Hysterectomy is surgery to remove a woman’s womb (uterus).
The uterus is a hollow muscular organ that nourishes the developing baby during pregnancy.
You may have all or part of the uterus removed during a hysterectomy. The fallopian tubes and ovaries may also be removed.
There are many different ways to perform a hysterectomy.
It may be done through:
• A surgical cut in the belly (called open or abdominal)
• Three to four small surgical cuts in the belly and then using a laparoscope
• A surgical cut in the vagina, aided by the use of a laparoscope
• A surgical cut in the vagina without the use of a laparoscope
• Three to four small surgical cuts in the belly, in order to perform robotic surgery
You and your doctor will decide which type of procedure. The choice will depend on your medical history and the reason for the surgery.
There are many reasons a woman may need a hysterectomy, including:
• Adenomyosis, a condition that causes heavy, painful periods
• Cancer of the uterus, most often endometrial cancer
• Cancer of the cervix or changes in the cervix called cervical dysplasia that may lead to cancer
• Cancer of the ovary
• Long-term (chronic) pelvic pain
• Severe endometriosis that does not get better with other treatments
• Severe, long-term vaginal bleeding that is not controlled with other treatments
• Slipping of the uterus into the vagina (uterine prolapse)
• Tumors in the uterus, such as uterine fibroids
• Uncontrolled bleeding during childbirth
Hysterectomy is a major surgery.
Some conditions can be treated with less invasive procedures such as:
• Uterine artery embolization
• Endometrial ablation
• Using birth control pills
• Using pain medicines
• Using an IUD (intrauterine device) that releases the hormone progestin
• Pelvic laparoscopy
Myomectomy (my-o-MEK-tuh-me) is a surgical procedure to remove uterine fibroids — also called leiomyomas (lie-o-my-O-muhs). These common noncancerous growths appear in the uterus. Uterine fibroids usually develop during childbearing years, but they can occur at any age.
The surgeon’s goal during myomectomy is to take out symptom-causing fibroids and reconstruct the uterus. Unlike a hysterectomy, which removes your entire uterus, a myomectomy removes only the fibroids and leaves your uterus.
Women who undergo myomectomy report improvement in fibroid symptoms, including decreased heavy menstrual bleeding and pelvic pressure.
Your doctor might recommend myomectomy for fibroids causing symptoms that are troublesome or interfere with your normal activities.
If you need surgery, reasons to choose a myomectomy instead of a hysterectomy for uterine fibroids include:
• You plan to bear children
• You want to keep your uterus
• Your doctor suspects uterine fibroids might be interfering with your fertility
In abdominal myomectomy (laparotomy), your surgeon makes an open abdominal incision to access your uterus and remove fibroids. Your surgeon will generally prefer to make a low, horizontal (“bikini line”) incision, if possible. Vertical incisions are needed for larger uteruses.
Laparoscopic or Robotic Myomectomy
In laparoscopic or robotic myomectomy, both minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.
Compared with women who have a laparotomy, women who undergo laparoscopy have less blood loss, shorter hospital stays and recovery, and lower rates of complications and adhesion formation after surgery.
There are limited comparisons between laparoscopic and robotic myomectomy. Robotic surgery may take longer and be more costly, but otherwise few differences in outcomes are reported.
• Laparoscopic myomectomy.
Your surgeon makes a small incision in or near your bellybutton. Then he or she inserts a laparoscope — a narrow tube fitted with a camera — into your abdomen. Your surgeon performs the surgery with instruments inserted through other small incisions in your abdominal wall.
• Robotic myomectomy.
Your surgeon inserts instruments through small incisions similar to those in a laparoscopic myomectomy, and then controls movement of the instruments from a separate console. Some surgeons are now performing single-port (one incision) laparoscopic and robotic myomectomies.
Sometimes, the fibroid is cut into pieces (morcellation) and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so that it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).
To treat smaller fibroids that bulge significantly into your uterus (submucosal fibroids), your surgeon may suggest a hysteroscopic myomectomy. Your surgeon accesses and removes the fibroids using instruments inserted through your vagina and cervix into your uterus.
A hysteroscopic myomectomy generally follows this process:
• Your surgeon inserts a small, lighted instrument through your vagina and cervix and into your uterus. He or she will most commonly use either a wire loop resectoscope to cut (resect) tissue using electricity or a hysteroscopic morcellator to manually cut the fibroid with a blade.
• A clear liquid, usually a sterile salt solution, is inserted into your uterus to expand your uterine cavity and allow examination of the uterine walls.
• Your surgeon shaves pieces from the fibroid using the resectoscope or the hysteroscopic morcellator, taking out the pieces from the uterus until the fibroid is completely removed. Sometimes large fibroids can’t be fully removed in one surgery, and a second surgery is needed.
Diagnostic laparoscopy is a procedure that allows a doctor to look directly at the contents of the abdomen or pelvis.
The procedure is usually done in the hospital or outpatient surgical center under general anesthesia (while you are asleep and pain-free).
The procedure is performed in the following way:
• The surgeon makes a small cut (incision) below the belly button.
• A needle or hollow tube called a trocar is inserted into the incision. Carbon dioxide gas is passed into the abdomen through the needle or tube. The gas helps expand the area, giving the surgeon more room to work, and helps the surgeon see the organs more clearly.
• A tiny video camera (laparoscope) is then placed through the trocar and is used to see the inside of your pelvis and abdomen. More small cuts may be made if other instruments are needed to get a better view of certain organs.
• If you are having gynecologic laparoscopy, dye may be injected into your cervix so the surgeon can view the fallopian tubes.
• After the exam, the gas, laparoscope, and instruments are removed, and the cuts are closed. You will have bandages over those areas.
An ovarian cyst is a sac filled with fluid that forms on or inside an ovary.
This article is about cysts that form during your monthly menstrual cycle, called functional cysts.
Functional cysts are not the same as cysts caused by cancer or other diseases. The formation of these cysts is a perfectly normal event and is a sign that the ovaries are working well.
Each month during your menstrual cycle, a follicle (cyst) grows on your ovary. The follicle is where an egg is developing.
• The follicle makes the estrogen hormone. This hormone causes normal changes of the uterine lining as the uterus prepares for pregnancy.
• When the egg matures, it is released from the follicle. This is called ovulation.
• If the follicle fails to break open and release an egg, the fluid stays in the follicle and forms a cyst. This is called a follicular cyst.
Another type of cyst occurs after an egg has been released from a follicle. This is called a corpus luteum cyst. This type of cyst may contain a small amount of blood. This cyst releases progesterone and estrogen hormones.
Ovarian cysts are more common in the childbearing years between puberty and menopause. The condition is less common after menopause.
Taking fertility drugs often causes the development of multiple follicles (cysts) in the ovaries. These cysts most often go away after a woman’s period, or after a pregnancy.
Functional ovarian cysts are not the same as ovarian tumors or cysts due to hormone-related conditions such as polycystic ovary syndrome.
Endometrium is the lining of the inside of the womb (uterus). Overgrowth of this lining can create polyps. Polyps are fingerlike growths that attach to the wall of the uterus. They can be as small as a sesame seed or larger than a golf ball. There may be just one or many polyps.
The exact cause of endometrial polyps in women is not known.
They tend to grow when there is more of the hormone estrogen in the body.
Most endometrial polyps are not cancerous. Very few can be cancerous or precancerous.
The chance of cancer is higher if you are postmenopausal, on Tamoxifen, or have heavy or irregular periods.
Other factors that may increase the risk for endometrial polyps are:
• Tamoxifen, a treatment for breast cancer
• Postmenopausal hormone replacement therapy
• Family history of Lynch syndrome or Cowden syndrome (genetic conditions that run in families)
Endometrial polyps are common in women between 20 to 40 years of age.
DELIVERY BY CESAREAN SECTION
More than one mother in three gives birth by Cesarean section in the United States (it is also called C-section or, simply, section). In a C-section, surgery is performed, with an incision made in the mother’s abdomen and uterus, so the baby can be taken directly from the uterus instead of traveling through the birth canal.
Cesarean sections are done most often when:
• The mother has had a previous baby by Cesarean delivery
• The obstetrician feels that the baby’s health might suffer if born vaginally
• The fetus’s heartbeat slows abnormally or becomes irregular (in which case the obstetrician will perform an emergency C-section instead of taking the chance of allowing labor to progress)
While most babies are in a head-down position in the mother’s uterus, about three in one hundred newborns have their buttocks, feet, or both positioned to come out first during birth (a breech presentation). If your baby has assumed a breech position, your obstetrician will recommend a Cesarean section as the best means of delivery. The reason is because breech babies are more difficult to deliver vaginally, and complications are more likely to occur with a vaginally delivered breech baby. A doctor can determine the baby’s position by feeling the mother’s lower abdomen at particular points; the physician may decide to confirm the breech position by ordering an ultrasound or other tests.
The birth experience with a C-section is very different from that of a vaginal delivery. For one thing, the whole operation ordinarily takes no more than an hour, and—depending on the circumstances—you may not experience any labor at all. Another important difference is the need to use medication that affects the mother and may affect the baby. If given a choice of anesthetic, most women prefer to have a regional anesthesia—an injection in the back that blocks pain by numbing the spinal nerves—such as an epidural or a spinal.
Administration of a regional anesthesia numbs the body from the waist down, has relatively few side effects, and allows you to witness the delivery. But sometimes, especially for an emergency C-section, a general anesthetic must be used, in which case you are not conscious at all.
Your obstetrician and the anesthesiologist in attendance will advise you which approach they think is best, based on the medical circumstances at the time.
Because of the effects of the anesthesia and the way the baby is delivered, babies born by C-section sometimes have difficulty breathing in the beginning and need extra help. A pediatrician or other person skilled in newborn problems usually is present during a Cesarean section to examine and assist the baby’s breathing, if necessary, immediately after birth.
If you were awake during the operation, you may be able to see your baby as soon as she’s been examined and proclaimed healthy. She may then be taken to the nursery to spend several hours in a temperature-controlled crib or isolette. This allows the hospital staff to observe her while the anesthesia wears off and she adjusts to her new surroundings.
If general anesthesia was used during the delivery, you may not wake up for a few hours. When you do, you may feel groggy and confused. You’ll probably also experience some pain where the incision was made. But you’ll soon be able to hold your baby, and you’ll quickly make up for lost time.
Don’t be surprised if your baby is still affected by the anesthesia for six to twelve hours after delivery and appears a little sleepy. If you’re going to breastfeed, try to nurse her as soon as you feel well enough. Even if she’s drowsy, her first feeding should provide a reason for her to wake up and meet her new world—and you. It will also help stimulate your breastmilk production.
As mentioned, many obstetricians believe that once a woman has a C-section, her subsequent babies should be delivered the same way because of higher rates of complications with vaginal deliveries after previously having a C-section. However, many women are candidates for a vaginal birth after Cesarean section (VBAC). But a decision to do this will depend on a number of factors and should be made together with your doctor.
If you’re the father-to-be, discuss your role and presence in the delivery room and ways you can best support your partner during the birth.
Tubal ligation is surgery to close a woman’s fallopian tubes. (It is sometimes called “tying the tubes.“)
The fallopian tubes connect the ovaries to the uterus. A woman who has this surgery can no longer get pregnant. This means she is “sterile.” Tubal ligation is done in a hospital or outpatient clinic.
• You may receive general anesthesia. You will be asleep and unable to feel pain.
• Or, you will be awake and given spinal anesthesia. You may also receive medicine to make you sleepy. The procedure takes about 30 minutes.
• Your surgeon will make 1 or 2 small surgical cuts in your belly. Most often, they are around the belly button.
Gas may be pumped into your belly to expand it. This helps your surgeon see your uterus and fallopian tubes.
• A narrow tube with a tiny camera on the end (laparoscope) is inserted into your belly.
Instruments to block off your tubes will be inserted through the laparoscope or through a separate small cut.
• The tubes are either burned shut (cauterized), clamped off with a small clip or ring (band), or completely removed surgically.
Tubal ligation can also be done right after you have a baby through a small cut in the navel. It can also be done during a C-section.
Tubal ligation may be recommended for adult women who are sure they do not want to get pregnant in the future.
The benefits of the method include a sure way to protect against pregnancy and the lowered risk of ovarian cancer.
Women who are in their 40s or who have a family history of ovarian cancer may want to have the whole tube removed in order to further decrease their risk of later developing ovarian cancer.
However, some women who choose tubal ligation regret the decision later. The younger the woman is, the more likely she will regret having her tubes tied as she gets older.
Tubal ligation is considered a permanent form of birth control.
It is NOT recommended as a short-term method or one that can be reversed. However, major surgery can sometimes restore your ability to have a baby. This is called a reversal. More than half of women who have their tubal ligation reversed are able to become pregnant. An alternative to tubal reversal surgery is to have IVF (in vitro fertilization).
A mastectomy is surgery to remove the breast tissue. Some of the skin and the nipple may also be removed. However, surgery that spares the nipple and skin can now be done more often. The surgery is most often done to treat breast cancer.
Before surgery begins, you will be given general anesthesia. This means you will be asleep and pain-free during surgery.
There are different types of mastectomies. Which one your surgeon performs depends on the type of breast problem you have. Most of the time, mastectomy is done to treat cancer. However, it is sometimes done to prevent cancer (prophylactic mastectomy).
The surgeon will make a cut in your breast and perform one of these operations:
• Nipple-sparing mastectomy: The surgeon removes the entire breast, but leaves the nipple and areola (the colored circle around the nipple) in place. If you have cancer, the surgeon may do a biopsy of lymph nodes in the underarm area to see if the cancer has spread.
• Skin-sparing mastectomy: The surgeon removes the breast with the nipple and areola with minimal skin removal. If you have cancer, the surgeon may do a biopsy of lymph nodes in the underarm area to see if the cancer has spread.
• Total or simple mastectomy: The surgeon removes the entire breast along with the nipple and areola. If you have cancer, the surgeon may do a biopsy of lymph nodes in the underarm area to see if the cancer has spread.
• Modified radical mastectomy: The surgeon removes the entire breast with the nipple and areolar along with some of the lymph nodes underneath the arm.
• Radical mastectomy: The surgeon removes the skin over the breast, all of the lymph nodes underneath the arm, and the chest muscles. This surgery is rarely done.
• The skin is then closed with sutures (stitches).
One or two small plastic drains or tubes are very often left in your chest to remove extra fluid from where the breast tissue used to be.
A plastic surgeon may be able to begin reconstruction of the breast during the same operation. You may also choose to have breast reconstruction at a later time. If you have reconstruction, a skin- or nipple-sparing mastectomy may be an option.
Mastectomy will take about 2 to 3 hours.
WOMAN DIAGNOSED WITH BREAST CANCER
The most common reason for a mastectomy is breast cancer.
If you are diagnosed with breast cancer, talk to your health care provider about your choices:
• Lumpectomy is when only the breast cancer and tissue around the cancer are removed. This is also called breast conservation therapy or partial mastectomy. Most of your breast will be left.
• Mastectomy is when all breast tissue is removed.
You and your provider should consider:
• The size and location of your tumor
• Skin involvement of the tumor
• How many tumors there are in the breast
• How much of the breast is affected
• The size of your breast
• Your age
• Medical history that may exclude you from breast conservation (this may include prior breast radiation and certain medical conditions)
• Family history
• Your general health and whether you have reached menopause
The choice of what is best for you can be difficult. You and the providers who are treating your breast cancer will decide together what is best.
WOMEN AT HIGH RISK FOR BREAST CANCER
Women who have a very high risk of developing breast cancer may choose to have a preventive (or prophylactic) mastectomy to reduce the risk of breast cancer.
You may be more likely to get breast cancer if one or more close family relatives has had the disease, especially at an early age. Genetic tests (such as BRCA1 or BRCA2) may help show that you have a high risk.
However, even with a normal genetic test, you may still be at high risk of breast cancer, depending on other factors. It may be useful to meet with a genetic counselor to assess your level of risk.
Prophylactic mastectomy should be done only after very careful thought and discussion with your doctor, a genetic counselor, your family, and loved ones.
Mastectomy greatly reduces the risk of breast cancer, but does not eliminate it.
Infertility means you cannot get pregnant (conceive).
There are 2 types of infertility:
• Primary infertility refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
• Secondary infertility refers to couples who have been able to get pregnant at least once, but now are unable.
Many physical and emotional factors can cause infertility. It may be due to problems in the woman, man, or both.
Female infertility may occur when:
• A fertilized egg or embryo does not survive once it attaches to the lining of the womb (uterus).
• The fertilized egg does not attach to the lining of the uterus.
• The eggs cannot move from the ovaries to the womb.
• The ovaries have problems producing eggs.
Female infertility may be caused by:
• Autoimmune disorders, such as antiphospholipid syndrome (APS)
• Birth defects that affect the reproductive tract
• Cancer or tumor
• Clotting disorders
• Drinking too much alcohol
• Exercising too much
• Eating disorders or poor nutrition
• Growths (such as fibroids or polyps) in the uterus and cervix
• Medicines such as chemotherapy drugs
• Hormone imbalances
• Being overweight or underweight
• Older age
• Ovarian cysts and polycystic ovary syndrome (PCOS)
• Pelvic infection resulting in scarring or swelling of fallopian tubes (hydrosalpinx) or pelvic inflammatory disease (PID)
• Scarring from sexually transmitted infection, abdominal surgery or endometriosis
• Surgery to prevent pregnancy (tubal ligation) or failure of tubal ligation reversal (reanastomosis)
• Thyroid disease
Male infertility may be due to:
• Decreased number of sperm
• Blockage that prevents the sperm from being released
• Defects in the sperm
Male infertility can be caused by:
• Birth defects
• Cancer treatments, including chemotherapy and radiation
• Exposure to high heat for prolonged periods
• Heavy use of alcohol, marijuana, or cocaine
• Hormone imbalance
• Medicines such as cimetidine, spironolactone, and nitrofurantoin
• Older age
• Retrograde ejaculation
• Scarring from sexually transmitted infections (STIs), injury, or surgery
• Toxins in the environment
• Vasectomy or failure of vasectomy reversal
• History of testicular infection from mumps
Healthy couples under age 30 who have sex regularly will have about a 20% per month chance of getting pregnant each month.
A woman is most fertile in her early 20s. The chance a woman can get pregnant drops greatly after age 35 (and especially after age 40). The age when fertility starts to decline varies from woman to woman.
Infertility problems and miscarriage rates increase significantly after 35 years of age. There are now options for early egg retrieval and storage for women in their 20’s. This will help ensure a successful pregnancy if childbearing is delayed until after age 35. This is an expensive option.
However, women who know they will need to delay childbearing may consider it.