Vaginal hysterectomy

Definition

Vaginal hysterectomy is a surgical procedure to remove the uterus through the vagina. Vaginal hysterectomy involves a shorter time in the hospital, lower cost and faster recovery than does the most common alternative, abdominal hysterectomy. However, if your uterus is enlarged, vaginal hysterectomy may not be possible.

Any type of hysterectomy usually includes removal of the cervix as well as the uterus, often along with one or both ovaries and fallopian tubes (salpingo-oophorectomy). All these organs are located in your pelvis and are part of your reproductive system.

Female reproductive system

Female reproductive system

The ovaries, fallopian tubes, uterus, cervix and vagina make up the female reproductive system. ...

Why it's done

Vaginal hysterectomy treats many different gynecologic problems, including:

• Fibroids. Many hysterectomies are done to permanently treat fibroids — benign tumors in your uterus that can cause persistent bleeding, anemia, pelvic pain, pain during intercourse and bladder pressure. If you have large fibroids, you may need an abdominal hysterectomy.
• Endometriosis. Endometriosis occurs when the tissue lining your uterus (endometrium) grows outside of the uterus, involving the ovaries, fallopian tubes or other organs. Most women with endometriosis have an abdominal hysterectomy, but sometimes a vaginal hysterectomy is possible.
• Gynecologic cancer. If you have cancer of the uterus, cervix, endometrium or ovaries, your doctor may recommend a hysterectomy to treat it. Most of the time, an abdominal hysterectomy is done during treatment for ovarian cancer, but sometimes vaginal hysterectomy may be appropriate for women with cervical cancer or endometrial cancer.
• Uterine prolapse. When pelvic supporting tissues and ligaments get stretched out or weak, the uterus can descend or sag into the vagina, causing urinary incontinence, pelvic pressure or difficulty with bowel movements. Removing the uterus with hysterectomy and repairing pelvic relaxation may relieve those symptoms.
• Abnormal vaginal bleeding. When medication or a less invasive surgical procedure doesn't control irregular, heavy or very long periods, hysterectomy can solve the problem.
• Chronic pelvic pain. If you have chronic pelvic pain clearly caused by a uterine condition, hysterectomy may help, but only as a last resort. Chronic pelvic pain can have several causes, so an accurate diagnosis of the cause is critical before having a hysterectomy for pelvic pain.

For most of these conditions — with the possible exception of cancer — hysterectomy is just one of several treatment options. You may not even need to consider hysterectomy unless medications and less invasive gynecologic procedures have failed.

You cannot get pregnant after you've had a hysterectomy. If you're less than completely sure you're ready to give up your fertility, explore other treatments.

Risks

Although vaginal hysterectomy is generally safe, any surgery has risks. These include blood loss or clots, infection, damage to surrounding organs or reaction to anesthesia. Surgical risks are higher in women who are obese or who have diabetes or high blood pressure.

The location of the uterus in the pelvis means there is a risk of injury to other pelvic and abdominal organs during vaginal hysterectomy, including the bladder, ureters or bowel. The risk of organ injury is greater if large fibroids, severe endometriosis or cancer obstructs the surgeon's view or otherwise makes the surgery difficult.

How you prepare

• Gather information. It's normal to feel anxious about having a hysterectomy. Before the surgery, get all the information that you need to feel confident about it. Ask your doctor and surgeon questions. Read information about the procedure and learn all the steps involved if it makes you feel more comfortable.
• Follow your doctor's instructions about medication. Find out whether you should change your usual medication routine in the days leading up to your hysterectomy. Be sure to mention over-the-counter medications, dietary supplements and herbal preparations.
• Discuss what type of anesthesia you'll have. You may prefer general anesthesia, which makes you unconscious during surgery, but regional anesthesia — also called spinal or epidural block — is often an option. If you're having a vaginal hysterectomy, regional anesthesia will block the sensation in the lower half of your body.
• Arrive fasting. It's best not to eat anything but a light supper the night before surgery. A small amount of clear liquid may be all right, but check with your doctor.
• Arrange for help. Although you're likely to recover sooner after a vaginal hysterectomy than after an abdominal one, it still takes time. Be sure to have someone to help at home for the first week or two.

What you can expect

During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it. The uterus is then removed through the vagina.

During vaginal hysterectomy
You may be put under general anesthesia, so you won't be awake for the surgery. If you choose a spinal block (regional anesthesia), you may opt for a medication that makes you drowsy (intravenous sedative) or you may remain awake during your surgery.

Your legs will be placed in stirrups, similar to the position you're in for a Pap smear. Sometimes, a urinary catheter is passed through your urethra to empty your bladder. Your vagina is cleansed with a sterile solution prior to the surgery.

To perform the hysterectomy, the surgeon makes an incision inside your vagina to access the uterus. Using long instruments, the surgeon clamps the uterine blood vessels and separates your uterus from the connective tissue, ovaries and fallopian tubes. The uterus is removed through the vaginal opening, and absorbable stitches are used to control any bleeding inside the pelvis. Except in cases of suspected uterine cancer, the surgeon may cut an enlarged uterus into smaller pieces and remove it in sections (morcellation).

In some cases, your doctor may recommend a laparoscopic-assisted vaginal hysterectomy (LAVH) or robotic hysterectomy. Both procedures allow your doctor to remove the uterus vaginally but also make it possible for your doctor to view your pelvic organs through a laparoscope. Most of the procedure is performed through small abdominal incisions with the use of long, thin surgical instruments inserted through the incisions. The uterus is then removed through an incision made in your vagina. Your doctor might recommend LAVH or robotic hysterectomy if he or she suspects you may have scar tissue (adhesions) on your pelvic organs from prior surgeries or from endometriosis.

There is always a risk that severe endometriosis or pelvic adhesions may force your surgeon to switch from a vaginal to abdominal hysterectomy during the surgery. Your doctor should discuss this possibility with you before the surgery begins.

After the vaginal hysterectomy
After surgery, you'll be in a recovery room for a few hours and in the hospital for one to three days. You'll take medication for pain and to prevent infection. Your health care team will encourage you to get up and move as soon as you're able.

It's normal to have bloody vaginal discharge for several days to weeks after a hysterectomy, so you'll need to wear sanitary pads.

Physical aftereffects
After a hysterectomy, you'll no longer have periods or be able to get pregnant.

If you were still having periods before the surgery and your ovaries were not removed, they will continue producing hormones and eggs until you reach menopause. If your ovaries and fallopian tubes were removed with your uterus, you'll begin menopause immediately after surgery and may experience symptoms such as vaginal dryness and hot flashes. Your doctor may prescribe medications to treat the symptoms.

Recovery after a vaginal hysterectomy is shorter and less painful than after an abdominal hysterectomy. Most women feel better within a week and make a full recovery in one to two weeks. Even if you feel like you're back to normal, don't lift anything over 20 pounds or have vaginal intercourse until six weeks after surgery. Contact your doctor if your pain worsens instead of letting up or if you develop nausea, vomiting or bleeding heavier than a menstrual period.

Emotional aftereffects
After hysterectomy, many women report improved mood and increased sense of well-being. Others enjoy life more because they're no longer experiencing symptoms such as bleeding or pelvic pain. Many report an increase in sexual satisfaction as well — perhaps because they're not afraid of becoming pregnant, or perhaps because, before the hysterectomy, a condition such as uterine fibroids was causing pain during intercourse.

Some women feel a sense of loss and grief after hysterectomy, which is normal. Others may experience depression related to losing the ability to become pregnant. If sadness or negative feelings begin to interfere with your enjoyment of everyday life, talk to your doctor.