Vaginal Hysterectomy

What is a hysterectomy?

A hysterectomy is an surgical procedure to remove a woman's uterus, or womb.   The uterus is where a baby grows when a woman is pregnant.   In some cases, the ovaries and fallopian tubes also are removed.   Currently, the majority of hysterectomies performed are abdominal hysterectomies, in which a large incision is made in the abdomen and the uterus and sometimes other organs are removed.  However, there are some advantages to a vaginal hysterectomy which we will soon explore.

The Uterus

The uterus protects and nourishes a fetus from conception to birth, and aids in the delivery of the baby. It also produces the monthly menstrual flow, or period.

If the egg that is released during a woman's normal monthly cycle is not fertilized, the lining of the uterus is shed by bleeding, or menstruation.

After a hysterectomy, a woman can no longer have children and menstruation stops. The ovaries generally continue to produce hormones, although in some cases they may have reduced activity.

What is a vaginal hysterectomy?

With a vaginal hysterectomy, the surgeon makes an incision inside and near the top of the vagina. The surgeon then reaches through this incision to cut and tie off the ligaments, blood vessels, and fallopian tubes.  Once the uterus is cut free, it is removed through the vagina.   The procedure normally takes one to two hours. The hospital stay is usually one to two days, and return to normal activities takes about one to two weeks.

Since the uterus is removed through the vagina, a vaginal hysterectomy is appropriate only for conditions in which the uterus is not too large, and in which the whole abdomen does not require examination using a more extensive surgical procedure.   In addition, the woman will need to have her legs raised up in a stirrup device throughout the procedure.   Women who have not had children may not have a large enough vaginal canal for this type of procedure.  If a woman’s uterus is too large, if she cannot have her legs raised in the stirrup device for prolonged periods, or if she has other reasons why the whole upper abdomen must be further examined, the surgeon will usually recommend an abdominal hysterectomy. 

The advantages of this procedure are that it leaves no visible scar and is less painful. The disadvantage is that it is more difficult for the surgeon to see the uterus and surrounding tissue. Large fibroids usually cannot be removed using this technique. It is very difficult to remove the ovaries during a vaginal hysterectomy, so this approach may not be possible if the ovaries are involved. 

When Hysterectomy is Recommended

In most cases, a hysterectomy is only performed for serious medical conditions, and after all nonsurgical options have been explored.   Some of the most common reasons for a vaginal hysterectomy are:

• Fibroids - Common non-cancerous (benign) tumors of the uterus and they are the most frequent reason for recommending a hysterectomy.  They are made up of muscle and fibrous tissue, and grow from the muscular wall of the uterus.   Many women have fibroids and are unaware of it because they have no symptoms.
  In some women, however, the fibroids may cause heavy bleeding, pelvic discomfort and pain and sometimes pressure on other organs.
• Prolapse – This sometimes occurs as a woman ages. The vaginal supports begin to lose their tone and sag downward or prolapse.  When this happens, the bladder or rectum may also be pulled downward.  If the prolapse worsens, some women experience problems in controlling bladder or bowel functions, and other difficult symptoms. 
• Persistent vaginal bleeding – A hysterectomy is sometimes recommended for women whose periods are extremely heavy, irregular or last for many days each cycle, and cannot be controlled by nonsurgical methods. 

Advantages of Vaginal Hysterectomy

In cases where a vaginal hysterectomy is an option, it is usually preferred by the patient.  There are several advantages to choosing a vaginal hysterectomy over an abdominal hysterectomy.  Following are some of them:  

• The vaginal hysterectomy is typically less painful than abdominal hysterectomy.  There is also less of a risk of infection.  
• In general, recovery from vaginal hysterectomy takes less time than abdominal hysterectomy procedures. You will likely be able to walk around the day of your surgery and will go home within one or two days. 
• Most women are able to return to normal activities within one to two weeks. You should avoid lifting heavy objects for four to six weeks and avoid vaginal intercourse for four to six weeks.
• The scars are not visible.

Risks of Hysterectomy

All surgical procedures involve risks, including infections and complications related to anesthesia.  Women who smoke, are obese, or have serious heart or lung disease are at higher risk of complications.  As with any major procedure, serious complications such as blood clots, severe infection, adhesions, postoperative hemorrhage, bowel obstruction or injury to the urinary tract can happen.  Rarely, even death can occur.

In addition to surgical risks, there may be longer-term physical and psychological effects, potentially including depression and loss of sexual pleasure.  If the ovaries are removed along with the uterus prior to menopause, there is an increased risk of osteoporosis and heart disease as well. In making a decision, you should also consider that a hysterectomy is not reversible. After a hysterectomy, you will no longer be able to bear children and you will no longer menstruate. You need to think about the impact these changes would have on you.

The  Procedure

Your surgeon will discuss how to prepare for your operation.   For example, if you smoke you may be asked to quit, as smoking will increase your risk of getting a chest or wound infection and slow your recovery.   You may be asked to stop taking oral contraceptives or hormone replacement tablets four weeks before your operation.   If you are sexually active and have not gone through menopause, you should use an alternative method of birth control during this time to prevent pregnancy.

The operation is done under general anesthesia, which means you will be asleep during the procedure.  You will be asked not to eat or drink for at least six hours before the procedure.   During a vaginal hysterectomy, the vagina is stretched and kept open by special instruments. There are no external incisions made, although there is an internal incision at the top of the vagina around the cervix.   The uterus and cervix are then cut from their supporting ligaments and surrounding tissue, and then the connecting blood vessels are tied off.   They are removed through the vagina, which is then closed to prevent infection and to keep the intestines from dropping downward.

Recovery

A vaginal hysterectomy usually requires a hospital stay of one to two days.  You should follow your physician’s recommendations as to when you can resume your normal activities. 

After the Procedure

Each woman reacts differently, both emotionally and physically.  For example, many women report an increase in enjoyment of sex, especially if they had a lot of bleeding and pain before surgery.   Some women feel more relaxed  because they don’t have to worry about getting pregnant.   On the other hand, if the ovaries were removed prior to natural menopause, the loss of hormones can cause vaginal dryness and make sexual relations uncomfortable.  There are several options available to treat this condition, such as hormone replacement therapy or using a vaginal lubricant.  

In addition, some women report having a strong negative emotional reaction after a hysterectomy. Most feel better after a few weeks, but some women feel depressed for a long time.   Other women experience a feeling of relief after a hysterectomy. Losing the ability to bear children can cause emotional distress for some women. Some women feel they have suffered a loss, and may grieve and go through depression.   Talking things over with your healthcare provider, your partner, a friend or a counselor often helps.   It may help to talk with a friend or another woman who has had a hysterectomy before and after your operation.

Remember

A hysterectomy is an irreversible surgical procedure.  You should explore all of your options and be aware of all of the risks, benefits and possible effects of the surgery before scheduling the procedure.  A vaginal hysterectomy usually results in less stress to your body as well as a shorter recovery time.  Your physician is the best person to determine if a vaginal hysterectomy is an option for your particular case.