Hysterectomy (Removal of the Uterus): Reasons, Types, Procedure and Recovery

In short: Hysterectomy is the second most common gynaecological operation after caesarean section. The main reasons are fibroids (30% of cases), endometriosis (20%), prolapse of the uterus, bleeding that does not respond to treatment and cancer. It may be total, partial or radical, and is done through the vagina, the abdomen or by laparoscopy. The stay in hospital is 2–4 days, with a return to activity in about 6–8 weeks.

The uterus (womb) has two main functions:

• It is the site where pregnancy occurs.
• It is the source of monthly bleeding (menses).

This means that after a hysterectomy, a woman will no longer be able to become pregnant and will no longer have periods. Many patients feel understandably anxious before this surgery, and it’s completely normal to want clear, honest information about what to expect.

Indications for Hysterectomy – Removal of the Uterus

Generally, hysterectomy is recommended for women who have already tried conservative treatments without lasting relief. However, the following conditions often make hysterectomy the most appropriate option:

• Fibroids account for about 30% of hysterectomy cases.
• Endometriosis and adenomyosis account for around 20% of cases.
• Uterine prolapse.
• Uterine bleeding that does not respond to medical therapy, balloon diathermy, or a Mirena coil accounts for around 20% of cases.
• Uterine, ovarian, and cervical cancers account for around 10% of cases.
• Chronic pelvic pain.
• Uncontrollable postpartum hemorrhage.

Types of Hysterectomy – Removal of the Uterus

Hysterectomy can involve removing the uterus alone, or the uterus together with the ovaries and fallopian tubes, depending on the patient’s individual condition.

In women who have not reached menopause, healthy ovaries are usually kept, because removing them brings on early menopause and increases long-term risks to the heart and bones. Removing the fallopian tubes at the same operation (salpingectomy) is often recommended, as many ovarian cancers are now thought to begin in the tubes.

There Are Three Main Types of Hysterectomy

• Total hysterectomy, which includes removal of the cervix — this is the most common type of hysterectomy.
• Subtotal hysterectomy, which preserves the cervix and is mainly used for uterine fibroids or to manage abnormal bleeding patterns.
• Radical hysterectomy, which includes removal of the cervix, the upper part of the vagina, and surrounding parametrial tissue. This type of surgery is performed only in cancer cases.

Although the overall number of hysterectomies has declined over the years, 55% are performed on women between the ages of 35 and 49.

Approaches for Hysterectomy

The most suitable approach for hysterectomy is determined by:

• The patient’s specific condition
• The experience of the surgeon

The Approaches for Removal of the Uterus Include

• Vaginal hysterectomy: performed through an incision in the vagina. This approach is associated with less pain, no visible scar, a shorter hospital stay, and faster recovery (around 4 weeks). When it is technically possible, it is considered the preferred approach for benign conditions, as it has fewer complications overall than abdominal surgery; its suitability depends on the size and mobility of the uterus.
• This approach is particularly suitable in cases of uterine prolapse — especially when other repairs (such as a rectocele or enterocele repair) are planned — and for women with a uterus of normal or moderately enlarged size. It is not used for cervical cancer, which needs a specialised radical operation.
• Abdominal hysterectomy: performed through an incision in the lower abdomen that may reach up to 20 cm in length. This approach is usually chosen for very large fibroids, some ovarian and cervical cancers, and when other approaches are not suitable; many early endometrial cancers are now treated laparoscopically.
• **[**Laparoscopic hysterectomy:** a camera is introduced through three or four small openings in the abdomen; the freed uterus is usually removed through the vagina or, if it is large, cut into smaller pieces inside a protective bag, because cutting it up without a bag could spread an unsuspected cancer.
• Laparoscopic-assisted vaginal hysterectomy: the uterus is released using the laparoscope and then removed vaginally. Hospital stay is typically just one day, with a recovery time of around two weeks.

Before undergoing hysterectomy, it’s a good idea to ask your doctor about:

• The risks of the operation
• Alternative treatments for your condition
• Whether the following tests are needed to help determine the best approach:
• Pap smear (to rule out cervical cancer)
• Endometrial biopsy or hysteroscopy (to rule out uterine cancer or hyperplasia when there is abnormal bleeding)
• Pelvic ultrasound (to assess the size of fibroids, polyps, or ovarian masses)

Risks of uterus removal surgery:

Hysterectomy is considered one of the safest operations in gynecology. Like any surgery, it carries some risk of complications during or after the procedure, but for most patients, the benefits outweigh the risks.

These potential complications include:

• Wound infection
• Internal bleeding
• Urological and bowel injuries
• Deep venous thrombosis and pulmonary embolism
• Anesthesia-related complications
• Paralytic ileus

Preparing for Surgery to Remove the Uterus

Patients undergoing hysterectomy are usually admitted on the day of the operation or the day before. Hair is not shaved (if needed it is trimmed with clippers, which lowers infection risk), and a dose of antibiotic is given shortly before surgery to help reduce the risk of infection.

The operation is performed under general anesthesia and may last between 1 and 2 hours. After the patient is intubated, a Foley catheter is inserted into the urinary bladder, followed by cleaning and draping of the surgical area.

After surgery, patients are monitored in the recovery room for a few hours to check vital signs, and will receive pain relief (pain levels vary and tend to be greatest after abdominal hysterectomy).

Patients are encouraged to begin moving around about six hours after the operation, once the Foley catheter has been removed, to help reduce the risk of blood clots.

Hospital stay is usually 1–2 days after vaginal or laparoscopic hysterectomy and about 2–4 days after abdominal hysterectomy.

Some light spotting after surgery is normal, as long as it does not resemble menstrual-type bleeding — if this occurs, please contact your doctor promptly.

Most patients can gradually return to daily activities 6 to 8 weeks after surgery. During this recovery period, it’s important to:

• Avoid heavy work
• Avoid lifting heavy weights
• Avoid sexual intercourse and vaginal douching
• Avoid constipation
• Care for the wound with proper dressing, and inform your doctor if redness or swelling develops
• Follow your doctor’s guidance regarding daily activities
• Discuss with your doctor whether hormone replacement therapy is needed if the ovaries were removed

Life After Hysterectomy

• Amenorrhea (no more periods)
• Relief from the bleeding and abdominal pain experienced before surgery
• No possibility of pregnancy
• If the ovaries are removed along with the uterus, menopausal symptoms such as hot flashes, nervousness, vaginal dryness, sleep disturbances, and osteoporosis may occur. In these cases, hormone therapy may be recommended.
• Sexual life is generally not negatively affected. Some women who previously felt uterine contractions during intercourse may notice this sensation disappear, while others report increased enjoyment once pain and bleeding are resolved.
• Women who undergo subtotal hysterectomy should continue routine Pap smears to screen for cervical cancer.
• Many patients feel a renewed sense of confidence once their previous symptoms are resolved, while others may experience feelings of emotional loss — these feelings are valid and worth discussing with your doctor.
• Urgency or urge incontinence may occur and can sometimes require medical treatment.

Partial Hysterectomy

In a partial hysterectomy, only the body of the uterus is removed, while the cervix and ovaries are preserved. This can be performed abdominally, vaginally, or laparoscopically.

Patients who choose this option should continue regular cervical screening (HPV test or Pap smear) at the intervals recommended for their age.

Advantages

• Shorter operating time
• Slightly quicker recovery in some women (studies have not shown better sexual or bladder function compared with total hysterectomy)
• No vaginal cuff, so no risk of vaginal shortening or cuff granulation tissue

Disadvantages

As with any surgical procedure, partial hysterectomy carries some potential downsides:

• Pain and wound infection
• Anesthesia-related complications
• Possible damage to internal organs, such as the bladder, bowel, or ureters
• Emotional adjustment
• Hormonal changes: in some women the ovaries may stop working a little earlier than expected after any hysterectomy, which can bring menopausal symptoms sooner.
• The risk of cervical cancer remains, since the cervix is preserved.

Some women (roughly 5–20%) continue to have light monthly bleeding from the remaining cervix, and a small number later need a further operation to remove it.

If you have questions about hysterectomy or would like to discuss which approach may be right for you, the team at Dr. Najeeb Layyous’s clinic is here to help guide you through your options with care and clarity.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist