Hysterectomy

Epidemiology of fibroids

Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of gynecological visits. ^[2]  These benign uterine tumors increase in size and frequency as women age but revert in size after menopause. Factors that contribute to fibroid growth include estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and transforming growth factor-beta. ^[3]

The frequency of fibroid appearance in African American women is 2-3 times higher than in White women. Women who are obese or who experience menarche when younger than 12 years are at increased risk of fibroid development due to prolonged exposure to estrogen. Women who have had children are at a lesser risk for fibroid development than are women who have never been pregnant. ^[4]

Each fibroid arises from a single monoclonal cell line from the smooth-muscle cells of the myometrium. ^[5] Most (60%) fibroids are chromosomally normal. The rest have nonrandom chromosomal abnormalities that can be separated into 6 cytogenic subgroups, which are trisomy 12, translocation between chromosome 12 and 14, rearrangements of the short arm of chromosome 6 and the long arm of chromosome 10, and deletions of chromosomes 3 and 7. ^[6]

Asymptomatic fibroids are relatively slow growing and characterize most of the tumors found in patients. Previously, uterine size (consisting of asymptomatic fibroids) equivalent to 12 weeks' gestation (280 g) had been the standard threshold for recommending a hysterectomy. Thus, asymptomatic fibroids of smaller size were handled via observation, with an annual pelvic examination and/or transvaginal ultrasonography.

Currently, surgical procedures are not recommended for fibroids based on uterine size alone in the absence of symptoms. According to Reiter et al, no increased incidence in perioperative morbidity existed posthysterectomy in those women with a fibroid uterus larger than 12 weeks' gestational size compared to those women with a fibroid uterus smaller than 12 weeks' gestational size. ^[7] They concluded that hysterectomy for a large asymptomatic fibroid uterus may not be needed as a means of preventing increased operative morbidity associated with future growth, unless a sarcomatous change is observed.

In patients who experience symptoms with fibroids, the symptoms are related to the size, location, and number of fibroids within the uterus. As many as one third of patients with symptomatic uterine fibroids experience abnormal bleeding, cramping, and prolonged and heavy menstrual periods, which can result in anemia. The growth of fibroids to large sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic pain or pressure, pain during sexual intercourse, reduced urinary capacity due to increased bladder pressure, constipation due to increased colon pressure, and infertility or late miscarriages. ^[3]

Epidemiology of endometriosis

Endometriosis is responsible for approximately one fifth of hysterectomies, and it affects women during their reproductive years. ^[8] It is a disease in which tissue similar to the endometrium is present outside the endometrial cavity (in other areas of the body). Such sites include all the reproductive organs, bladder, intestines, bowel, colon, and rectum. Other sites may include uterosacral ligaments, the cul-de-sac, pelvic sidewalls, and surgical scars. This ectopic endometrial tissue responds to monthly hormonal stimulation and, thus, breaks down and bleeds into the peritoneal cavity when located there, causing internal bleeding, inflammation of the surrounding areas, and formation of scar tissue. Scar tissue then can become bands of adhesions that are capable of distorting internal anatomy. Patients also may experience symptoms of pelvic pain; pain during bowel movements, urination, and sexual intercourse; and infertility or miscarriages.

Currently, no cure exists for endometriosis. Although many women seek hysterectomy for pain relief, it does not provide a definite cure because some women in whom one or both ovaries are preserved may continue to experience problems with endometriosis that was left behind.

Epidemiology of pelvic relaxation

Genital prolapse is the indication for approximately 15% of hysterectomies. Various stresses on the pelvic muscles and ligaments can cause significant weakening and, thus, uterine prolapse. The prime cause of insult to the pelvic support structures is childbirth. Therefore, multiple pregnancies and vaginal deliveries increase the risk for uterine prolapse. A few less dramatic causes of increased pelvic pressure include straining during bowel movements, chronic coughing, and obesity. Also, significant pelvic structure weakening occurs postmenopause because estrogen, which pelvic tissues need to maintain their tonicity, is not present in significant amounts after menopause.

Women with mild pelvic relaxation may be free of symptoms. However, patients with moderate-to-severe relaxation may experience symptoms that include heaviness and pressure in the vaginal area; low back pain, leakage of urine, which can worsen during heavy lifting, coughing, laughing, or sneezing; urinary tract infections; retention of urine; and problems with sexual intercourse. ^[8] Although several techniques that provide temporary improvement and control of pelvic relaxation exist, in moderate-to-severe situations, hysterectomy may provide a more functional and longer-lasting results.

Epidemiology of cancer of reproductive organs

Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in the United States, with an estimated 67,880 new cases in 2024. ^[9] It affects women aged 35-90 years, with a mean age of 62 years. Cancer begins in the lining of the endometrium and can spread to other reproductive organs and to the rest of the body.

Stage 1 endometrial cancer is confined to the corpus, or body, of the uterus. Symptoms may include bleeding between periods or, as is in most cases, spotting in patients after menopause. Stage 1 endometrial cancer is very slow growing and highly curable. A hysterectomy is the preferred method of treatment. Not only is the uterus removed, but the ovaries and fallopian tubes also are removed because ovaries are a possible site for more cancer, or they may secrete hormones that play a synergistic role in the growth of the cancer. Surgical menopause due to bilateral oophorectomy compared to natural menopause does not increase all-cause, cardiovascular, or cancer mortality. ^[10] Only in cases of early endometrial cancers in women who are in their second or early part of the third decade of life are attempts made to preserve the ovaries.

In stage 2 endometrial cancer, the cancer has spread to the cervix. Approximately 13,820 new cases of cervical cancer are diagnosed annually in the United States. ^[9]  Symptoms of cervical cancer include bleeding between periods, bleeding postmenopause, or bleeding after sexual intercourse. In some cases, radical hysterectomy (removal of the uterus, cervix, top portion of vagina, ovaries, fallopian tubes, and tissues in the pelvic cavity surrounding cervix) may be the treatment of choice, along with chemotherapy or radiotherapy if needed.

In stage 3A endometrial cancer, the cancer has spread to the ovaries and fallopian tubes. This may be treated with a TAH and bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries), along with chemotherapy or radiotherapy if needed. In stage 3B, the cancer has spread to the vagina. In this case, a vaginectomy or radical hysterectomy must be performed, along with chemotherapy or radiotherapy if needed. By stage 3C, the cancer has entered the lymph nodes. In this case, lymph node dissection and hysterectomy is the treatment of choice, along with chemotherapy or radiotherapy if needed.

United States statistics

Approximately 600,000 hysterectomies are performed each year in the United States. In 2021, the percentage of women aged 18 years or older who had undergone a hysterectomy was 14.6%, according to the US Centers for Disease Control and Prevention (CDC). Non-Hispanic Black women were most likely to have had a hysterectomy (16.3%), followed by non-Hispanic White women (15.6%), Hispanic women (12.5%), and Asian women (6.1%). ^[11]

Other statistics on hysterectomy in the United States are as follows ^[12] :

• The hysterectomy rate remained stable from 21.4% in 2006 to 21.1% in 2016.

• From 2006-2016, rates of hysterectomy differed by age. Overall rates were highest among women aged 70-74 years and lowest among women younger than 35 years. Hysterectomy rates among women aged 50-54 years decreased from 28.1% in 2006 to 24.7% in 2016.

• Hysterectomy rates also differed by geographic region. In 2016, the overall rate was highest for women living in the South (24.6%) and lowest for those in the Northeast (15.6%). Hysterectomy rates in the Midwest increased slightly from 21.0% in 2006 to 21.7% in 2016; slight declines occurred in all other regions.

• From 2006-2016, hysterectomy rates increased slightly from 23.2% to 24.2% among non-Hispanic White women and decreased slightly from 22.6% to 21.7% among non-Hispanic Black women, and from 13.2% to 12.8% among Hispanic women. For those aged 50 years and older, rates of hysterectomy were significantly higher among non-Hispanic Black women than among non-Hispanic White and Hispanic women.

Indications

Reasons for choosing hysterectomy are treatment of uterine cancer, ovarian cancer, some cases of cervical cancer, and various common noncancerous uterine conditions, such as fibroids, endometriosis, uterine prolapse, and adenomyosis. These common noncancerous conditions can lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Contraindications

Vaginal hysterectomy is contraindicated in only 10-20% of cases, eg, uterine size greater than 280 g, previous multiple abdominal or pelvic surgeries, advanced uterine or cervical malignancies, and ovarian malignancies.

Various hysterectomy procedures are available, including the following:

• Total abdominal hysterectomy involves removal of the uterus and cervix through an abdominal incision.

• Supracervical or subtotal hysterectomy is removal of the uterus through an abdominal incision, while sparing the cervix.

• Radical hysterectomy is extensive surgery that, in addition to removal of the uterus and cervix, might include removal of lymph nodes, loose areolar tissue near major blood vessels, upper vagina, and omentum.

• Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical removal of the ovary and salpingo-oophorectomy is the removal of the ovary and the fallopian tube.

• Vaginal hysterectomy is removal of the uterus and the cervix through the vagina.

• Laparoscopy-assisted vaginal hysterectomy is vaginal hysterectomy with the help of laparoscopy.

• Total laparoscopic hysterectomy is complete removal of the uterus and cervix with the assistance of a laparoscope and laparoscopic instruments. The specimen is either removed vaginally or through a laparoscopic port. The vaginal vault is then closed laparoscopically.

The uterus is the inverted pear-shaped female reproductive organ that lies in the midline of the body, within the pelvis between the bladder and the rectum. It is a dynamic female reproductive organ that is responsible for several reproductive functions, including menses, implantation, gestation, labor, and delivery. It is responsive to the hormonal milieu within the body, which allows adaptation to the different stages of a woman’s reproductive life. The uterus adjusts to reflect changes in ovarian steroid production during the menstrual cycle and displays rapid growth and specialized contractile activity during pregnancy and childbirth. It can also remain in a relatively quiescent state during the prepubertal and postmenopausal years.

The ovaries are small, oval-shaped, and grayish in color, with an uneven surface. The actual size of an ovary depends on a woman’s age and hormonal status; the ovaries, covered by a modified peritoneum, are approximately 3-5 cm in length during childbearing years and become much smaller and then atrophic once menopause occurs. A cross-section of the ovary reveals many cystic structures that vary in size. These structures represent ovarian follicles at different stages of development and degeneration.