A large number of women from my mother’s era had no clue what was involved in getting a hysterectomy. Today, we are lucky – there are now varying degrees of a hysterectomy, as well as different techniques that are commonly used to perform the surgery. While it’s great to have options, that means its essential for any woman who is thinking about getting a hysterectomy to take the time to learn the differences and discuss each technique with your doctor. I believe that women should keep their bodies as whole as possible, as long as doing so does not interfere with their health, comfort and safety. That’s why I encourage women to opt for the least invasive technique that is available to them. To help you make an informed decision, let’s go through the different procedures, and what each one involves.
In a total hysterectomy, the entire uterus and cervix are removed (ovary status is officially referred to separately). Total hysterectomy can be done abdominally (abbreviated TAH), most often with an incision made along the bikini line. In more emergent situations, a vertical type of incision is made through the abdominal wall from the belly button to the pubis. This type of surgery requires more downtime and healing time than others. TAH can also be performed through the vagina, with no large incision through the belly. If this method is an option, it may be one to consider, as the healing time will be less.
The newer and more sophisticated procedures use laparoscopy to assist in the hysterectomy procedure. In laparoscopic hysterectomy, the organs are visualized and manipulated through a laparoscope, and the uterus is removed either through the vagina (laparoscopically assisted vaginal hysterectomy, or LAVH) or through a small incision in the stomach.
Whether they use the vagina or the small incision in the abdomen depends on the size of the uterus and issues that are requiring the surgery to begin with. The incisions are tiny (~½”, beneath the belly button and on the lower pelvis/abdomen, beneath the bikini line). You may have several small incisions that tend to heal very quickly.
This type of surgery lends itself to a much quicker recovery, with far less disruption of the bowel and pelvic floor architecture. It is best performed by a laparoscopic specialist, someone who does this type of surgery often, as not all surgeons are skilled at this. Factors in choosing this method include the reasons for doing the surgery, the patient’s anatomy, and the surgeon’s preference. If you have a strong preference as to which method is used, be sure to communicate this to your surgeon.
While doing a hysterectomy, a surgeon may also remove the ovaries and fallopian tubes. This is called a bilateral salpingo-oophorectomy, or BSO. (Together with a total abdominal hysterectomy this is referred to as a TAH/BSO). Sometimes this is not decided until the time of the surgery, but you should discuss the possibility ahead of time. There are numerous considerations to make before you consent to this surgery, mainly because of the artificial onset of menopause due to loss of your natural sex hormones. Again, the decision depends on the individual problems that are at issue here. If this is the only choice available to you, know that it’s possible to regain your hormonal balance with the help of excellent support measures and a healthy lifestyle.
Young women who must undergo a BSO should seriously consider suitable estrogen replacement for several health benefits. The younger you are, the more important it will be to consider replacement. We try to suggest bioidentical transdermal estradiol options when needed — complemented with bioidentical progesterone and nutritional supplements. When supplemented properly many young women can feel excellent post-surgery.
In a partial or subtotal (supracervical = above the cervix) hysterectomy, the ovaries and/or cervix are left whole. These procedures, too, can be performed abdominally, vaginally, or laparoscopically. Regrettably, a lot of women don’t know these options exist, and aren’t made aware of them by their practitioners. Several doctors take out the cervix automatically as a precaution against cervical cancer.
At our practice, we’ve seen that the benefits of retaining your cervix (more sexual enjoyment and sounder inner pelvic architecture) outweigh the relative risks. Remember, if you do choose to keep your cervix, you will need to continue normal annual screenings and Pap tests.
Here at the clinic, we typically refer women for a laparoscopically-assisted supracervical (partial) hysterectomy (LASH, or LSH). We suggest women try to keep their ovaries (no BSO) if at all possible, however this is case dependent as well. Again, not all doctors are skilled in these newer techniques. Those who are skilled often specialize in endometriosis treatment, as well. You may have to look for them in your local area or be willing to travel somewhere else to have your procedure.
We also recommend considering your options on preparing yourself for surgery. To start you may want to read our articles about hysterectomy, sign up for a few sessions of acupuncture, and use Peggy Huddleston’s book and audio cassette, Prepare for Surgery, Heal Faster, to enhance your healing and decrease your recovery time.