Hysterectomy for Endometriosis

Overview

Hysterectomy is surgery to remove the uterus. In cases where a hysterectomy is being performed to treat endometriosis, oophorectomy (removal of the ovaries) and excision of lesions are usually performed too. Hysterectomy and oophorectomy and are considered radical surgeries because you will lose organs and function, unlike in a conservative surgery such as excision alone.

Hysterectomy and oophorectomy cause many permanent changes in the body, including infertility. These surgeries are options for treatment in women whose endometriosis is severe and has not responded to medication or less invasive surgeries such as excision. Oophorectomy and hysterectomy are not appropriate for women who want to have children in the future.

In combination with oophorectomy and complete excision of all endometrial implants, hysterectomy can be a cure endometriosis in some women.

What does it involve?
Take time choosing your surgeon and hospital. Ask each surgeon you consider how many hysterectomies for endometriosis they have performed, and what their rates of success are. Find out details about all of your surgical options, the procedures involved, recovery time, and the risks and benefits associated with each. Do not be afraid to ask questions.

Prepare yourself mentally and psychologically for surgery. Mental preparation might involve reading about the procedure and the changes that will occur in your body after surgery. The more knowledge you have, the better prepared you will feel. Psychological preparation might include speaking with women who have undergone the surgery to gain a more personal perspective on what it entails and how life changes afterward. You can prepare physically by being in the best condition possible before surgery. Eat nutritiously and get plenty of sleep and exercise in the weeks leading up to the surgery. Finally, you can make plans with friends, family or church groups to get help with rides to and from the hospital and help with shopping, housework, and childcare while you are recovering. Do everything you can in advance to reduce stress in the period after the surgery.

You will be asked to stop eating a few hours before surgery. If your surgery might involve removing implants from the bowel, you may need to complete bowel preparation (commonly known as bowel prep) the night before. The bowel prep process can be unpleasant, but it helps prevent complications. Bowel prep involves a few hours on a liquid diet followed by drinking a series of solutions designed to clean out your intestines. You will need to stay near a bathroom and relieve yourself frequently during this process. Consider purchasing soothing wipes or hemorrhoid cream to have on hand during bowel prep.

When you arrive at the hospital, vital signs will be taken, and blood may be drawn. Before surgery, you will receive an intravenous (IV) line and general anesthesia to make you sleep.

Hysterectomy surgery may be performed by laparoscopy (through three or four small incisions), laparotomy (performed through one large abdominal incision), or vaginally. Vaginal surgeries do not involve any incisions, and they may require less time to perform. In women who have not had children, the vaginal canal may not be large enough to permit vaginal surgery. Laparoscopic surgeries tend to be less painful and have faster recovery time than those performed by laparotomy, or abdominal, surgery. The advantage of abdominal surgery is that it allows the surgeon to examine the entire pelvic cavity very carefully for endometrial implants. However, abdominal surgery is more likely to result in post-surgical infection. In general, hysterectomy takes approximately two hours to perform. If your uterus is especially large, surgery requires more time.

Hysterectomy may be total (also called complete), or sub-total. In a total hysterectomy, the uterus and the cervix are removed. In a sub-total hysterectomy, the cervix is retained. Removing the cervix reduces the risk that your endometriosis will recur. However, retaining the cervix provides support for the vagina and avoids certain side effects.

During hysterectomy surgery, the surgeon will also remove the ligaments, nerves, and blood supply associated with the organs they are removing.

If you have deep or extensive endometrial lesions on your bowel, the surgeon may need to resect part of your intestines. In this case, you will spend more time in the operating room and more time recovering in the hospital before you go home.

After surgery, a specialist nurse will teach you how to care for your wound. Recovery at home requires about two weeks for vaginal or laparoscopic surgeries, or six weeks if the surgeon used a wide abdominal incision. You will feel groggy and tired for the first two or three days. You may experience moodiness, feeling blue, anxiety, or nightmares; these should pass after a few days. While you finish your recovery at home, get plenty of rest. Take pain medications as needed. A heating pad may also soothe your sore abdomen. Carefully monitor your incisions (if any) for signs of complications. Call your doctor immediately if you experience swelling or redness in the surgical area. Do not have sex or insert anything into your vagina (also known as pelvic rest) and avoid showers and baths until your doctor has said you can resume your routine. You should be able to resume all of your normal activities after your doctor says healing is complete.

Your surgeon will schedule a follow-up appointment four to six weeks after your surgery. At this appointment, the surgeon will examine your incisions to see how they are healing. They will ask you questions about your recovery and discuss laboratory results for the tissue removed during the surgery.

Intended Outcomes
The goal of hysterectomy surgery is to cure endometriosis by removing all endometrial tissue in the body.

Results
An article published in 2014 reviewed the results of 67 clinical studies spanning from 1980 to 2014 on the incidence of endometriosis pain after hysterectomy. Researchers concluded that endometriosis recurs in 67 percent of hysterectomies if the ovaries are left intact. In cases where the ovaries were conserved, women were six times more likely to experience recurring endometriosis pain and eight times more likely to need further surgery than women whose ovaries were removed. Hormone replacement therapy raises the risk of recurrence after surgery by 3.5 percent. However, researchers point out that the greatest factor in the recurrence of endometriosis after hysterectomy is that surgery failed to excise all endometrial implants.

Constraints
Any surgery carries risks including blood clots, blood loss, infection, breathing problems, scarring, reactions to medication, and heart attack or stroke during the surgery. Short-term complications of surgery for endometriosis can include pain in the surgical area, constipation, diarrhea, bladder or vein irritation, nausea, vomiting, fatigue, nightmares, trouble sleeping, headaches, and shoulder pain from gas trapped beneath the diaphragm. Rarely, surgery for endometriosis could result in damage to surrounding pelvic structures.

Call your doctor if you notice symptoms of infection such as fever, bleeding, swelling, or increased pain at the incision, or severe abdominal cramping and pain. Notify your doctor if you experience chest pain, shortness of breath, discharge from the wound, abnormal or foul-smelling vaginal discharge, pain or swelling in your calves, painful or frequent urination, or vomiting more than 24 hours after the surgery.

Hysterectomy with oophorectomy will cause immediate surgical menopause. You will permanently lose the ability to have children. Since the goal of oophorectomy is to deprive endometrial implants of your body’s main source of estrogen, estrogen replacement therapy (ERT) may not be a good option. You will experience menopause symptoms including hot flashes, cold, clammy feeling, mood swings, irritability, depression, fatigue, anxiety, dread, vaginal dryness, itching, tingling, or electrical zapping sensations in the skin, memory problems, more fragile fingernails, bone loss that can lead to osteoporosis. Menopause symptoms can be more intense in cases of surgical menopause than in natural menopause.

If you receive a total hysterectomy, the top of your vagina where the cervix used to be will be sutured shut. The vagina will be shorter and lose its ability to elongate during sex. Removal of the cervix also makes it more likely that your vagina may prolapse, or descend to or through the vaginal opening. Surgery to correct vaginal prolapse is frequently unsuccessful.

The removal of the ligaments and other support structures associated with the uterus and ovaries also removes part of the support system for the pelvic region. You may experience pain or other issues with your hips, lower back, or spine after hysterectomy. You may lose sensation and blood flow the tissue that remains in the vaginal vault. The remaining pelvic organs may drift down to rest on top of your vagina, increasing the risk of prolapse.

Hysterectomy with oophorectomy may not be effective in relieving your pain from endometriosis. If any endometrial implants are left in your body after surgery, they may still react painfully to other sources of estrogen in the body. Endometrial implants may create estrogen. Fat tissues manufacture estrogen, especially in women who are overweight. Finally, some plant-based foods contain estrogen-like compounds.

Your endometriosis may recur. You may need surgery again in the future to treat new implants.