Hysterectomy is a surgical operation to remove all or part of the uterus, and sometimes its appendages (ovaries and fallopian tubes). Because the uterus is inseparable from maternity, hysterectomy is performed in very specific situations, after careful consideration of the patient.

Hysterectomy is the surgical removal of the uterus. As a reminder, the uterus is this organ which, during pregnancy, receives the embryo and then the fetus. Outside of pregnancy, this small muscle is the cause of period bleeding.

Depending on the age of the patient and the indication for the operation, there are different types of hysterectomy:

• subtotal hysterectomy: the body of the uterus is removed, but not the cervix;
• total hysterectomy: body and cervix are removed;
• total hysterectomy with salpingo-oophorectomy (with bilateral annexectomy or total non-conservative hysterectomy): body of the uterus, cervix, ovaries and tubes of Falote are removed;
• radical hysterectomy: total hysterectomy is followed by ablation of the upper 1/3 of the vagina and pelvic lymph nodes.

The operation can be performed under general or locoregional anesthesia (epidural or spinal anesthesia), depending on the operating technique used. There are actually several depending on the route used:

Abdominal hysterectomy (or laparotomy)

An incision is made in the abdomen, usually at the upper limit of pubic hair (Pfanenstriel incision). This method is used in particular in the event of a large uterus;

Vaginal hysterectomy

The uterus is removed through an incision located deep in the vagina. This technique is indicated in cases of small to medium size uterus, exteriorized genital prolapse and benign pathology;

The laparoscopic hysterectomy

Small incisions of 5 to 10 mm are made in the abdomen in order to breathe CO2 gas into the abdominal cavity and to introduce surgical instruments;

Celio-vaginal hysterectomy

Laparoscopy and vaginal route are combined.

The surgeon chooses the most suitable method according to the type of hysterectomy, the size of the uterus, the age and the morphology of the patient.

Different pathologies can lead to proposing a hysterectomy to the patient:

• fibroids: these benign, hormone-dependent masses that develop in the lining of the uterus are common, especially after 40 years. The vast majority do not cause any disorder but sometimes, certain fibroids (particularly the submucosal membranes) are the cause of heaviness in the lower abdomen, dyspareunia (pain during sexual relations) and bleeding periods. When it is not possible to remove only the fibroids (by operative hysteroscopy or myomectomy), a hysterectomy may be offered to the woman if she does not want any more children.
• endometriosis: this disease is characterized by the proliferation of endometrium (uterine tissue) outside the uterine cavity. When this tissue grows on the uterine muscle, it is called adenomyosis. Endometriosis and adenomyosis can cause severe pain, especially during menstruation or during sexual intercourse. A hysterectomy can be offered to the woman if this pain strongly impacts her quality of life, if the treatments are no longer effective and when she no longer wishes to have a child. Note, however, that some women choose hysterectomy without ever having had a child, as the impact of the disease on daily life is important.
• uterine prolapse: age and pregnancy can lead to prolapse, more commonly known as “organ descent”. In the event of significant discomfort and / or advanced stage of prolapse, and if the woman does not wish any more children, a hysterectomy may be proposed.
• gynecological cancers: in case of uterine cancer, a hysterectomy is systematically performed. It may also be necessary for cancer of the cervix, ovaries or fallopian tubes, depending on the severity of the cancer.
• bleeding complications of childbirth: in the event of failure of conservative measures to stop bleeding during delivery, a so-called hemostatic hysterectomy can be performed. However, this scenario remains quite rare. 

The days following the operation

Hospitalization lasts 3 to 6 days. Analgesics are administered intravenously the first few days, then orally. Anticoagulant injections are also given to prevent phlebitis.

It is generally possible to get up the day after the operation.

Vaginal bleeding is normal the days after the operation. The threads or staples are removed after 1 week on average.

A sick leave is prescribed for 2 to 4 weeks, depending on the type of hysterectomy. During convalescence, sport, carrying heavy loads, sexual intercourse, bathing and wearing a tampon are prohibited. In addition, it is important to consult when faced with these different signs of complication: profuse vaginal bleeding, fever, severe abdominal or vaginal pain, pain when urinating, redness or discharge from the scar, calf pain, difficulty in breathing.

Does hysterectomy always lead to menopause?

Any hysterectomy stops menstruation since it corresponds to the evacuation of the uterine lining in each cycle in the absence of pregnancy. On the other hand, hysterectomy does not necessarily lead to menopause: it all depends on whether the ovaries are preserved or not. Total hysterectomy with salpingo-oophorectomy and radical hysteroctemia effectively lead to a so-called surgical menopause. In the absence of contraindications, hormone replacement therapy for menopause can be started as soon as you leave the hospital to avoid climacteric disorders (hot flashes, weight gain, night sweats, irritability, vaginal dryness, decreased libido. …)

Subtotal and total hysterectomy, called conservative, do not lead to menopause: the woman will continue to experience the symptoms of the cycle (painful breasts, changing mood, etc.) but without the rules, and will be menopausal naturally.

What about sexuality after a hysterectomy?

Physiologically, there is no reason for hysterectomy to decrease desire and pleasure. It is sometimes even the opposite when it makes it possible to put an end to pain on penetration, in the case of fibroids for example. However, hysterectomy can have a psychological impact in women, because the uterus has a strong feminine symbolism. It is therefore important to take this aspect into account and to encourage the patient to put this difficulty into words, if necessary with a psychologist.