Most women would welcome the prospect of being free of periods for ever. This is especially so if menstruation has been a time of particular misery. However, removal of the uterus leads to permanent loss of fertility, and involves the risks of major surgery. If the ovaries are removed as well it causes sudden onset of the menopause. It is not something to be embarked upon lightly or for relatively trivial reasons. The purpose of this chapter is to describe some of the problems that might arise during or after the operation. Most of them are relatively minor and easily treatable. While you’re reading this section, please do bear in mind that serious complications are rare.
Complications during the operation
Complications during the operation itself are likely to prolong the operation and the recovery time and may necessitate further surgery.
The anaesthetic may pose risks, particularly if you have other health problems such as heart or lung disease or are a heavy smoker. Risks are greater with general anaesthetics and can be reduced with the use of spinal or epidural anaesthetics but the latter are not suitable for everyone.
Haemorrhage (excessive blood loss) is the most common complication of the operation itself. If this should happen, you may need a blood transfusion, depending on the severity of the bleeding.
Damage to structures which lie beside the uterus is extremely rare, occurring in about two per cent of hysterectomies, but if this does occur it may prolong the operation and the recovery time and further surgery may be required.
Damage to the bladder is more common in women who have previously had a caesarean section because the bladder can stick to the lower part of the uterus and the cervix. For this reason, you may be advised to opt for a subtotal hysterectomy if you’ve had one or more caesarean sections. However, repair of bladder injuries is usually straightforward and the bladder works normally afterwards.
More seriously, the ureters which carry urine from the kidneys to the bladder may be damaged during hysterectomy. This is very uncommon and usually occurs only in complicated cases, for example, in women with very large fibroids or those who have had previous pelvic operations.
Bowel damage may occur during operations for severe endometriosis if the disease has resulted in the bowel becoming stuck to the back of the uterus.
Complications after the operation
Problems are common during the recovery time, but most are minor and easily treated.
- Wound infections are most likely to affect women who are overweight and, although rarely serious, they may considerably delay recovery.
- Chest infections are common in smokers and those with a history of chest problems.
- Difficulty passing urine is very common after an operation. For this reason, a fine plastic tube called a catheter is left in the bladder to drain the urine during the first 12-24 hours. Urinary infections are also common but are easily treated with antibiotics.
- Bowel upsets, such as constipation and flatulence, affect nearly everyone, but are only temporary.
- Pain and stiffness from the operation itself are almost universal, although moving around helps. Although rest is important to help the healing process, you should never lie in bed for a long time after an operation. The nurses will help you gradually to regain mobility after the operation and the physiotherapist will advise you about suitable exercises.
- Anaemia may be a problem for some women after a hysterectomy, as a result of blood loss. This can aggravate feelings of tiredness and lethargy but is quickly put right with iron tablets, although severe anaemia, causing weakness, dizziness and lightheadedness, is best corrected by a blood transfusion.
Pelvic infections, at the operation site deep down in the pelvis, affect around five per cent of women. This may be because there has been some postoperative bleeding leading to a collection of blood (haematoma) which becomes infected. This usually causes a high temperature and anaemia. The doctor may be able to feel a haematoma when doing a pelvic examination or see it on an ultrasound scan. Treatment is with antibiotics. The haematoma either heals gradually or drains through the scar at the top of the vagina; if this occurs it gives rise to a temporary but very unpleasant and heavy discharge. Occasionally there may be fresh vaginal bleeding several days after the operation. This may also be a sign of infection and should be reported to a doctor. It must not be confused with the normal discharge of some old blood or the pinkish discharge that commonly occurs as the stitches at the top of the vagina start to dissolve.
More serious is the risk of blood clots in the deep veins of the legs or pelvis (deep venous thrombosis or DVT). If it isn’t spotted quickly, clots may pass to the lungs (pulmonary embolism) which is life threatening. Hospital staff are very aware of this potential risk, hence the use of inflatable boots to maintain the circulation through your legs during the operation (you will probably not be aware of these) and of elastic support stockings when you’re back on the ward. It helps to move around and do plenty of leg exercises, especially in the early stages after the operation. If you are at particular risk of blood clots or if you have had one in the past, you will be prescribed heparin injections (which reduce the blood’s tendency to clot) as an extra precaution.
Additional risk factors
If you are overweight or a heavy smoker, you are at greater risk of developing problems during or after surgery. Smokers are more prone to chest infections and, as smoking is now forbidden in most hospitals, it really is worth making a huge effort to cut down on your smoking before any operation. Hysterectomy causes significant risks for women who are seriously overweight because of the greater risk of wound and pelvic infections, venous thrombosis, anaesthetic difficulties and, in the case of prolapse, recurrence of the problem.
Most women feel much better after a hysterectomy once they have recovered from the actual operation, but a few have serious regrets, usually because they had reservations beforehand or had not fully thought through the consequences. It is important that women who have lost their ovaries are given adequate hormone replacement to relieve or prevent menopausal symptoms.
Loss of fertility
Changes in family circumstances affect many more people today than in earlier generations, and a young woman who has had a hysterectomy may come to regret it later on if she meets a new partner. On the other hand, some gynaecological problems that reduce fertility such as endometriosis or large uterine fibroids are also cured by hysterectomy, and this can lead to bitterly difficult decisions for some women. Loss of the uterus means permanent loss of the ability to bear a child but for some women this can be a positive decision if it has been preceded by years of suffering.
Your sex life
Most women encounter no difficulty with their sex lives once they have fully recovered from a hysterectomy. Indeed many say things actually get better. Very occasionally, a woman may feel the loss of her fertility as a psychological blow which has a negative effect on her sex drive. Removal of the ovaries is likely to give rise to problems such as vaginal dryness and painful intercourse but this is treatable with hormones (see page xx). It can also be helped by the use of lubricants such as KY jelly. A minority of women find that hysterectomy reduces their sex drive regardless of whether their ovaries have been removed.
The urinary bladder which stores and empties urine lies very close to the uterus and urinary problems are very common after a hysterectomy. These include urinary infections, inability to pass urine and the need to pass urine more frequently or more urgently. Such difficulties are usually only temporary and are more likely to affect women who experienced bladder problems before their operation. However if you have had a hysterectomy, you are significantly more likely to develop bladder weakness in the longer term compared with someone of the same age who still has her uterus.
Constipation is extremely common in people of all ages, including women who have had hysterectomies. Few women develop constipation for the first time after hysterectomy but the operation may aggravate an already existing problem. It may take many weeks for the bowels to recover fully after a hysterectomy, but there is no evidence that any permanent changes occur.
Most women feel very much better once they have recovered from a hysterectomy and serious regret is rare. However hysterectomy will not relieve any symptoms which are not strictly related to your periods. There is no evidence that women undergoing hysterectomy become depressed although removal of the ovaries, if untreated by HRT, may cause some unpleasant symptoms. If you have had unrealistic expectations about hysterectomy you may feel disappointed with the results afterwards, and some women will experience a reaction to loss of fertility. You are less likely to have any negative reactions if your decision to go ahead with a hysterectomy was properly thought out and discussed beforehand.
Hysterectomy leads to permanent loss of fertility and involves the risks of major surgery
Minor complications, such as chest, wound and pelvic infections, are common but easily treated
Serious complications are rare but may considerably prolong recovery time and necessitate further surgery
Complications are more common in women who smoke heavily, are overweight or have other health problems
Temporary upsets in mood and in bowel and bladder function occur commonly but these return to normal during the recovery period
Following hysterectomy there is an increase in the longer term risk of developing bladder weakness