Having a hysterectomy

I’m having a hysterectomy. What do I need to know about this operation?

A hysterectomy is the surgical removal of your uterus. It usually also includes the removal of your cervix and may include removal of fallopian tubes and ovaries. In Australia about 1 in every 30 women will need or seek a hysterectomy.

Women choose a hysterectomy for many reasons, including heavy bleeding, pelvic pain and uterine prolapse. Other hysterectomies are done for life-saving reasons such as for cancer treatment or life-threatening uterine bleeding.

There are three different ways gynaecologists perform hysterectomies

1. Total abdominal hysterectomy

The first is an abdominal hysterectomy (AH) that involves an open abdominal incision, usually horizontal just along the bikini like. This is often performed for very large uteruses that have fibroids, or where women have severe abdominal adhesions from previous surgery, severe endometriosis, or infections. Recovery in hospital usually takes 4-7 days and usually women require 6-8 weeks before resuming normal activity. Although less commonly needed today because of the availability of 'keyhole' surgery, sometimes this 'open' surgery is still required. At TasOGS both Dr Connan and Dr Hingston can perform this type of hysterectomy.

2. Total laparoscopic hysterectomy

The second surgical method is the total laparoscopic hysterectomy (TLH) also sometimes called a ‘key-hole’ hysterectomy. This technique is used for hysterectomies where the tubes and/or ovaries are also being removed, where excision of endometriosis is also occurring, and often for women who have not had vaginal births and so a vaginal hysterectomy is not possible. Recovery is hospital is usually 1-3 days and women can often resume normal activity 2-4 weeks after surgery. This type of hysterectomy is best performed by gynaecologists who have additional training in advanced laparoscopy ('key-hole' surgery).

After 5 years of general training Dr Connan spent 18 months at the Royal Women’s Hospital (Melbourne) specialising in endometriosis 'key hole' surgery and laparoscopic hysterectomies. She then worked as a specialist in the same gynaecology team from 2010 to 2013. For the past 7 years laparoscopic hysterectomies have been Dr Connan’s primary method of hysterectomy in those for whom the technique is suitable.

3. Vaginal hysterectomy

The third hysterectomy technique is the vaginal hysterectomy (VH) that requires only an incision in the vagina. This is usually the technique of choice for women with a normal-sized uterus having had previous vaginal births or pelvic floor prolapse. Recovery is hospital is usually 2-3 days and women usually require 6 weeks before resuming normal activity. At TasOGS Dr Hingston performs this type of hysterectomy.

Which surgical technique should I have?

This is best discussed with your gynaecologist. There are differences with surgical risks and differences with recovery among the different methods of hysterectomy, making the choice very dependent on features and characteristics of both patient and uterus. Not all gynaecologists can do all types of hysterectomy.

Are there advantages to a ‘key-hole’ laparoscopic hysterectomy (TLH)?

When compared with a traditional 'open' hysterectomy, a laparoscopic hysterectomy often reduces recovery time, hospital stay, and postoperative pain, but may be associated with a slightly higher risk of complications (in particular urinary tract injuries), particularly when performed by less experienced gynaecologists.

What questions should I ask my gynaecologist?

It is important to understand the reason why you may need a hysterectomy, and if one technique is recommended over another, the reasons why one type of surgery may be more suitable for you.

Every patient and every uterus is different, and what may be suitable for one person may not be the best choice for another.

Other questions that may be helpful to ask include:

• How many hysterectomies have you done? And of this type?
• What is your complication rate?
• How do you manage such complications?
• How long will I stay in hospital?
• When can I drive after surgery?
• When can I have sex after surgery?
• When can I return to all normal activities?
• Do I still need PAP smears?
• Does this influence my menopause?

Although recovery after a laparoscopic or vaginal hysterectomy can be rapid, hysterectomies are still a major operation. Make sure you have all your questions and concerns answered before your surgery.

At TasOGS we strive to make sure you are well informed before any surgical procedure you may require. Please speak to your gynaecologist if you have any further questions or concerns.

Endometriosis – painful or painless?

Period pain – what’s all the fuss about? I must first confess that I have never really had major issues with my periods. When I was young having them was a nuisance on sports day, but other than the social inconvenience, they never amounted to much. After I completed my family I was keen to avoid them, and a Mirena IUD has been my solution – though not necessarily the right solution for everyone.

For many women however, including some of my closest friends, periods have defined, redefined and even destroyed their lives at times.

As a obstetrics & gynaecology trainee my interest in period pain arose from my love of laparoscopic surgery. From this interest I spent 18 months training in advanced laparoscopic surgery at the Royal Women’s Hospital in the Pelvic Pain/Endometriosis unit. After my training I took a specialist role and continued to work in the Unit as a gynaecologist and surgeon. Women from all over Victoria and beyond came with pelvic pain looking to us for answers and solutions for their pain.

Many things can cause pelvic pain

Endometriosis is one of the diseases that can cause pelvic pain. Defined as 'ectopic endometrial tissue' – meaning tissue that's normal found only in the lining of the uterus, shedding once a month to give you your period, is instead also found outside the uterus elsewhere in the pelvis. Endometriosis can be associated with debilitating and life-destroying pain.

Painful periods, pain when you have sex, pain when you open your bowels, pain mid-cycle or all-cycle, spotting before your period, bloating and infertility are just some of the common symptoms that you might experience with endometriosis.

Endometriosis diagnosis & treatment

Diagnosis and treatment of endometriosis is most effectively done with surgery, although we generally start first with simpler interventions.

Ultrasound has improved dramatically over the last few decades, and can now identify endometriosis cysts (endometriomas), and in specialised ultrasound facilities (such as Women’s Imaging in Hobart for Tassie Women) can also find deeply invasive endometriosis.

However because only 5% of  those with with endometriosis will have either endometriomas or deeply invasive endometriosis, many women even with strongly-suggestive symptoms can still have a normal ultrasound. For these women laparoscopic surgery may be required to find answers.

Adding to the myriad of symptoms that women with endometriosis often experience, unfortunately even surgery to remove areas of endometriosis doesn’t always result in complete relief from symptoms or improvement in fertility.

While surgery to excise, rather than simply cauterise, areas of endometriosis is often very effective, we also know that for many women endometriosis will recur in the future, requiring more surgery and the potential risks that that brings.

Endometriosis – an often ignored women's health issue

For many women I’ve met and cared for with endometriosis, their stories of being told ‘you're a woman, it's normal to have painful periods’, ‘just take a panadol’, or ‘it's all in your head’ are sadly all too frequent.

Women with endometriosis are often challenged daily with pain. Their pain is real and often profound. It often impacts every part of their lives. What they need first is acknowledgement and understanding of their condition.

At TasOGS we believe endometriosis is all too often one of the unheard women’s health issues. Considering it effects up to 1 in 10 women, it’s likely that you know someone who is affected but who may have never spoken about it.

If you have symptoms that you think might be related to endometriosis, make sure you talk to your GP. There are many treatments, including both medications and surgery, than can be useful in managing the often debilitating symptoms of endometriosis.

There are also many great websites with more information about endometriosis, including Endometriosis Australia and the Pelvic Pain Foundation of Australia.