Hysterectomy

When a hysterectomy may be recommended

A hysterectomy is an operation to remove the womb (uterus). Afterwards you no longer have periods and cannot become pregnant, so it is a permanent step, and a decision I never rush. It may be one option, among several, for:

• fibroids (non-cancerous growths of the muscle of the womb) that cause heavy bleeding, pain or pressure;
• adenomyosis (tissue similar to the lining of the womb growing into its muscle wall), which causes heavy, painful periods;
• heavy periods that have not improved with other treatments;
• endometriosis (similar tissue growing outside the womb) with severe symptoms, alongside removal of the endometriosis itself;
• some pre-cancerous changes, such as atypical hyperplasia (a pre-cancerous thickening of the lining of the womb).

It is only suitable if you are sure you do not want a pregnancy in the future, and it is usually considered when other treatments have not helped or are not right for you. I will give you my honest view, and the decision is yours.

Alternatives to consider first

Depending on the cause, and on whether you hope to become pregnant, the alternatives include:

• a hormone-releasing coil (a small device placed in the womb that releases a hormone), which makes periods much lighter for many women;
• medicines that reduce bleeding, and hormone treatments that lighten or stop periods;
• endometrial ablation (a short procedure that destroys the lining of the womb), if you do not want a future pregnancy and the womb is not much enlarged (contraception is still needed afterwards);
• removing fibroids while keeping the womb (myomectomy), often by robotic surgery, or removing fibroids and polyps (small growths of the lining) from inside the womb with a slim telescope passed through the vagina (hysteroscopy);
• uterine artery embolisation (blocking the blood supply to fibroids so that they shrink), carried out by a specialist radiologist, to whom I can refer you;
• surgery to remove endometriosis while keeping the womb;
• waiting, if you are close to the menopause, after which fibroids usually shrink and periods stop.

You can read more on the fibroids, adenomyosis, endometriosis and hysteroscopy pages.

Choices about the cervix, tubes and ovaries

The cervix

In a total hysterectomy the womb and the cervix (the neck of the womb) are both removed; in a subtotal hysterectomy the cervix is kept. Keeping it has not been shown to make a difference to sex, or to bladder or bowel function. If you keep it, you will need to continue cervical screening, some women go on having light monthly bleeding, and in a keyhole operation the womb usually has to be removed by contained morcellation (described below). Keeping the cervix is not usually advised after abnormal cervical screening results or pre-cancerous changes in the womb.

The fallopian tubes

The fallopian tubes carry eggs from the ovaries to the womb, so after a hysterectomy they no longer have a role. Removing them at the same operation (salpingectomy) may lower the risk of ovarian cancer, because some ovarian cancers are thought to begin in the tubes.

The ovaries

If you have not reached the menopause and your ovaries are healthy, I usually advise keeping them. They carry on producing hormones, so the menopause does not start straight away, although your periods stop. Even so, the menopause can come somewhat earlier than it otherwise would.

If the ovaries are removed before the menopause, the menopause starts straight away (a surgical menopause), whatever your age. HRT (hormone replacement therapy) is then usually advised, at least until around 51, the average age of the menopause, to ease symptoms and help protect your bones, unless there is a reason you should not take it.

Removing the ovaries may be worth considering if they are affected by disease, such as severe endometriosis, if you have a high inherited risk of ovarian cancer, or if you are close to or past the menopause.

How I carry out a hysterectomy

I usually carry out a hysterectomy by keyhole surgery, under a general anaesthetic. Keyhole surgery is either laparoscopic, in which I hold the instruments directly, or robotic, in which I control them from a console beside you using the da Vinci system. Through a few small incisions, I free the womb from its attachments, protecting the bladder and the ureters (the tubes that carry urine from the kidneys to the bladder), and remove it through the vagina. The top of the vagina (the vaginal vault) is then closed with stitches. For most women, keyhole surgery means less pain, a shorter stay in hospital and a quicker return to normal life than open surgery. It is not suitable for everyone, and I will tell you honestly whether it suits you.

When the womb is not enlarged, or has dropped down (prolapse), a vaginal hysterectomy (removing it entirely through the vagina, with no incisions on the abdomen) can be a good choice.

Larger wombs and contained morcellation

A womb too large to come out through the vagina in one piece can be cut into smaller pieces inside a protective bag, and removed through the vagina or one of the small incisions (contained morcellation).

Occasionally, a womb that appears to contain only fibroids also contains a sarcoma (a rare cancer of the muscle of the womb): according to the RCOG, in between about 1 in 300 and 1 in 1,250 women under 50, and more often with age. Scans, and sometimes a sample of the lining of the womb, help me to assess the risk, but no test before surgery can rule out every rare cancer of this kind. If a sarcoma is cut into pieces, cancer cells could spread inside the abdomen and make the cancer harder to treat. The bag reduces the risk of spreading tissue, although it cannot remove that risk completely.

Patient information from the Royal College of Obstetricians and Gynaecologists (RCOG) advises against morcellation for women over 50 or after the menopause, when an unexpected cancer is more likely. Your age, whether you have reached the menopause and any worrying findings on your scans or tests all affect whether morcellation is suitable. If it is not, we will discuss the alternatives, such as removing the womb in one piece through a larger incision.

Open surgery

Open surgery (an abdominal hysterectomy, through a larger incision in the lower abdomen) is rarely needed in my practice, although it can be the safer choice for a very large womb. Since 2013, more than 99% of my abdominal operations have been keyhole rather than open, and my conversion rate from keyhole to open surgery has been around 0.1% (about these figures).

Robotic surgery for a large or complex womb

For many straightforward hysterectomies, laparoscopic and robotic surgery give similar results, and I use both. For complex operations, the Royal College of Obstetricians and Gynaecologists concluded in 2022 that robotic surgery can be considered safe and a more effective tool than conventional keyhole surgery, with fewer conversions to open surgery, including for women with a BMI of 30 or more (RCOG Scientific Impact Paper No. 71). When the womb is large or unusually shaped, when earlier operations have left scar tissue that binds organs together (adhesions), or when there is severe endometriosis, I prefer robotic surgery. In my experience it helps in three ways:

• a magnified, three-dimensional view, so that I can see and protect the bladder, bowel and ureters;
• instruments with wrist-like joints, for precise stitching deep in the pelvis, such as closing the top of the vagina;
• a steady, comfortable position at the console, which matters during a long, complex operation.

Laparoscopic surgery remains a good option for many women, and I will explain which approach I recommend, and why. My robotic operating lists run at Spire St Anthony's Hospital in Sutton and Nuffield Health Parkside Hospital in Wimbledon.

Risks of the operation

A hysterectomy is a major operation, and all surgery carries risks. Serious complications are uncommon, and I will explain how each applies to you. The main risks are:

• bleeding, which occasionally needs a blood transfusion;
• infection of the wounds, the bladder or the top of the vagina;
• injury to the bladder, bowel or ureters;
• blood clots in the legs or lungs (venous thromboembolism), made less likely by early walking, compression stockings and, for some women, blood-thinning injections;
• the top of the vagina opening up, which is rare and usually needs an operation to repair;
• conversion to open surgery, if that becomes the safer option;
• the risks of a general anaesthetic, which your anaesthetist will discuss with you.

You will have full written information well before your operation.

Recovery

I give each patient a personal plan for recovery in writing. As a guide, after a keyhole hysterectomy:

• most women stay one night in hospital and are walking comfortably within a few days;
• desk-based work is usually possible after two to four weeks, and physical work takes longer;
• heavy lifting and sex should wait for around six weeks, while the top of the vagina heals.

Light bleeding can continue for a few weeks, and recovery after open surgery takes longer. I will explain the results of the laboratory examination of the womb (histology). Many women feel relief after a hysterectomy, and some also feel a sense of loss, even when the decision was right for them.

If you have heavy bleeding, a fever, worsening pain, a painful or swollen calf, or difficulty passing urine after you go home, contact the hospital ward straight away, using the number on your discharge letter, or call NHS 111. In an emergency, such as chest pain or sudden breathlessness, call 999. For non-urgent questions, my secretary, Helen, can help.

Cervical screening afterwards

Your cervical screening should be up to date before a hysterectomy. Afterwards:

• after a total hysterectomy, most women no longer need cervical screening, provided previous results were normal and no abnormal cells are found when the cervix is examined in the laboratory;
• if you have had abnormal cervical cells in recent years, or any are found after the operation, you may need tests from the top of the vagina (vault smears) for a time, which I will explain;
• if you keep your cervix, you continue routine cervical screening as before.

How I can help

At your first consultation, which lasts about 30 minutes, I will go through your symptoms and the treatments you have tried and, with your permission, examine you. I can scan you during the consultation at Parkside Hospital and the CRP Clinic; at Spire St Anthony’s and Ashtead Hospital, I arrange a scan at the hospital and see you again to go through the results.

Consultations are in English or Arabic, in person or by video. If you already have scans or reports, my secretary, Helen, can send you a secure link to upload them. You can read about fees and insurance and where I see patients, or book an appointment.