Hysterectomy for cancer

Most hysterectomies are carried out to relieve problems that are troublesome or debilitating but not life threatening, so you are able to weigh up the pros and cons beforehand. When cancer of the uterus, cervix or ovaries is diagnosed, the decision about treatment usually has to be made very quickly and there may be no alternative to a hysterectomy. Nevertheless, it is still important that you fully understand the proposed treatment, whether you have any choices and what will happen afterwards. Ask a relative or friend to come to the hospital with you to help you remember what is said and write down what questions you want to ask.

Hysterectomy may be only one part of your treatment and several specialists are likely to be involved in deciding the best course of action, including the gynaecologist, a pathologist who is responsible for examining tissue specimens and an oncologist (cancer specialist) who will advise about the necessity for additional treatment, such as radiotherapy or chemotherapy. There are often specialised nurses attached to such a team and they can be a great help in providing explanations, reassurance and support.

Cancer of the endometrium (uterine lining)

Endometrial cancer is most common after the menopause and is extremely rare in women under the age of 40. It causes abnormal bleeding after the menopause or prolonged and irregular bleeding in younger women. The diagnosis may be suspected by the presence of abnormal thickening of the uterine lining on a scan and is confirmed by examination of a sample from the lining (endometrial biopsy – see earlier).

The endometrial lining is surrounded by the thick muscle wall of the uterus so it is rare for this type of cancer to spread beyond the uterus, and a hysterectomy therefore gives a very good chance of a complete cure. The ovaries are also removed to minimise the risk of any cancer spread. If the pathologist who examines the uterus and ovaries after the operation has the slightest suspicion that the cancer may have spread beyond the uterus, a course of radiotherapy (X-ray therapy) will be recommended to destroy any cancer cells that may have entered the surrounding tissues with the object of achieving a complete cure.

The hysterectomy is normally performed through an abdominal incision, although occasionally the gynaecologist may decide that a vaginal or laparoscopically assisted approach is appropriate. Whatever method is used, it is likely that it will take a little longer than usual to recover fully afterwards, because the women concerned tend to be older than those having hysterectomies for other reasons.

As most women with cancer of the endometrium are already menopausal or beyond their fertile years, the decision to perform a hysterectomy is rarely a difficult one for the woman herself although there will always be exceptions to this, particularly for women who have never had children. Unfortunately, this form of cancer is more common in childless women. As cancer of the endometrium may be caused by high oestrogen levels, oestrogen-containing HRT cannot usually be prescribed. However all cases are different and if menopausal symptoms are a problem after the operation, this should be discussed with the gynaecologist or oncologist.

Cancer of the cervix

This form of cancer affects the neck of the uterus and is usually prevented from developing by early detection of abnormal cells through the cervical smear programme. If a smear test shows up pre-cancerous cells, they are removed by a procedure called colposcopy, which involves a detailed inspection of the cervix through a magnifying system (colposcope). This enables the removal of abnormal cells by simple treatments which leave the uterus and cervix to function normally. This pre-cancerous condition is known as cervical intraepithelial neoplasia (CIN) and must not be confused with cervical cancer itself.

Despite the effectiveness of the smear programme, some women still develop cervical cancer, sometimes at a relatively young age. If the tumour is fairly small, it can be treated by hysterectomy but, if it has started to spread, it cannot all be removed by hysterectomy and radiotherapy will be necessary, either as well as or instead of hysterectomy. Both these forms of treatment will result in loss of fertility, although a hysterectomy for cervical cancer does not usually involve removal of the ovaries. Theoretically, a woman who has a hysterectomy but still has her ovaries could have a child with a partner, but only with the use of in vitro fertilisation (IVF) and with the help of another woman willing to carry that child for them (a surrogate mother). Radiotherapy stops the ovaries from functioning so there is no prospect of future fertility. However, methods of retrieving and storing small pieces of an ovary are currently being researched and may become available in the future. Therefore, any young woman with cervical cancer faced with loss of fertility should have the opportunity of discussing the implications and any available options before treatment is started.

A hysterectomy for cervical cancer is a very major operation because it involves removal of additional tissues besides and below the cervix, and also removal of the lymph nodes in the pelvis to which cancer may spread. In particular the bladder and bowels may take longer to return to normal. Loss of the ovaries or of their function after treatment of cervical cancer can be compensated for with HRT because this form of cancer is not influenced by hormones.

Ovarian cancer

This condition is less clear than the others described above because there are many different types of ovarian cancer and it is not always possible to diagnose its extent or even its presence in advance of an operation. A woman may therefore face uncertainties about the precise nature of an operation to remove the cancer until after it is over. Nevertheless, a woman’s desire to retain her fertility will always be taken into consideration and is likely to influence decisions about her treatment.

The symptoms of ovarian cancer are very vague and varied, usually abdominal discomfort or swelling, possibly vague ill-health and weight loss. It may come to light because the woman herself or her doctor has felt a swelling in her abdomen. The suspicion is then confirmed by the results of an ultrasound scan. Blood tests may give additional information and sometimes a more detailed type of scan (computed tomography [CT] or magnetic resonance imaging [MRI] scan) is performed. Sometimes it is possible to be fairly confident about the diagnosis of cancer, but often there is uncertainty which can be resolved only by removal of the ovary and having it examined by the pathologist.

If a woman with suspected ovarian cancer has completed her family and is near to or through the menopause, she will most probably be advised to have both ovaries and the uterus removed in order to avoid the need for a second operation and to minimise the risk that the disease may come back. Even a benign tumour may develop in the other ovary in the future. If there are visible signs that the cancer has spread beyond the ovary, these areas are removed as well.

Ovarian cancer more commonly affects older women and is fortunately rare in women under 40. Its treatment in younger women always involves weighing up the risks of spread of the cancer against the risk that fertility will be lost, and the wishes and opinions of the woman herself are always taken into consideration. It may be possible to remove only the affected ovary and leave the uterus and remaining ovary if the woman is anxious to retain her fertility, unless there is obvious spread of the tumour. Treatment of ovarian cancer in young women will usually involve chemotherapy (use of drugs that destroy cancer cells) and there is a risk that this may also damage the egg-producing cells in the remaining ovary, although it is usually possible to select drugs that minimise this risk.

Further treatment

Hysterectomy for cancer may be followed by additional treatment with radiotherapy or chemotherapy, depending on what is found during the operation and the results of the pathologist’s tests on the tissues. As mentioned above, recommendations regarding further treatment are made by a team of specialists. Even if additional treatment is not required, further visits to the hospital will be necessary in order to check for any signs that the cancer may be recurring.

KEY POINTS

• Hysterectomy may be only one part of the treatment of cancer, together with chemotherapy and/or radiotherapy

   

• Most cancers of the uterus or ovaries occur in older women, beyond the age of the menopause

   

• In younger women, there should be full discussion of issues and options relating to fertility before treatment is commenced

   

• HRT is suitable for women after treatment of ovarian or cervical cancer, but not after treatment outerine body (endometrial) cancer