salpingo-oophorectomy is the removal of the ovary and the fallopian tube.
• Vaginal hysterectomy is removal of the uterus and the cervix through the vagina.
• Laparoscopy-assisted vaginal hysterectomy is vaginal hysterectomy with the help of laparoscopy.

The uterus is the inverted pear-shaped female reproductive organ that lies in the midline of the body, within the pelvis between the bladder and the rectum. It is a dynamic female reproductive organ that is responsible for several reproductive functions, including menses, implantation, gestation, labor, and delivery. It is responsive to the hormonal milieu within the body, which allows adaptation to the different stages of a woman’s reproductive life. The uterus adjusts to reflect changes in ovarian steroid production during the menstrual cycle and displays rapid growth and specialized contractile activity during pregnancy and childbirth. It can also remain in a relatively quiescent state during the prepubertal and postmenopausal years.

The ovaries are small, oval-shaped, and grayish in color, with an uneven surface. The actual size of an ovary depends on a woman’s age and hormonal status; the ovaries, covered by a modified peritoneum, are approximately 3-5 cm in length during childbearing years and become much smaller and then atrophic once menopause occurs. A cross-section of the ovary reveals many cystic structures that vary in size. These structures represent ovarian follicles at different stages of development and degeneration

Medical Therapy

Although hysterectomy is often the definitive treatment for many pelvic pathologies, nonsurgical alternatives should always be attempted in elective cases.

Hormonal therapy, gonadotropin-releasing hormone antagonists, progesterone-containing IUD, endometrial ablation, focused ultrasonographic surgery, cryotherapy, and uterine artery embolization have been used with success.

In the 6 states studied, the diffusion of endometrial ablation has had a varying impact on hysterectomy rates among women with benign uterine conditions. However, endometrial ablation is used as an additive medical technology rather than a substitute.