Having a Hysterectomy

Having a Hysterectomy

Patient Information

Obstetrics & Gynaecology Service

Introduction

Your doctor has discussed with you the reasons why you are having a hysterectomy.  If you do not understand any part of the explanation, then please ask the doctor to go through it with you again very thoroughly.

In most cases, hysterectomy is performed because of period problems or because the womb is enlarged or diseased, which can cause heavy and painful periods.  Sometimes a hysterectomy is required to treat a prolapse, in which case it is done through the vagina and information about this is included in the booklet “vaginal repairs”.

Hysterectomy is the only treatment which guarantees complete absence of periods.  It is hoped that this leaflet will provide answers and information to questions you may have and will help in relieving some of the worries you may be feeling about the operation.

What is a hysterectomy?

A hysterectomy is an operation to remove the womb and cervix.  The womb and cervix are ideally removed through the vagina (a vaginal hysterectomy). This can be assisted or performed entirely by keyhole surgery (referred to as laparoscopically assisted vaginal hysterectomy and total laparoscopic hysterectomy respectively).  Sometimes it is not possible to remove the uterus vaginally and therefore the operation is done via a cut on the abdomen (a total abdominal hysterectomy).  (See diagram 1)

Diagram 1

In a hysterectomy that is performed abdominally or laparoscopically, fallopian tubes are now recommended to be removed as well.  In some cases it is possible to do this during a vaginal hysterectomy, but this requires a high degree of skill from the operator.  This is shown to reduce the background risk of ovarian cancer in the future by up to 50% after the operation.  If you and your doctor decide that removal of your ovaries is also required, then the operation is called a hysterectomy and bilateral salpingo-oopherectomy.

Diagram 2

What are the benefits of hysterectomy?

If the womb is completely removed, you will no longer have periods and there will be usually no need for you to have smear tests unless you have had abnormal smear tests before the hysterectomy; in this case, ask your doctor for details.  The operation will usually solve most problems associated with periods, although hormonal problems such as pre-menstrual symptoms will only be relieved if you have your ovaries removed.  Removal of the Fallopian tubes reduces the risk of ovarian cancer, even if the ovaries are not removed.

Are there any risks involved in having a hysterectomy?

Like any other operation, there are some risks involved, although they are small.  Every precaution will be taken to avoid these complications: 

• Wound infection, bruising or delayed healing
• Passing urine frequently in the early days
• Longer term bladder problems, such as passing urine frequently because your bladder will miss the support it has from your uterus
• Damage to bladder or ureter (tube from kidneys to bladder) (7 in 1000 cases)
• Damage to bowel (4 in 1000 cases)
• Bleeding requiring blood transfusion (15 in 1000 cases)

• Return to theatre for additional stitches to stop bleeding (6 in 1000 cases)
• Pelvic abscess/infection (2 in 1000 cases)
• Blood clots in legs or lungs (4 in 1000 cases)
• Abdominal discomfort and/or shoulder tip pain because of pressure from the gas used during laparoscopy
• Death (1 in 4000 cases).

Alternatives

Any alternatives would have been discussed and tried prior to your decision to have this operation.

Removal of ovaries 

If your ovaries are removed during surgery, you may need to start hormone replacement therapy (HRT).  Your doctor will discuss the reasons for removing your ovaries, and HRT will be discussed with you at this stage.  HRT will be started after your surgery.

Pre-operative clinic

Before your operation, you will be invited to attend the pre-operative clinic at the Thomas Linacre Centre or Leigh Infirmary, depending on which is more convenient for you. 

You will have blood taken for routine investigations and you will be asked some general questions regarding your health. 

The enhanced recovery nurse

You may see the enhanced recovery nurse in the pre-operative clinic.  The enhanced recovery nurse is a specialist nurse who can simplify your admission and can facilitate a quicker discharge.  The specialist nurse will be able to answer any questions you have about your admission, will discuss discharge arrangements, and talk you through your admission, length of stay and treatment on the ward.

How long will I have to stay in hospital? 

 You will stay between one and three nights, although this can vary.  The type of hysterectomy you have will have a strong influence on this.  As soon as you no longer need medical or nursing attention, you will be able to go home.

You may need to arrange for help at home after your discharge.  Please let the enhanced recovery nurse know if there will be problems getting this help before you come into hospital.  This would enable the nursing staff to get input from Social Services if needed.

What sort of anaesthetic will I have? 

Most women have a general anaesthetic, but the anaesthetist will discuss this with you and, if required, may suggest an alternative type of anaesthesia.

Who is an anaesthetist?

An anaesthetist is a doctor trained to perform anaesthesia, who will make sure you remain asleep and well whilst your operation is carried out.  He/she will also advise on the care you need immediately after your operation and prescribe the most appropriate pain-relieving medications for you.

Spinal anaesthetic     

Using an injection in your back, the lower part of your body is numbed, reducing the feeling in this area and taking away any sensation of pain.  You will remain awake throughout the operation, but if you are anxious, you may be sedated so you are less aware of the experience.

General anaesthetic

This sends you to sleep so you don't feel, see or hear anything during your operation.

Are there any risks involved in having a general anaesthetic? 

Most people are able to have a general anaesthetic, but there are some risks and complications.  The majorities of them are relatively minor and includes soreness and swelling around the site of the intravenous injection, sore throat, nausea, vomiting and feeling “run down” for several days afterwards.

More serious complications are uncommon and are usually related to major procedures or to poor health.  Your anaesthetist will discuss any such risks with you before you have your operation.

If you are worried about anything relating to your anaesthetic, please talk it through with your anaesthetist.  He/she will help you decide whether or not to go ahead with the general anaesthetic.

When do I meet my anaesthetist? 

Your anaesthetist will usually come and see you before you go to theatre.  He/she will ask some questions about your medical history, such as if you smoke or if you have any allergies etc. This helps the anaesthetist to build up an overall picture of your health before your operation and helps him/her decide on the most appropriate type of anaesthetic for you.

What kind of incisions is used? 

Hysterectomies can also be done through the vagina, providing the uterus is not very enlarged.  In this case, there will be no visible incision as it will be inside the vagina and all stitches used will dissolve.

If the procedure is performed with the assistance of or entirely by keyhole surgery, then you will have few small incisions on your lower tummy.  These are required to allow doctor to look inside your tummy during the operation.   They are closed with stitches that dissolve.

In general, surgical incisions for an abdominal hysterectomy (a hysterectomy performed through a cut in the tummy) are made in either an up and down or side-to-side direction.  The side-to-side incisions are those that would be covered by the bottom half of a bikini.  The type of incision used will depend upon the exact reasons for doing the operation and the size of your uterus (womb).

Admission day

On the day of admission, you will be admitted to the Surgical Admission Lounge.  You will book in with the admissions clerk and then the nursing staff will prepare you for theatre. 

The nurses will check your notes and relevant investigations.   They will ensure that your consent is correct, and all your questions are answered.  The nurse will provide you with a wristband for identification and complete an anaesthetic check list:

• Please have a bath or shower first thing in the morning. 
• Please remove makeup, nail polish and jewellery. 
• If you wear glasses, dentures or a hearing aid, these can be removed either in the surgical admission lounge, or in the anaesthetic room. 
•  It is necessary to put tape over your wedding ring. 
• You will be given a gown to wear, which ties at the back, and you can bring a dressing gown to put over the theatre gown whilst you are waiting for your operation. 
• You will be fitted with your compression stockings. 
• You will either walk or be taken to theatre on a trolley and then the nurse will return your property back to the Surgical Admission Lounge.

Once in the theatre department, you will be connected to a heart monitor (to check your heart while you are asleep) and an injection will be given to you in the back of your hand to send you to sleep.

Following your operation

Following your recovery from general anaesthetic, you will be taken to a ward.  You will be alert, aware of your surroundings and stable following your operation.  You will have an intravenous drip in your arm.  This is to give you extra fluids, to help to reduce thirst.

You may have a catheter (small tube) in your bladder to drain urine away.  This is usually removed the day after the operation.  You may have a gauze pack (like a tampon) in the vagina; this helps to reduce bleeding by applying pressure.

To help prevent blood clots (thrombosis) forming in your legs; an injection to thin your blood will be given daily after your operation, until you are fully mobile. You will be asked to wear compression stockings to reduce the risk.  You will be encouraged to walk shortly after you arrive on the ward, even on the same day of surgery.

Your blood pressure, pulse and temperature will be monitored regularly during this time.  This is routine and allows the nursing staff to check there are no post-operative complications.

You may receive pain relief using a patient-controlled analgesia (PCA). This is a machine that allows you to control your own analgesia (pain relief) every five minutes.

A cannula (fine plastic tube) - may be inserted into your leg to allow repeat injections of pain relief.

You may be given suppositories; these contain an anti-inflammatory drug given into your rectum (back passage), which gives pain relief. Tablets will be offered to you when you are eating and drinking following surgery.

All of the above will be discussed by your anaesthetist or a nurse specialist in pain relief.

We will help you to sit out of bed or re-position you to be sitting up in bed, and you will be encouraged to drink water and progress to other fluids and food as you can tolerate them.  Your intravenous drip will be removed when the nurses are happy with your fluid intake and output. 

We will encourage you to start moving about as soon as it is safe to do so.  Remember, being mobile reduces the risk of blood clots and chest infections.

Recovering after the operation

Many women have a slight vaginal discharge after the operation, which usually settles within about four to six weeks.

A small amount of vaginal bleeding can occur up to 10 to 20 days after surgery.  As long as this is no heavier than a normal period, no action is needed.

If you have pain when passing urine, it may mean that you may have a mild infection which needs treatment.  You should contact your family doctor (GP).

Constipation can be a problem; it is important to drink plenty of fluids and take lots of fibre in your diet, such as fruit, vegetables and wholemeal bread.

Breathing and mobility exercises

After your operation, you have a surgical wound and may become relatively immobile.  This increases your risk of developing a chest infection or blood clot (thrombosis) particularly if you have had a general anaesthetic.

You can help to prevent these complications and aid your recovery by using some of the advice in this leaflet, such as the following breathing exercises:

Breathing exercises

After an anaesthetic and while you are inactive, it is important to use your lungs well:

• Take a deep slow breath in through your nose,
• Hold for a count of two
• “Sigh” the air out.

Repeat this three times.  Do this regularly until you are up and about.  This exercise also helps to loosen phlegm and spit.

Circulation

Start this exercise immediately while sitting in bed to ensure good circulation in your legs.

Briskly circle, or bend and stretch your feet from the ankle, for 20 to 30 seconds as often as possible.

General advice after the operation

Avoid slumping in bed or staying still for too long.  Sit up straight or lie on your side if possible.

Bending your knees up, and placing a pillow over any abdominal wound, will ease the pain of coughing.

Day 1

You will be encouraged to do more for yourself, but rest as you feel the need.  Your catheter will be removed by the nursing staff when they feel that you are passing good amounts of urine.

You may take a shower when you feel ready.  “Wind” pains can be a problem, as well as constipation, so please ask the nursing/medical team for advice.  Suppositories or laxatives are available if needed.

If you have had abdominal surgery, your dressing(s) will be removed prior to discharge, and you will be advised about wound care and hygiene.

Some patients may be able to be discharged if the doctors and nurses feel that it is safe to do so. This is more likely if you have had a vaginal or keyhole type of hysterectomy.

Day 2

You will be encouraged to plan for your discharge home.

If there is any aspect of your operation you do not understand, please ask for help.

Do you understand what you are allowed and not allowed to do when you get home?   Ask if you need further explanation.

Discharge

On discharge from hospital, you will be given a letter for your GP and simple painkillers to take home.

The nurse on the ward will inform you whether or not a District Nurse is needed.  If so, then the staff will refer you to the district nurse service and they will contact you to make arrangements to see you.

Your questions answered

How long will it take for me to recover? 

It takes about six to eight weeks to get back to normal. This is often quicker if you have a vaginal or keyhole hysterectomy.  This varies from person to person, and you should return to normal activities at your own pace.  However, it is important for you to be as active as possible, as being bed-ridden can mean there is an increased risk of blood clots (thrombosis) occurring in the veins and lungs.  Although you need to be active, you should be sensible, and make sure you have periods of rest when you begin to feel tired.

When will I be able to go back to work? 

You should be able to go back to work after about six to eight weeks, depending on the type of work you do.  Those doing manual or physical work will need longer at home than those doing more sedentary (seated) office type work.

Lifting and exercise

It is recommended that you avoid the following until at least six weeks after surgery:

• Sit up exercises
• Lifting children or heavy objects
• Gardening
• Heavy housework
• Aerobic exercises.

When will I be able to drive? 

When the wound in your tummy has healed, does not cause any pain and when you can wear a seat belt and stop the car in an emergency without any discomfort.  This is usually between four to six weeks after your operation.

How long before I can have sexual intercourse? 

In general, most women wait until they have been for their six-week check-up.  This allows for the stitches in the vagina to heal.  Gentle sex, in most cases, could be attempted after about four to five weeks, although most women initially may just want a cuddle.

Will I lose interest in sex? 

Your sexual appetite should remain the same after the operations as it was before.  Both you and your partner may be nervous at first, wondering whether things will be the same, or if intercourse will be painful or difficult.  Some women feel more relaxed afterwards because the worry of pregnancy has been removed.

Are there any long-lasting effects? 

In general, there are no long-term effects.  However, you need to be aware that although the hysterectomy may solve the problem you had, other unrelated problems will not disappear, such as headaches and tiredness.  Occasionally a hysterectomy may aggravate irritable bowel symptoms and may leave you with an overactive bladder (need to pass urine frequently and urgently).  If this occurs you should ask for advice, since treatment is often available.

You may experience slight weight gain as you recover, through taking less exercise.  It is not unusual to experience mood swings after a hysterectomy and at times you may feel tearful.  This is normal and nothing to worry about.  In time, these feelings will pass but it is best to explain to your partner and family so that they will understand and be able to help you through these times.

Will I need hormone replacement therapy (HRT)?

If you have had your ovaries removed at the time of the hysterectomy, further discussions regarding hormone replacement therapy will be required and probably recommended.

And finally

Although you have had a major operation, after about three days you will be well on the way to recovery.  Some days will be better than others and remember don’t compare yourself with other patients, since each hysterectomy is different, and more importantly we are all individuals and therefore different.

Contact information

If you have any questions, please do not hesitate to ask the doctors and nurses.  If you are yet to have your operation or have had your operation and have gone home, you are welcome to telephone Swinley Ward, 01942 822568 for advice.