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Intervention:
Hysterectomy
ICD-10 code:
ICD-9 code: 68.9
MeSH D007044
Other codes:

A hysterectomy (from Greek ὑστέρα hystera "womb") is the surgical removal of the uterus, usually performed by a gynecologist. The International Classification of Health Interventions (ICHI is a system of classifying Procedure codes being developed by the World Health Organization. ICD-9-CM Volume 3 is a system of Procedural codes. It is a subset of ICD-9-CM (volumes 1 and 2 are used for Diagnostic codes. Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental The uterus (from the Latin word for womb) is the major Female reproductive organ of most Mammals including Humans One end the Gynaecology or gynecology (see spelling differences) refers to the surgical specialty dealing with health of the female reproductive system ( Uterus Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). The cervix (from Latin "neck" is the lower narrow portion of the Uterus where it joins with the top end of the Vagina.

Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes her hormonal levels considerably, so the surgery is normally recommended for only a few specific circumstances:

Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids that leaves the uterus intact, has been performed for over a century.

The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age. According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. National Center for Health Statistics ( NCHS) is part of the Centers for Disease Control and Prevention (CDC which is part of the United States Department of In the United States, 1/3 of genetic females can be expected to have a hysterectomy by age 60. [1] There are currently an estimate of 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade. [1]

Both the uterus and the ovaries have important life-long functions in the maintenance of a woman's health, and there is never an age or a time when the uterus and ovaries are not essential to health and well-being. [2] Additionally, the removal of otherwise healthy ovaries is a form of castration because it involves removal of the female gonads[3], which many opponents and even some supporters of hysterectomy[4] do not support.

Contents

Indications

Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Uterine fibroids (singular Uterine Fibroma) ( leiomyomata, singular leiomyoma) are Benign Tumors which grow from the muscle layers of Endometriosis (from endo, "inside" and metra, " Womb " is a common medical condition characterized by growth beyond or outside the uterus Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the Uterus) within the myometrium (the Female genital prolapse (or vaginal prolapse) is characterized by a portion of the Vaginal canal protruding from the opening of the Vagina. The term uterine cancer may refer to any of several different types of Cancer which occur in the Uterus, namely Uterine sarcomas Cervical cancer is Malignant Cancer of the Cervix uteri or cervical area Ovarian cancer is a cancerous growth arising from an Ovary. The cancer most commonly forms in the lining of the ovary (resulting in epithelial Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage. Obstetrical hemorrhage refers to heavy bleeding during Pregnancy, labor, or the Puerperium. [5]

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Uterine fibroids (singular Uterine Fibroma) ( leiomyomata, singular leiomyoma) are Benign Tumors which grow from the muscle layers of Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); uterine artery embolization, high intensity focused ultrasound or watchful waiting. Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher For other uses see Opiate (disambiguation, or for the class of drugs see Opioid. The menstrual cycle is a recurring cycle of physiologic changes that occurs in reproductive-age Females Overt menstruation (where there is blood flow from the Uterine artery embolization (UAE or Uterine Fibroid Embolization (UFE is a procedure where an interventional Radiologist uses a Catheter to deliver small HIFU ( high intensity focused ultrasound) (sometimes FUS or HIFUS) is a highly precise medical procedure using high-intensity focused Ultrasound In mild cases, no treatment is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4cm, hysteroscopic removal is an option. Hysteroscopy is the inspection of the uterine cavity by Endoscopy. A submucosal fibroid larger than 4cm, and fibroids located in other parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.

Technique

Most hysterectomies in the United States and in most parts of the world are done via laparotomy, sometimes called the "open technique" or "open hysterectomy". A laparotomy is a surgical procedure involving an incision through the Abdominal wall to gain access into the Abdominal cavity. A transverse incision (Pfannenstiel's incision) is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. Bleeding, technically known as hemorrhaging / haemorrhaging (see American and British spelling differences) is the loss of Blood from In Anatomy, the intestine is the segment of the alimentary canal extending from the Stomach to the Anus and in humans and other mammals consists In Anatomy, the urinary bladder is a hollow muscular, and distensible (or elastic organ that sits on the Pelvic floor in Mammals It is the However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.

An increasing number of uterine removals not involving removal of the ovaries are done through the cervix ("supracervical"), reducing the size of the incision and the recovery time as well. In this technique, the uterus is accessed either via the vaginal canal or through an incision inside the navel (or sometimes both, depending on the uterine problem being addressed by the surgery). The uterus itself is detached at the top of the cervical neck and pulled back through the vaginal canal (or out through the navel incision if fibroids or other indications prevent it from being able to pass through the cervix), after which the cervical neck is stitched shut. This provides the patient with a comparatively normal-length vagina which helps provide some support to the bladder, as well as a significantly decreased recovery time. [6] The main drawback with supracervical hysterectomy is the increased risk of cervical prolapse due to the removal of the much stronger uterus (which would normally support the organs around it to prevent prolapse). Prolapse literally means "To fall out of place" In Medicine, prolapse is a condition where organs such as the Uterus, fall down or slip out of place This surgery also does not eliminate the possibility of cervical cancer, since the cervix itself is left in place; those who have undergone this procedure must still have regular PAP smears to check for cervical cancer. Cervical cancer is Malignant Cancer of the Cervix uteri or cervical area

The newest technique is robotic-assisted laparoscopic hysterectomy. Laparoscopic surgery, also called Minimally invasive surgery (MIS, bandaid surgery, Keyhole surgery, or pinhole surgery Instead of a large incision, a few tiny incisions are made through which thin instruments are passed. This new technique significantly reduces scarring, pain, healing time, blood loss, and duration of hospital stay when compared to open technique.

Another advanced technique has been developed as Nerve sparing Abdominal Hysterectomy: Intrastromal Abdominal Hysterectomy which is a bloodless, nerve-sparing technique that does not disturb the pelvic support system. It also proves to be an effective alternative to the traditional hysterectomy, with advantages such as reduced blood loss,prevent cervical cancer,and shortens hospital stay, and less frequent post-operative complications

Benefits

Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy. Prophylaxis ( Greek "προφυλάσσω" to guard or prevent beforehand) is any medical or Public health procedure whose purpose Oophorectomy (or ovariectomy) is the surgical removal of an Ovary or ovaries [7] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only Hormone replacement therapy (HRT) to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT. Estrogens (US otherwise oestrogens or œstrogens) are a group of Steroid compounds named for their importance in the Estrous cycle, Hormone replacement therapy (HRT or in Britain Hormone therapy (HT now often referred to as "treatment" rather than therapy is a system of medical treatment [8]

The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. Year 1994 ( MCMXCIV) was a Common year starting on Saturday (link will display full 1994 Gregorian calendar) The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness. [4]

One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[9]. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome. Fibromyalgia (FM is a disorder classified by the presence of chronic widespread Pain and tactile Allodynia. Chronic fatigue syndrome ( CFS) is the most common name given to a poorly understood variably debilitating disorder or disorders of uncertain causation Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder[10].

Risks and side effects

The average onset age of menopause in those who underwent hysterectomy is 3. Menopause is the permanent shutting down of the female Reproductive system, a considerable length of time before the end of the lifespan 7 years earlier than average. [11] This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal systems. Although sometimes referred to as surgical menopause, that is incorrect and misleading because it implies that its effects are the same as with natural menopause. In fact, those who are naturally menopausal have the benefit of the functions of their uterus and ovaries (which continue to produce small amounts of hormones even after natural menopause), while those who undergo hysterectomy and/or removal of the ovaries have a permanent loss of their functions.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies. Osteoporosis is a Disease of Bone that leads to an increased risk of fracture. A fracture is the (local separation of an object or material into two or more pieces under the action of stress. [12][13][14][15][16][17] This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.

Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.

Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact. [18] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[19] while conversely, increased testosterone levels in women are associated with a greater sense of sexual desire. Testosterone is a Steroid hormone from the Androgen group In mammals testosterone is primarily secreted in the testes of males and the Ovaries [20] Hysterectomy has also been found to be associated with increased bladder function problems, such as incontinence. [21]

Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. An ectopic pregnancy is a Complication of pregnancy in which the fertilized Ovum is implanted in any tissue other than the uterine wall Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature[22].

Alternatives

Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation is a Medical procedure that is used to remove ( ablate) or destroy the endometrial lining of a woman's Uterus. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed without removing the uterus. This procedure is called a "myomectomy. Myomectomy refers to the surgical removal of Uterine fibroids also known as Myomas. " A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically. [23] Various other techniques (such as Fibroid Artery Embolization, Myolysis, HALT, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus. [24]

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation. Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals Endometrial ablation is a Medical procedure that is used to remove ( ablate) or destroy the endometrial lining of a woman's Uterus. [25]

Uterine Fibroid Embolization

Known medically as uterine artery embolization, this approach to the treatment of fibroids blocks the arteries that supply blood to the fibroids causing them to shrink. It is a minimally-invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated — drowsy and feeling no pain. Fibroid embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally-invasive procedures. The interventional radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter--like a piece of spaghetti) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (flouroscopy).

Gender transitioning

Main article: Sex reassignment surgery female-to-male

Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of gender reassignment surgery for transmen. Sex reassignment surgery from female to male includes surgical procedures that will reshape a female body into a body with a male appearance Sex reassignment surgery (SRS gender reassignment surgery, or sex-change operation is a term for the Surgical procedures by which a person's physical A transman or transguy (often referred to as FTM) is short for Transsexual or Transgender man - a person who was naturally born or physically Some in the FTM community prefer to have this operation along with hormone replacement therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e. Hormone replacement therapy ( HRT) for Transgender and Transsexual people replaces the Hormones naturally occurring in their bodies with those g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition. The term uterine cancer may refer to any of several different types of Cancer which occur in the Uterus, namely Uterine sarcomas Coronary artery disease (CAD (or atherosclerotic Heart disease) is the end result of the accumulation of atheromatous plaques within the walls Real life experience ( RLE) sometimes called real life test ( RLT) is a process where Transsexual and Transgender people live [26] Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy)[27] to avoid undergoing multiple separate operations. Sex reassignment surgery from female to male includes surgical procedures that will reshape a female body into a body with a male appearance [28]

References

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  27. ^ Hudson's FTM Resource Guide, "FTM Gender Reassignment Surgery, retrieved May 9, 2007. Events 1457 BC - Battle of Megiddo (15th century BC between Thutmose III and a large Canaanite coalition under the King of Year 2007 ( MMVII) was a Common year starting on Monday of the Gregorian calendar in the 21st century.
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External links

The Open Directory Project ( ODP) also known as dmoz (from directory MEDLINE ( Medical Literature Analysis and Retrieval System Online is a literature database of life sciences and biomedical information

Dictionary

hysterectomy

-noun

  1. (surgery) The surgical procedure to remove of all or part of the uterus.
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