Introduction Hysterectomy is the removal of the womb either due to structural changes or functional abnormalities. Womb is called the “Uterus” in medical terms and is situated in the lower part of the woman’s body. In its usual position and size, it is not felt either through one’s tummy nor through the vaginal opening. It’s main function is to help embryo (early fetus) and the placenta (structure attached to womb to nourish the baby) to grow and be sheltered inside it, till the baby is mature enough to exist independently after birth. The structure of this uterus therefore is conducive to this primary function it has to perform. Thus it consists of a muscle wall and a special lining called the endometrium. Both these components are responsive to the reproductive hormones released by the ovary and have specific functions to perform such as nurturing of the baby, formation of the placenta and then expulsion of the baby at birth. The muscle is a special smooth muscle which has the capacity to contract and tighten during menstruation to expel the menstrual blood and during delivery to expel the baby and the placenta. This helps in emptying of the womb and control of bleeding. The lining is a special hormone sensitive tissue which prepares itself to accept the embryo. In absence of formation of the embryo the lining is shed off and is called menstruation. Is hysterectomy always necessary ? How can I prevent a hysterectomy ? Hysterectomy may be a desperate decision sometimes by women with a fear of developing serious diseases like cancer. Also they may have misconceptions about alternative treatments which are used to avoid hysterectomy. By alternative methods, we mean, medications or small corrective operative procedures. These can ward off the symptoms and once the menopause sets in, all the problems may resolve. Yes friends, I am one of those fanatics like my innumerable patients, who wants to die with an intact body !!! How can this be accomplished ? Many preventive measures exist. The first one being proper lifestyle practices like diet, attitude and weight management. Birth control measures (to avoid unwanted pregnancies) as repeated miscarriages may cause diseases such as adenomyosis, which may need a
hysterectomy. If systems like LNGIUS are used, it can help prevent abnormalities that lead to hysterectomy. Why then is the uterus removed ? There are many emergency or non emergency reasons for which the uterus is removed. Emergency reasons : Fibroids and polyps are benign tumors of the uterus and cause pain, heavy menstrual bleeding or pressure symptoms for which the uterus may be removed. Diseases such as cancers of the endometrium, ovary or uterine cervix(lowest most part of the uterus ) Infections and heavy bleeding not responding to medical line of treatment . Constant pain in the pelvis which is due to abnormality such as adenomyosis of uterus or inflammation of associated structures not responding to medications. Displacement of the uterus and the vaginal walls outside the body through the vaginal opening ( uterine prolapse ) Heavy menstrual bleeding which is not controlled by medications. Sometimes the womb may be removed as a life saving procedure. Heavy bleeding after childbirth, severely infected uterus as in pelvic sepsis, Injured uterus due to childbirth or miscarriage related procedures are such conditions where an emergency removal of the womb is done ? How is the uterus removed ? It is a surgical procedure performed by experienced gynaecologist under anaesthesia. The anaesthesia can be regional where only the lower body is made numb or general where the entire body is anaesthetised. There are three major approaches to the removal. The approach can be through the tummy by taking a very low bikini incision, the vagina or through the laparoscope. The choice of technique depends on the reason of the hysterectomy for which it is performed, associated other conditions, previous surgeries, condition of the woman in context of the capacity to endure the surgery. Is the procedure safe ? What are the complications ? Hysterectomy is categorized as a major surgery. It is safe, in hands of experts such as gynaecologists who also have good knowledge of understanding of the pelvic floor and can tackle complications and overcome difficult situations. Procedural complications such as anaesthesia related issues, bleeding and injury to the adjacent organs such as the urinary tract or digestive tract, especially the intestines can occur. Proper patient selection, evaluation of the condition and choice of right approach is usually what is followed by us to avoid such a complication. Some
unforeseen complications such as thromboembolism ( release of a blood clot into the lung circulation ) or anaphylaxis ( severe allergies to medications ) can occur very rarely for which we practice surgical checklists and precautions to overcome such errors. Is the surgery performed for cancer conditions same ? What all organs are removed at the time of hysterectomy ? Does it mean that hysterectomy is the end of sexual life ? Are there any post procedure symptoms such as feeling of emptiness or sadness ? Hysterectomy performed for cancer conditions is a super major procedure and is called as a radical procedure and is several times more morbid than the one performed for non cancerous conditions. The uterus with the cervix and the tubes are removed . The ovaries are kept behind if healthy and when the patient is younger. In addition any pelvic floor deformity such as laxity is corrected to restore the urinary, defecation and coital functions. The vagina is kept in such a fashion that the coital activity can be undertaken with safety. The technique of this surgery that we perform is extremely evolved and undertaken in order to avoid any such post procedure problems. We take the woman and her husband through an extensive informative counselling sessions to help them understand the procedure and overcome the psychological hesitancy which may result. Even the catastrophic menopause which may sometimes occur due to removal of the ovaries is dealt with appropriate medicines at the right time. Real life examples Sheila is a 47 years old woman with history of massive fibroids in her womb and has been tolerating menstrual pain and heavy bleeding for the past 2 years. Every time she reports to the hospital and is diagnosed with severe anaemia and is unable to find time for surgery as the husband is in another state. She has stoped responding to even the medications given to help stop bleeding. She has two daughters 18 and 14 years of age. We corrected her anaemia with medications and performed a laparoscopic hysterectomy. Her ovaries were kept behind and the vagina is well suspended. She went home on the third day of the operation and reported very happy at the end of a month. After 2 years now she is absolutely happy, healthy without pain, anemia and bleeding and has a satisfactory married life. Gayatri is 52 years old, diabetic , obese and has undergone angioplasty for a heart condition and needs to take blood thinners. Becomes anaemic on and off due
to uterine bleeding and does not respond to medicines. On proper ultrasonographic evaluation, we found that she has an intra-cavitatory fibroid and therefore we decided to do hysterectomy for her. Abdominal hysterectomy with proper preoperative stabilisation was done. She is perfectly normal since the past 6 months Varsha is now 48 years of age and her uterus juts outside her body and leads to urinary problems, constipation and is a huge hindrance for intimacy. She has been suffering silently for 6 years and finally mustered courage to undergo the vaginal approach hysterectomy. Along with this we repaired her vaginal laxity and she now leads a very normal life. Kishori is a 37 years old woman complaining of painful heavy irregular menstrual bleeding for 6 months. Her local doctor advised her to undergo hysterectomy as she has no desire to have further pregnancies. She consulted me for second opinion. Careful evaluation revealed that she had undergone 2 pregnancy terminations, had anemia and thyroid disorder. Sonography revealed enlarged uterus due to adenomyosis. We corrected her anemia and thyroid disorder and inserted LNGIUS (system loaded with levonorgestrel hormone which is meant for intrauterine placement). It’s been two years since now she is relieved of her symptoms and we have avoided hysterectomy.