What is a hysterectomy?

A hysterectomy is surgical removal of the uterus.  The surgeon can remove the uterus alone (supracervical hysterectomy), or the uterus and cervix (total hysterectomy), or the uterus with the cervix, ovaries, and tubes (total hysterectomy with salpingo-oophorectomy). 

Why do women have hysterectomies?

-Heavy vaginal bleeding that is not controlled by hormonal treatment.  Hormonal treatment includes birth control pills, birth control patch, birth control ring, the progesterone implant (Nexplanon), or the progesterone intra-uterine device (Mirena).
-Heavy vaginal bleeding that is not controlled with or recurs after an endometrial ablation.
-Chronic Pelvic Pain and/or bleeding from Adenomyosis
-Chronic Pelvic Pain from endometriosis
-Heavy bleeding or pain caused by fibroids
-Cancer of the uterus, ovaries, fallopian tubes, or cervix
-Prolapse of the uterus

How is a hysterectomy performed?

The method your surgeon will use to perform the hysterectomy depends on the size of the uterus, the configuration of your pelvis, their skill set, and the reason for the hysterectomy. 

A vaginal hysterectomy may be used if there is uterine prolapse or if their is a problem in which the uterus needs to be removed and the uterud is small enough to fit out the vagina.  The surgeon enters the abdominal/pelvic cavity through the vagina.  This route allows the surgeon to remove the uterus and cervix, and then in the case of prolapse repair the hernias that are present.  The top of the vaginal will be re-attached to strong support structures in the pelvis and the front and back walls of the vagina may be repaired in order to correct cystoceles (bladder bulges into the vagina) or rectoceles (rectal bulges into the vagina).  Also, a sling may be needed to support the urethra to correct stress urinary incontinence.  If there is not prolapse then the uterus and cervix will be removed and the top of the vagina will be closed.  This can be a nice approach because the only incision is in the vagina and therefore is less pain then other approaches.

An abdominal hysterectomy may be done if there is a large uterus or for cancer.  This approach will require an incision in the skin and subcutaneous tissues of the abdominal wall.  The incision may be horizontal like a Cesarean scar or vertical depending on how much visualization is needed in the abdomen.  A vertical scar can allow more room to operate.

A laparoscopic hysterectomy may be done for any of the above reasons except for an initial prolapse surgery.  However, if a woman has already had a hysterectomy and the vagina itself is prolapsing, then a laparoscopic surgery to re-attach the vagina to support structures may be done (laparoscopic sacrocolpopexy).  I personally prefer to take a laparoscopic approach if the surgery is for chronic pelvic pain, adenomyosis, or endometriosis to minimize the size of the abdominal incisions as well as to offer me a thorough examination or the pelvis for causes of pain.  Some gynecologic oncologists will take a laparoscopic approach for cancer surgery.  Some gynecologists will take a laparoscopic approach for fibroid surgery. A laparoscopic hysterectomy can be supracervical (remove the uterus but leave the cervix) or a total laparoscopic supracervical hysterectomy (remove the uterus and cervix).

My Hysterectomy

 Last April I awoke in a hotel room in San Francisco.  I was there for a conference on total laparoscopic hysterectomy.  I looked at the white sheets on the bed and remembered the time over two years before when I awoke in a hotel room in Maui and my sheets were covered in blood.  I was so embarrassed.  I took the sheets off the bed and placed them in a tight ball and left a note asking the maid to change the sheets.  I have a lot of stories like this of unanticipated heavy bleeding that soaked thru my clothes or onto the sheets.  A lot of women have these stories, and we usually put up with this for a long time, and do not recognize this bleeding as unacceptable until someone else tells us that it's not okay.  I am a gynecologist.  I take care of women every day.  I don't take of myself as well as I do others.  I am working on it.  

I was always one of those girls with a longer and heavier period.  My first period at age 12 lasted 10 days.  When I was a senior in high school, I left a school field trip because I was doubled over in pain with cramping.  I took a train home by myself lying on my side in a ball. Sweating with the pain.  The pain passed and I went to a math test that afternoon.  I discovered Advil in college and OB tampons and  managed things well on my own.  I don't think I ever reported any of this to a doctor.

The pain and the period changed when I was about 38.  The cramping was deeper and made me more nauseous.  I was an OB/Gyn resident at the time (I went to medical school @ age 30 after doing a PhD program).  I don't think I'd seen a doctor my whole residency.  I worked 80 to 120 hours a week and the memories mostly surround the medicine (which I loved) and some of the personal interactions with faculty and others (which I did not love).  When I tried to have some tests ordered over the phone, my very lovely doctor called me and asked me to come into the office.

My gynecologist @ home was a lovely Indian woman who was my mother's and my sister's doctor and had delivered my nephew.  She shared an office with her husband who was a gastroenterologist.  There was no TV in the waiting room.  The phones were on very low volume.  There was an alter in the waiting room with Hindu Gods.  Her manner was calm and she was very thorough.  She retired a few years ago and I feel a little at sea.  

I went in for an appointment.  She did a thorough work-up. A 4 cm fibroid was found in my uterus. Fibroid? Me?  I found this a little hard to wrap my mind around.  I was an ob/gyn resident.  I knew how to manage fibroids.  But what was I supposed to do with my own fibroid?  Also, I didn't really think there was going to be an actual explanation for my pain and bleeding.

My doctor and I had a talk, and I decided to manage my period pain and bleeding with birth control pills.  It did help for a while.  However, of course I was a terrible pill taker and would miss pills, and then have spotting, then miss a bunch of pills, and then start over.  Overall I was not that bothered, and although imperfect I could tolerate my periods.  I started doing adventure travel two years later and did not have any wilderness mishaps.  

I saw my doctor for an annual exam.  She thought I should have some follow up because I was not completely well controlled on the pill.  She asked me to see a colleague for an endometrial biopsy and ordered a pelvic ultrasound.  The biopsy was normal (and felt like a hot poker going thru my bladder).  The ultrasound showed that my fibroid was gone.  The colleague put me on a stronger birth control pill.  This is somewhat astounding -- as a physician I am very rigorous and insist on sticking to facts -- I also encourage women to take care of themselves.  I can not believe that I accepted the explanation that my 4 cm fibroid had "disappeared."  I had noticed that the tech who had done my ultrasound at the hospital was wearing a big pink sweatshirt with cats on it.  Don't get me wrong -- I am a crazy cat lady -- but when I start wearing cat sweatshirts to work it will mean it's time to call it a day.
 
I took the pills as best I could remember, because of the sleep deprivation associated with staying up all night to deliver babies.  I did have some heavier bleeding and gushing off and on.  I saw my doctor for an annual exam.  She asked how the pills were controlling the bleeding.  I reported fair.  This time she had ultrasound available in her office.  She had me have an ultrasound right away.  I walked into the room and I knew the tech from the hospital.  I changed and placed the drape over my lap.  She came into the room.  She handed me the probe to place in my vagina.  She started to scan.  I asked her how things looked and was the fibroid 4 cm.  She said no, it was 10 cm.  Holy Crap!  When did that happen?

What to do? What to do?  I decided the next day I was on call I was going to ask every Ob/Gyn I saw what I should do about my fibroids.  I was told that on ultrasound I had a 10 cm submucous fibroid.  This means that the fibroid is partly in the cavity of the uterus.  This explained the gushing and bleeding.  I am a surgeon.  I like surgical solutions.  They are definitive and in my mind cleaner.  To me medical solutions are slow and plodding.  I was leaning towards a hysteroscopic resection of my fibroids.  I knew who the two people were who were most expert in the area (one advantage to my job).  Hysteroscopy would be day surgery.  However, my fibroid was big and would require an expert.  Someone suggested an endometrial ablation.  I did not think that would work for me.  Someone else suggested a uterine artery embolization.  I did not want to have fevers and be passing fibroid pieces or the whole fibroid.  I thought this would happen because my fibroid was submucous.  I ran into another colleague who is very strait forward and she agreed with me -- in my case because of the fibroid size and location I should have surgery.  I decided on the doctor I would go see.  

I went to see my own doctor for a talk.  She had come to the same conclusion.  We also decided I would go on Lupron since I was mildly anemic and gushing.  There was absolutely no room in my job for me to be compromised from a medical problem.  I started Lupron and made my consultation appointment.  

I went to the appointment a few months later.  It got bumped a month due to the doctor's schedule.  I was not bleeding at all on Lupron.  This was fantastic.  I was a little short tempered which created difficulties for me at work.  I was working in a rather chaotic clinic.  I stayed on the Lupron to keep from bleeding.  I knew it would be temporary.  I met with the fellow first at the consultation appointment.  We talked about options.  She mentioned hysterectomy.  I was 42.  No children.  Not ready to shut the door.  She mentioned laparoscopic removal of fibroids.  I did not know people were doing this.  I was very interested.  I had an ultrasound and an office hysteroscopy.  Turned out there was not a large submucous component to my fibroid.  After a discussion of the surgical options I decided on laparoscopic myomectomy.  The surgery was booked for 3 months later.

I had my surgery the Friday of memorial day weekend. It took 4 hours.  It was kind of nice to be a patient.  To just lie there with good pain control and have a nice nurse take care of you.  I could see why some people really like to be patients.  They took out 5 fibroids.  I went home the next morning.  I stayed at my mother's for 4 days.  There was more incisional pain then I expected the first few days.  I took Vicodin 3 times a day at first, but then after 4 days twice a day, then at night after a week.  I was tired.  I decided to go back to work part time on the second week, and full time the third.  The first day back to the hospital when I rounded on surgical patients I had a new appreciation for how they felt.  As the summer went on my energy improved, and when my period returned it was light to normal.  Awesome.

My periods were good for about 5 years.  After a few years I started to have one heavy day (usually the second), but it was tolerable.  Then about 2 years ago I started to have the surprise gushing again.  At the time my sister was dying of a brain tumor.  My sister died in January 2010.  The grief was a heavy cloak. I wanted to go to bed for a year.  The following August I went sea kayaking off of norhtern Vancouver Island. It was a small crack of sunlight in the darkness. I could see my grief, anxiety, and depression as separate entities.  But I of course had a surprise heavy period.  That fall I started to have hot flashes.  I put myself on prometrium.  It helped with the bleeding.  After a while the hot flashes got worse and I added estrogen. Then the periods got worse and I put myself back on a birth control pill.  I saw one of my partners to work up the bleeding.  I had another endometrial biopsy.  It was negative.  I had an ultrasound.  I had a new 2 cm submucous fibroid.  I continued the birth control pills.  

Then the universe decided to scream at me.  That's what happens when you don't listen.  I was seeing patients in August of 2011 and I started to gush.  I went into the bathroom and put on a pad.  I had already soaked thru a tampon.  I saw another patient.  I felt myself gushing more.  I went into the bathroom.  Soaked pad.  I put on three pads -- two next to each other and one over the middle -- my own technique to handle gushing.  I sat down to see patients making sure not to sit on my white coat.  I did not want there to be a blood stain.  I had on a black skirt.  At lunch I had to go home and change.  That night I saw my therapist and described the day and made a vow to take care of myself and make a plan.  I knew telling her would make me act.  I prescribed myself Lupron and gave it to myself that night watching television.  I felt gross from bleeding. 

I knew I needed a hysterectomy.  I knew I wanted a laparoscopic hysterectomy.  But who was I going to ask to do it?   The person I should ask to do it was a senior partner.  Our relationship was very much about him reminding me that he was my senior partner.  I could have gone to a teaching hospital -- but why make such a fuss about something that could be done well locally.   The partner agreed to do my hysterectomy and subbested help from  a consultant from the teaching hospital as an assist.  I agreed. I really liked the consultant -- he is a fantastic surgeon and a really nice person.  I liked the plan.  The surgery was booked for 3 months later.  I took the Lupron.  I was short tempered again.  I figure it was better than bleeding through my scrubs.

I had my hysterectomy in December 2011.   My hysterectomy went well.  Everyone was a little nervous.  I was not.  I also asked to have my ovaries removed.  My surgeons flinched at this.  I do not know why.   I was having hot flashes already and I was turning 50 soon. Both my surgeons, my anaesthesiologist, and my nurse anasthetist were male -- I found this funny.  I enjoyed my overnight stay, and for the first time sleep over in that hospital with people taking care of me instead of me taking care of others.

It's been over a year.  I am taking estrogen for hot flashes.  I definitely need the estrogen.  I feel myself getting very warm on the day I am due to change my patch.  This warmth makes me irritable.  I love not bleeding.  I love traveling and knowing I will not bleed on the sheets or on the beach.  I tried some testosterone and some progesterone.  I did not find that these helped, and I felt that they made me irritable.  My sister died three years ago and my grief has appropriately lifted, and it has been 1 year since my hysterectomy.  My energy is a lot better. I take no medications except my estrogen on a daily basis.  It feels good to be healthy.