Hysterectomy

Article Last Updated: Aug 22, 2006

Author: Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, e! "ersey
#ysterecto$y is the $ost co$$on non%pregnancy&related $a'or surgery perfor$ed on !o$en in the
United States( )his surgical procedure involves re$oval of the uterus and cervi*, and for so$e conditions,
the fallopian tu+es and ovaries( ,easons for choosing this operation are treat$ent of uterine cancer and
various co$$on noncancerous uterine conditions that lead to disa+ling levels of pain, disco$fort, uterine
+leeding, and e$otional stress( Although this procedure is highly successful in curing the disease of
concern, it is a surgical alternative !ith the acco$panying ris-s, $or+idity, and $ortality that an operative
procedure carries and it leads to sterility in !o$en !ho are pre$enopausal( )he patient $ay +e
hospitali.ed for several days and $ay re/uire 6&02 !ee-s of convalescence( Co$plications such as
e*cessive +leeding, infection, and in'ury to ad'acent organs also $ay occur(
#istory of the Procedure
1n ove$+er 0234, Charles Clay perfor$ed the first hysterecto$y in 5anchester, 6ngland( 1n 0727,
,ichardson, 58, perfor$ed the first total a+do$inal hysterecto$y 9)A#:, in !hich the entire uterus and
cervi* !ere re$oved 9"ohns, 077;:(
Pro+le$
Epidemiology of fibroids
<i+roids, or leio$yo$as, account for one third of hysterecto$ies and one fifth of gynecological visits, and
they create an annual cost of =0(2 +illion 9Lepine, 077;> ?hao, 0777:( )hey are +enign uterine tu$ors that
increase in si.e and fre/uency as !o$en age +ut revert in si.e post$enopausally 9@ood!in, 2000> A'erulff,
0776:( <actors that have proven to contri+ute to fi+roid gro!th include estrogen, progesterone, insulinli-e
gro!th factors 1 and 11, epider$al gro!th factor, and transfor$ing gro!th factor&+eta 9@uarnaccia, 2000:(
)he fre/uency of fi+roid appearance in African A$erican !o$en is 2&4 ti$es higher than in !hite !o$en(
Bo$en !ho are o+ese or e*perience $enarche !hen younger than 02 years are at increased ris- of fi+roid
develop$ent due to prolonged e*posure to estrogen( Bo$en !ho have had children are at a lesser ris- for
fi+roid develop$ent than !o$en !ho have never +een pregnant 98e$ello, 2000:(
6ach fi+roid arises fro$ a single $onoclonal cell line fro$ the s$ooth&$uscle cells of the $yo$etriu$
9)o!nsend, 07;0:( 5ost 960C: fi+roids are chro$oso$ally nor$al( )he rest have nonrando$
chro$oso$al a+nor$alities that can +e separated into 6 cytogenic su+groups, !hich are triso$y 02,
translocation +et!een chro$oso$e 02 and 03, rearrange$ents of the short ar$ of chro$oso$e 6 and the
long ar$ of chro$oso$e 00, and deletions of chro$oso$es 4 and ; 9@ross, 2000:(
Asy$pto$atic fi+roids are relatively slo! gro!ing and characteri.e $ost of the tu$ors found in patients(
Previously, uterine si.e 9consisting of asy$pto$atic fi+roids: e/uivalent to 02 !ee-sD gestation 9220 g: had
+een the standard threshold for reco$$ending a hysterecto$y( )hus, asy$pto$atic fi+roids of s$aller si.e
!ere handled via o+servation, !ith an annual pelvic e*a$ination andEor transvaginal ultrasound(
Currently, surgical procedures are not reco$$ended for fi+roids +ased on uterine si.e alone in the a+sence
of sy$pto$s( According to ,eiter et al 90772:, no increased incidence in perioperative $or+idity e*isted
posthysterecto$y in those !o$en !ith a fi+roid uterus larger than 02 !ee-sD gestational si.e co$pared to
those !o$en !ith a fi+roid uterus s$aller than 02 !ee-sD gestational si.e( )hey concluded that
hysterecto$y for a large asy$pto$atic fi+roid uterus $ay not +e needed as a $eans of preventing
increased operative $or+idity associated !ith future gro!th, unless a sarco$atous change is o+served(
1n patients !ho e*perience sy$pto$s !ith fi+roids, the sy$pto$s are related to the si.e, location, and
nu$+er of fi+roids !ithin the uterus( As $any as one third of patients !ith sy$pto$atic uterine fi+roids
e*perience a+nor$al +leeding, cra$ping, and prolonged and heavy $enstrual periods, !hich can result in
ane$ia( )he gro!th of fi+roids to large si.es $ay cause pressure on local organs> thus, presenting
sy$pto$s $ay include pelvic pain or pressure, pain during se*ual intercourse, reduced urinary capacity
due to increased +ladder pressure, constipation due to increased colon pressure, and infertility or late
$iscarriages 9@uarnaccia, 2000:(
Epidemiology of endometriosis
6ndo$etriosis is responsi+le for appro*i$ately one fifth of hysterecto$ies, and it affects !o$en during
their reproductive years 9Lee, 0723:( 1t is a disease in !hich tissue si$ilar to the endo$etriu$ is present
outside the endo$etrial cavity 9in other areas of the +ody:( Such sites include all the reproductive organs,
+ladder, intestines, +o!el, colon, and rectu$( Fther sites $ay include uterosacral liga$ents, the cul&de&sac,
pelvic side!alls, and surgical scars( )his ectopic endo$etrial tissue responds to $onthly hor$onal
sti$ulation and, thus, +rea-s do!n and +leeds into the peritoneal cavity !hen located there, causing
internal +leeding, infla$$ation of the surrounding areas, and for$ation of scar tissue( Scar tissue then can
+eco$e +ands of adhesions that are capa+le of distorting internal anato$y( Patients also $ay e*perience
sy$pto$s of pelvic pain> pain during +o!el $ove$ents, urination, and se*ual intercourse> and infertility or
$iscarriages 9Beir, 2000:(
Currently, no cure e*ists for endo$etriosis( Although $any !o$en see- hysterecto$y for pain relief, it
does not provide a definite cure +ecause so$e !o$en in !ho$ one or +oth ovaries are preserved $ay
continue to e*perience pro+le$s !ith endo$etriosis that !as left +ehind(
Epidemiology of pelvic relaxation
@enital prolapse is the indication for appro*i$ately 0GC of hysterecto$ies( Harious stresses on the pelvic
$uscles and liga$ents can cause significant !ea-ening and, thus, uterine prolapse( )he pri$e cause of
insult to the pelvic support structures is child+irth( )herefore, $ultiple pregnancies and vaginal deliveries
increase the ris- for uterine prolapse( A fe! less dra$atic causes of increased pelvic pressure include
straining during +o!el $ove$ents, chronic coughing, and o+esity( Also, significant pelvic structure
!ea-ening occurs post$enopause +ecause estrogen, !hich pelvic tissues need to $aintain their tonicity, is
not present in significant a$ounts after $enopause(
Bo$en !ith $ild pelvic rela*ation $ay +e free of sy$pto$s( #o!ever, patients !ith $oderate&to&severe
rela*ation $ay e*perience sy$pto$s that include heaviness and pressure in the vaginal area> lo! +ac-
pain, lea-age of urine, !hich can !orsen during heavy lifting, coughing, laughing, or snee.ing> urinary
tract infections> and pro+le$s !ith se*ual intercourse 9Lee, 0723:( Although several techni/ues that
provide te$porary i$prove$ent and control of pelvic rela*ation e*ist, in $oderate&to&severe situations,
hysterecto$y $ay provide a $ore functional and longer&lasting result and even $ay prevent the need for a
second operation in case prolapse sy$pto$s !orsen later !ith the develop$ent of cystocele andEor
rectocele(
Epidemiology of cancer of reprodctive organs
Cancer of the uterus, or endo$etrial cancer, is the $ost co$$on gynecological cancer in the United States,
!ith an esti$ated 46,000 ne! cases in 2000 9@reenlee, 2000:( 1t affects !o$en aged 4G&70 years, !ith a
$ean age of 62 years( Cancer +egins in the lining of the endo$etriu$ and can spread to other reproductive
organs and to the rest of the +ody(
Stage 0 endo$etrial cancer is confined to the corpus, or +ody, of the uterus( Sy$pto$s $ay include
+leeding +et!een periods or, as is in $ost cases, spotting in patients after $enopause( Stage 0 endo$etrial
cancer is very slo! gro!ing and highly cura+le( A hysterecto$y is the preferred $ethod of treat$ent( ot
only is the uterus re$oved, +ut the ovaries and fallopian tu+es also are re$oved +ecause ovaries are a
possi+le site for $ore cancer, or they $ay secrete hor$ones that play a synergistic role in the gro!th of the
cancer( Fnly in rare cases of early endo$etrial cancers in !o$en !ho are in their second or early part of
the third decade of life are atte$pts $ade to preserve the ovaries(
1n stage 2 endo$etrial cancer, the cancer has spread to the cervi*( Appro*i$ately 02,200 ne! cases of
cervical cancer diagnoses occur annually in the United States 9Sa!aya, 2000:( Sy$pto$s of cervical cancer
include +leeding +et!een periods, +leeding post$enopause, or +leeding after se*ual intercourse( 1n so$e
cases, radical hysterecto$y 9re$oval of the uterus, cervi*, top portion of vagina, ovaries, fallopian tu+es,
and tissues in the pelvic cavity surrounding cervi*: $ay +e the treat$ent of choice, along !ith
che$otherapy or radiotherapy if needed(
1n stage 4A endo$etrial cancer, the cancer has spread to the ovaries and fallopian tu+es( )his $ay +e
treated !ith a )A# and +ilateral salpingo&oophorecto$y 9re$oval of the uterus, fallopian tu+es, and
ovaries:, along !ith che$otherapy or radiotherapy if needed( 1n stage 4B, the cancer has spread to the
vagina( 1n this case, a vaginecto$y or radical hysterecto$y $ust +e perfor$ed, along !ith che$otherapy
or radiotherapy if needed( By stage 4C, the cancer has entered the ly$ph nodes( 1n this case, ly$ph node
dissection and hysterecto$y is the treat$ent of choice, along !ith che$otherapy or radiotherapy if needed(
<re/uency
Appro*i$ately 600,000 hysterecto$ies are perfor$ed annually in the United States, !ith a cost of
appro*i$ately =G +illion per year(
)he US Centers for 8isease Control and Prevention 9C8C: esti$ated 2(6 $illion US !o$en had a
hysterecto$y fro$ 0720&0774( 8uring this span, the C8C studied ho! the rates of hysterecto$y differed
+y age, geographic region, and conditions associated !ith hysterecto$y( Annually, the rates !ere highest
a$ong !o$en aged 30&33 years and lo!est a$ong !o$en aged 0G&23 years( 6ach year, the highest rate of
hysterecto$ies !as in the South, !ith an incidence of 6(2 cases per 0000 population, !hile in the
ortheast, 5id!est, and Best, the rates !ere 4(7, G(G, and 3(7 cases per 0000 population, respectively
9Lepine, 077;:(
)he $ost co$$on $edical reasons for undergoing a hysterecto$y include +enign fi+roid tu$ors,
dysfunctional uterine +leeding 98UB:, endo$etriosis, and uterine prolapse( Uterine cancer is not as
co$$on +ut is an i$portant reason for undergoing a hysterecto$y(
Clinical
Preoperative evaluation includes the follo!ing:
Co$plete history and physical: 6valuate, in detail, any co$or+id conditions such as dia+etes
$ellitus, hypertension, cardiac disease, or asth$a(
5edication history such as use of aspirin, oral hypoglyce$ics, heparin, or !arfarin
PAP s$ear, endo$etrial sa$pling, ultrasonography, CBC count, +lood type and cross $atch, and,
depending upon age and ris- factors, 6C@ and chest radiograph: 1n case of $alignancy,
preoperative staging can +e deter$ined !ith the help of +iopsies, CA) scans, 1HP, cystoscopy,
+ariu$ ene$a, etc(
INDICATIONS
Reasons for choosing hysterectomy are treatment of uterine cancer and various
common noncancerous uterine conditions that lead to disabling levels of pain,
discomfort, uterine bleeding, and emotional stress
R!!"ANT ANATO#$
Total abdominal hysterectomy involves removal of the uterus and cervi%
through an abdominal incision
Supracervical or subtotal hysterectomy is removal of the uterus through an
abdominal incision, &hile sparing the cervi%
Radical hysterectomy is e%tensive surgery that, in addition to removal of
the uterus and cervi%, might include removal of lymph nodes, loose areolar
tissue near ma'or blood vessels, upper vagina, and omentum
Oophorectomy and salpingo(oophorectomy) Oophorectomy is the surgical
removal of the ovary and salpingo(oophorectomy is the removal of the
ovary and the fallopian tube
"aginal hysterectomy is removal of the uterus and the cervi% through the
vagina
*aparoscopy(assisted vaginal hysterectomy is vaginal hysterectomy &ith
the help of laparoscopy
CONTRAINDICATION
Haginal hysterecto$y is contraindicated in only 00&20C of cases, eg, uterine si.e greater
than 220 g 9Aovac, 077;:, previous $ultiple a+do$inal or pelvic surgeries, advanced
uterine or cervical $alignancies, and ovarian $alignancies(
+OR, -.
*ab Studies
C/C count, .A. smear, endometrial sampling, ultrasonography, blood
type and cross match, and, in some cases, chest radiography, !C0, CAT
scan, #RI, cystoscopy, barium enema, I"., blood chemistry, tumor
mar1ers, etc
#edical therapy
Although hysterectomy often is the definitive treatment for many pelvic
pathologies, nonsurgical alternatives al&ays should be attempted in elective
cases 2ormonal therapy, gonadotropin(releasing hormone antagonists, I-D(
containing progesterone, endometrial ablation, focused ultrasonographic surgery,
cryotherapy, and uterine artery emboli3ation have been used &ith success
Surgical therapy
Abdominal hysterectomy
In November 4567, Charles Clay performed the first hysterectomy in #anchester,
!ngland The earliest hysterectomies &ere supracervical, or subtotal,
hysterectomies The body of the uterus &as removed &hile the cervi% remained
intact In 4898, Richardson, #D, performed the first TA2, in &hich the entire
uterus &as removed :;ohns, 488<=
.rior to an abdominal hysterectomy, the patient undergoes a regional or general
anesthetic A patient remains a&a1e during a regional anesthetic, &ith only part
of the body being numbed to prevent pain +hen given a general anesthetic, the
patient is unconscious
The abdominal hysterectomy begins via a surgical incision >(5 inches long, made
either vertically, running from the navel to the pubic bone, or hori3ontally, running
along the top of the pubic hairline The cut e%poses the ligaments and blood
vessels surrounding the uterus These ligaments and blood vessels then are
separated from the uterus and cervi% In the process, the blood vessels are tied
off to prevent bleeding and to help in healing The uterus and cervi% are then cut
off at the superior portion of the vagina and removed The top of the vaginal cuff
is closed &ith sutures, and the surgical &ound is closed in layers
An abdominal hysterectomy may be performed in con'unction &ith a salpingo(
oophorectomy, in &hich the adne%a are removed, if needed .ossible
complications include surgical &ound infection? e%cessive bleeding? in'ury to the
bo&el, bladder, or ureter? or urinary tract infection Candidates for this surgery
include those &ho have fibroids, abnormal or heavy bleeding, chronic pelvic pain,
endometriosis, adenomyosis :endometrial tissue that has infiltrated the
myometrium=, uterine prolapse, cancer of the reproductive organs, or pelvic
inflammatory disease
Vaginal hysterectomy
In a vaginal hysterectomy, the uterus is removed through the vaginal introitus
.rior to surgery, the patient is given a regional or a general anesthetic and the
s1in surrounding the vagina is prepped &ith an antibacterial solution A surgical
incision is then made in circular fashion around the cervi% and through the upper
vagina to e%pose the tissue and blood vessels around the cervi% and uterus The
tissues and vessels are cut and tied off for the uterus and cervi% to be removed
from the top of the vagina The upper part of the vagina &here the surgical
incision &as made then is sutured
.ossible complications include surgical &ound infection? e%cessive bleeding?
in'ury to the bo&el, bladder, or ureter? or urinary tract infection Often,
colporrhaphy :reconstructive surgery= is done to repair or prevent cystocele,
rectocele, and@or vaginal vault prolapse Candidates for this surgery include
those &ho have fibroids, abnormal or heavy bleeding, adenomyosis, uterine
prolapse, early(stage cancer of the reproductive organs, or precancerous
conditions of reproductive organs
Laparoscopically assisted vaginal hysterectomy
*aparoscopically assisted vaginal hysterectomy :*A"2= is a procedure that uses
laparoscopic surgical techniAues and instruments to remove the uterus, cervi%,
and@or fallopian tubes and ovaries through the vagina .rior to surgery, the
patient is usually given a general anesthetic and the abdomen and vagina are
prepared &ith an antibacterial solution
*A"2 begins &ith several small abdominal incisions inferior to the belly button,
&hich allo& the insertion of the laparoscope and other surgical tools In order for
the surgeon to observe the inside of the body clearly, the peritoneal cavity is
inflated &ith gas :usually carbon dio%ide=, and a camera, &hich is attached to the
laparoscope, captures and produces a continuous image that is magnified and
pro'ected onto a television screen -sing the laparoscopic surgical tools, the
tissues and vessels surrounding the uterus are cut and tied off The uterus and
cervi% then is removed through the vagina, and the top of the vaginal cuff is
sutured The fallopian tubes and ovaries also may be removed during this
surgical procedure
.ossible complications include surgical &ound infection? e%cessive bleeding?
in'ury to the bo&el, bladder, or ureter? or urinary tract infection Candidates for
this surgery include those &ho have had previous abdominal surgery, large
fibroids, chronic pelvic pain, endometriosis, or pelvic inflammatory disease, or
those &ho &ant an oophorectomy Today, robotic laparoscopic surgery, such as
procedures involving the da "inci Surgical Robot, also is being refined to
evaluate the performance of *A"2
Comparisons of hysterectomy procedures
+ith the various hysterectomy procedures available, physicians must limit health
care dollars associated &ith these surgical procedures &hile maintaining Auality
health care for patients "arious studies have been performed to decide &hich
surgical procedure is most suitable in terms of economics and patient health
In a study provided by Carter et al :4886=, patients undergoing *A"2 &ere
compared to patients undergoing TA2 .atients in both categories shared similar
demographics, pathological diagnoses, and a common symptom of severe
disabling pelvic pain Results of the study sho&ed that operative time for *A"2
:466 B 74 min= &as significantly longer than for TA2 :85 B CD min= No significant
difference in blood loss occurred bet&een the 9 groups, &ith patients &ho
under&ent *A"2 losing 94> B 59 m* compared to patients &ho under&ent TA2
and lost 988 B 74 m* The length of stay for patients in the *A"2 group :949C B
D5<C d= &as significantly shorter than for patients in the TA2 group :7C6 B D8>
d=
.ostoperative pain levels also &ere measured on a 4D(point activity scale, &ith 4
eAual to no pain and 4D eAual to unbearable pain On day 4, no significant
difference bet&een *A"2 :>>= and TA2 :>6= &as noted 2o&ever, on day <,
pain &ith *A"2 :95= &as significantly less than &ith TA2 :7>=, and, by &ee1 7,
*A"2 :46>= continued to produce significantly less pain than TA2 :45=
.ostoperative activity levels also &ere measured on a 4D(point activity scale, &ith
4 eAual to e%tremely limited activity and 4D eAual to no limits on activity On day
4, no significant difference bet&een *A"2 :76= and TA2 :77= activity levels &as
noted 2o&ever, on day <, activity post(*A"2 :<5= &as significantly greater than
after TA2 :C5=, and, by &ee1 7, *A"2 :8>= continued to allo& significantly more
activity than TA2 :<8=
.atients undergoing *A"2 remained in the hospital for 9C days, costing
E49,546? patients undergoing TA2 remained in the hospital for 6C days, costing
E4D,C44 Therefore, patients undergoing *A"2 apparently have shorter
hospitali3ation and more rapid recuperation and return to normal activities, but
they spend longer time in the operating room .atients undergoing TA2 have the
prime advantage of shorter operation time Although the hospital costs for *A"2
are significantly greater than for TA2, patients &ho undergo *A"2 usually return
to &or1 earlier and thus reAuire less time off &or1 This means eAually important
savings in disability insurance for patients undergoing *A"2 :Carter, 4886=
In a study provided by *ipscomb :488<=, patients undergoing *A"2 &ere
compared to patients undergoing vaginal hysterectomy These patients &ere
randomly assigned to these 9 categories, and their primary and secondary
symptoms &ere fibroid tumors and pelvic pain, respectively The surgery time for
the *A"2 group :49D4 B 95C min= &as almost t&ice that for the vaginal
hysterectomy group :>6< B 9< min= The amount of blood lost in the *A"2 group
:9D75 B 47DC m*= &as significantly less than the blood lost in the vaginal
hysterectomy group :7<>4 B 9>4C m*= The procedures &ere performed on an
outpatient basis, &ith the cost for the *A"2 group :E<8DC B CD4= being
significantly greater than the vaginal hysterectomy group :E6584 B 7CC=
The postoperative pain in the 9 groups &as the same, e%cept for postoperative
day 9, on &hich patients undergoing *A"2 reAuired significantly more pain
medication than patients undergoing vaginal hysterectomy /ased on these
results, *A"2 apparently may not be the first choice in patients &ho are good
candidates for vaginal hysterectomy :*ipscomb, 488<=
The severity of the pathological disorder must be the 1ey standard in selecting
the type of hysterectomy, in order to maintain optimum surgical practice In
studies performed in the -nited States, France, and the -nited ,ingdom in &hich
strict guidelines based on the severity of the pathological disorder have been
implemented, most patients under&ent successful vaginal hysterectomy &ithout
abdominal or laparoscopic assistance :,ovac, SR 4885=
In fact, after revie&ing over 5D reports involving appro%imately <DDD patients,
physician(revie&ers &ho supported the use of systemic guidelines for selecting
the appropriate hysterectomy route suggested that vaginal hysterectomy should
be selected in 5DG of cases because the vaginal route is contraindicated in only
4D(9DG of cases, eg, uterine si3e greater than 95D g, :,ovac SR, 488<=
2o&ever, these findings should not lead physicians to disregard the use of *A"2
because it still may be useful in certain cases, especially in cases &ith pelvic
adhesions from prior surgery and infections In order to conserve health care
dollars, these reports suggest that laparoscopic techniAues should not be
implemented in more than 9DG of scheduled hysterectomies :,ovac, 4885=
In a study performed by #a1inen et al :9DD4= in Finland during 488>, a total of
4D,44D hysterectomies, consisting of C5<C abdominal, 45D4 vaginal, and 9676
laparoscopic operations sho&ed a rate of overall complications of 4<9G, 977G,
and 48G, respectively The most freAuent complications &ere infections, &ith
occurrences of 4DCG, 47G, and 8G for abdominal, vaginal, and laparoscopic
operations, respectively In'uries to the ureter &ere most common in the
laparoscopic group :&ith a relative ris1 of <9= compared to the abdominal group,
&hile bo&el in'uries &ere most freAuent in the vaginal group :&ith a relative ris1
of 9C= compared to the abdominal group Severe hemorrhagic events occurred
&ith freAuencies of 94G, 74G, and 9<G in the abdominal, vaginal, and
laparoscopic group, respectively From these results, the significance of a
surgeonHs e%pertise in reducing severe complications, especially in *A"2 and
vaginal hysterectomy, is apparent :#a1inen, 9DD4=
Follo&(up
After the surgery, it ta1es 6(> &ee1s to recover Recovery is earlier in cases of
vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy
No lifting anything heavy for > &ee1s after the surgery
In case of oophorectomy in premenopausal &omen, patients e%perience
menopausal symptoms li1e hot flashes, vaginal dryness, and mood disturbances
Return to .ossible complications of hysterectomy include surgical &ound
infection? e%cessive bleeding? in'ury to the bo&el, bladder, ureter, or ma'or blood
vessel? urinary tract infection, postoperative thromboembolism, atelectasis, early
onset of menopause, and loss of ovarian function
normal se%ual activities is e%pected after > &ee1s of surgery
CO#.*ICATION
.ossible complications of hysterectomy include surgical &ound infection?
e%cessive bleeding? in'ury to the bo&el, bladder, ureter, or ma'or blood vessel?
urinary tract infection, postoperative thromboembolism, atelectasis, early onset of
menopause, and loss of ovarian function
F-T-R! AND CONTRO"!RSI!S
Although hysterectomy is often the definitive treatment for many pelvic
pathologies, nonsurgical alternatives al&ays should be attempted in elective
cases 2ormonal therapy, gonadotropin(releasing hormone antagonists,
progesterone(containing intrauterine device, endometrial ablation, cryotherapy,
and uterine artery emboli3ation have been used &ith success
As more pharmacologic and invasive radiologic interventions become available,
the number of hysterectomies performed not only in the -nited States but also
abroad &ill continue to decrease
Not only &ill surgical techniAues continue to be updated and improved, but
preoperative and postoperative interventions, such as the use of epoetin alfa
:.rocrit=, &ill improve morbidity, mortality, and Auality of life &hen this surgical
procedure is performed
/ecause the uterus is associated &ith femininity, some &omen e%perience a
sense of loss after a hysterectomy 2o&ever, some &omen find a hysterectomy
to enhance their Auality of life because it provides relief of symptoms and definite
contraception
R!F!R!NCI!S
/achmann 0A !poetin alfa use in gynecology .ast, present and future J
Reprod Med #ay 9DD4?6>:C Suppl=)C78(66 I#edlineJ
Carter ;!, Ryoo ;, ,at3 A *aparoscopic(assisted vaginal hysterectomy) a
case control comparative study &ith total abdominal hysterectomy J Am
Assoc Gynecol Laparosc Feb 4886?4:9=)44>(94 I#edlineJ
Demello A/ -terine artery emboli3ation AORN J Apr 9DD4?<7:6=)<8D(9,
<86(5, 5DD(6 passim? Aui3 5D8(46 I#edlineJ
0ood&in SC, +ong 0C -terine artery emboli3ation for uterine fibroids) a
radiologistHHs perspective Clin Obstet Gynecol ;un 9DD4?66:9=)649(
96 I#edlineJ
0reenlee RT, #urray T, /olden S Cancer statistics, 9DDD CA Cancer J
Clin ;an(Feb 9DDD?CD:4=)<(77 I#edlineJ
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Obstet Gynecol ;un 9DD4?66:9=)77C(68 I#edlineJ