Hysterectomy is surgery to remove the uterus, also referred to as the womb. Among surgeries specific to women, hysterectomies are the second most common in the U.S. (after cesarean sections). One in three women in the U.S. have had a hysterectomy by age 60. Hysterectomy is major surgery that involves important considerations regarding the type of hysterectomy, type of anesthesia, preoperative preparations, and postoperative pain management.
Hysterectomy is an option for treating many conditions. The following are the most common, as identified by the Office on Women’s Health at the U.S. Department of Health and Human Services:
- Uterine fibroids. Noncancerous growths that can cause pain and heavy bleeding.
- Uterine prolapse. Slippage of the uterus into the vagina.
- Endometriosis. Tissue similar to the lining of the uterus that grows outside of the uterus.
- Adenomyosis. Thickening of the uterus.
- Cancer or precancer of the uterus, cervix, ovaries, or endometrium (the lining of the uterus).
- Heavy or unusual vaginal bleeding.
In some cases, nonsurgical options or less extensive surgeries are available to treat these conditions.
The type of hysterectomy you have will depend on the condition being treated. These are the primary types:
- Partial hysterectomy (also called subtotal or supracervical). The surgeon removes the upper part of the uterus, leaving the cervix in place. The cervix is the lower, narrower end of the uterus that is attached to the vagina.
- Total hysterectomy. The surgeon removes the entire uterus, including the cervix.
- Radical hysterectomy. The surgeon removes the uterus, cervix, tissue on both sides of the cervix, and the upper part of the vagina. This type is most often used to treat cancer.
In some hysterectomies, the surgeon also removes the ovaries, fallopian tubes, or both. This decision may be based in part on the reasons for your hysterectomy and your risk for ovarian cancer.
The procedure used for a hysterectomy will depend on several factors. These factors include the condition being treated, the patient’s health history, the size of the uterus, the surgeon’s level of experience with the procedure, and patient preference.
These are the options:
- Vaginal hysterectomy. The surgeon removes the uterus through a small cut at the top of the vagina. This is the least invasive technique and has the shortest recovery time.
- Laparoscopic hysterectomy. A laparoscope is an instrument with a thin, lighted tube and a small camera; the surgeon inserts it through a small incision in the abdomen, often through the bellybutton, to view internal organs during the procedure. This view helps the surgeon guide the small surgical tools used to remove the uterus through small cuts in the abdomen or vagina.
- Robotic hysterectomy. This is a type of laparoscopic hysterectomy in which the surgeon guides a robotic arm to do the surgery through small cuts in the lower abdomen.
- Abdominal hysterectomy. The surgeon removes the uterus through a cut in the lower abdomen. With this procedure, it may take longer to fully recover. But its use may be necessary due to the size of the uterus, the need to examine surrounding tissue, or other factors.
The procedure used for the surgery may impact the type of anesthesia used, the recovery time, the level of postoperative pain, and the potential for chronic pain.
Consult with your surgeon’s office and follow their guidance. Tell the anesthesiologist, who is a medical doctor with specialized training, about any health problems you have, any negative reactions you have had to anesthesia, and all prescribed and over-the-counter medicines, vitamins, and supplements you take. Don’t leave anything out. This information affects decisions by your anesthesiologist about how to safely administer sedation or anesthesia during surgery.
Discuss realistic expectations for the surgery, the best hysterectomy procedure for your circumstances, and options for pain management after surgery.
The anesthetic and sedation you will receive to keep you comfortable and pain-free during surgery will depend on the type of hysterectomy you are having, your prior reactions to anesthesia, and your preferences and those of the surgeon, among other factors. You can discuss these options with your anesthesiologist prior to surgery.
- General anesthesia is used for almost all laparoscopic hysterectomies and is often used for abdominal and vaginal hysterectomies. General anesthesia renders you unconscious. It also impairs your breathing, so a breathing tube, ventilator, and inhalation anesthetic may be used.
- Neuraxial anesthesia in the form of a spinal block or epidural is an option for some vaginal and abdominal hysterectomies. This regional anesthesia numbs your body from your abdomen to your toes. Sedation can be provided as needed for patient comfort, including deep sedation so you remain unaware during surgery. Anesthesia medication is administered through a needle (for a spinal block) or through a needle and catheter (for an epidural) in your lower back.
Use of a spinal block or epidural allows for a quicker recovery than when general anesthesia is used. There is also some evidence associating neuraxial anesthesia with reduced incidence of chronic pain. However, it has not been firmly established to what extent these outcomes might be more tied to the hysterectomy procedure used than to the choice of anesthesia.
Steps can be taken before, during, and after surgery to manage any pain you might otherwise feel after surgery. Consulting with the anesthesiologist for your surgery can help. These are some options for pain management:
- Preoperative medications. Many physicians will consider administering medications, such as acetaminophen, before or during the procedure to help with postoperative pain.
- Preoperative counseling. Because there can be a psychological component to pain, you may want to consider a pre-surgical psychological assessment. Sometimes this type of assessment is required by the insurance company or the surgeon’s office. If it is not required but you feel you would benefit from one, ask your surgeon’s office about the option.
- Extension of the epidural. If an epidural nerve block is used during surgery, it can continue to be used for postoperative pain relief, with the dosage adjusted through the catheter.
- Postoperative medications. Non-opioid options—which should be prioritized—include nonsteroidal drugs, like ibuprofen, and the steroid dexamethasone.
- Postoperative nerve blocks. Evidence is still being gathered on the efficacy of several postoperative nerve blocks, including erector spinae plane, quadratus lumborum, and transversus abdominis plane (TAP) blocks. Recent findings suggest that the benefits of TAP may be confined to abdominal hysterectomies, but these nerve blocks can be a good option to try before opioids if other medicines are not working.
- Opioids for breakthrough pain. Opioids should be used sparingly—primarily when other options are not alleviating your pain. An opioid may also be the best option if existing health conditions or drug interactions prevent you from using other medicines or methods of pain relief.
Anesthesiologists who specialize in pain management can work with you before and after surgery to develop a plan tailored to your condition, personal history, and preferences. They will consult with you after surgery to determine what is working and what is not, and they will adjust your pain management treatment based on the level of pain you are experiencing.
According to the Office of Women’s Health, resumption of normal activities after a vaginal, laparoscopic, or robotic procedure can take place after three to four weeks. For abdominal surgery, the recovery time can be as long as four to six weeks.
The Office of Women’s Health notes other changes that you may experience after a hysterectomy:
- Better quality of life. You should no longer experience the symptoms, such as bleeding and pain, that led to the need for the procedure.
- Symptoms of menopause. You will no longer have periods. If your ovaries were removed during the hysterectomy, you may have other menopause symptoms as well, such as hot flashes. (If the ovaries were not removed, they may continue to produce hormones that will delay the onset of other menopause symptoms.)
- Changes in your sex life. Some people experience vaginal dryness or a lower sex drive after a hysterectomy, especially if the ovaries were removed. However, many people report a better sex life because of the relief from pain or heavy vaginal bleeding.
- Increased risk for other health problems. Removal of both ovaries could put you at higher risk for bone loss, heart disease, and urinary incontinence (leaking of urine). Talk with your doctor about how to prevent these problems.
Chronic pain is pain that lasts three months or longer. Estimates vary widely on the likelihood of chronic pain after a hysterectomy, from 10% to 50%.
The risk is higher for those who have an abdominal hysterectomy. For example, patients who underwent a vaginal hysterectomy were 50% less likely to experience chronic postoperative pain than patients who had an abdominal hysterectomy, according to a study of 766 women that was published in the May 2015 issue of Anesthesiology®.
Some research has identified additional factors that may increase the risk of chronic pain following a hysterectomy:
- Preoperative pelvic pain
- Preoperative fibromyalgia
- Acute postoperative pain
- Anxiety, depression, pain catastrophizing, and other psychological factors
Consult with your surgeon or a pain management specialist before surgery to discuss ways to minimize your risk of developing chronic pain.
If you experience chronic pain after surgery, know that it’s treatable. Consult with a physician who specializes in treating such pain. These physicians complete four years of medical school followed by further training in a specialty, such as anesthesiology, physical medicine and rehabilitation, psychiatry, or neurology. This is followed by an additional year of training to become an expert in chronic pain.
Be sure your specialist is certified in a pain medicine subspecialty by a member board of the American Board of Medical Specialties, such as the American Board of Anesthesiology.
As medical doctors, anesthesiologists work with your surgical team to evaluate, monitor, and supervise your care before, during, and after surgery—delivering anesthesia, leading the Anesthesia Care Team, and ensuring your optimal safety.