Definitions:

Hysterectomy is an operation which involves the removal of a woman's uterus, usually with the cervix. (Total Hysterectomy)

"Complete hysterectomy" is a term in common usage which usually refers to the removal of uterus, cervix, fallopian tubes and ovaries. It is not a strict medical term. When surgeons perform this operation, they call it "Total Hysterectomy with bilateral salpingooophorectomy". While this is clearly a mouthful, it is unambiguous to the gynecologist.

Abdominal hysterectomy refers to the removal of the uterus through an incision in the abdomen. Like a c-section incision this will usually be a "bikini" incision (we say pfannanstiel) but not always. Sometimes it will be necessary or preferable to use a vertical incision.

Vaginal Hysterectomy is the removal of the uterus and cervix through the vagina. The tubes and ovaries can also sometimes be removed through this approach. The advantage is that there is no abdominal incision to recover from and usually this operation is less painful for that reason -- but not everyone is a candidate.

Laparoscopic hysterectomy -- A laparascope is a small video camera inserted into the abdomen through a small incision (usually a centimeter or less) at the umbilicus. Instruments can be put through other small incisions and used to assist with vaginal hysterectomy or in some cases perform a total laparoscopic hysterectomy.

For more than a decade "hysterectomy" has been a dirty word in the press and other media, including the internet. And yet, during this same time period, practicing gynecologists like myself have been constantly besieged by a steady stream of intelligent women requesting this operation. Generally they are well educated patients who have listened to the opinions of friends and relatives who have previously undergone hysterectomy with almost universally positive experiences. In my practice the vast majority of patients describe the results of their hysterectomies in superlative terms. "Its the best thing I ever did!" "I wish I had done it ten years sooner" etc. But as with all satisfied customers, they tend to be infinitely less vocal than those with a negative experience. Hysterectomy has therefore come to be thought of as a form of mutilation of women by wicked doctors for their personal profit.

Most women who have this surgery do not have life-threatening conditions like cancer which make it a mandatory operation. (Actually probably less than 15% of hysterectomies are done for life-threatening indications.) The remainder of these surgeries are performed for "elective" reasons:

• Fibroid tumors -- a.k.a. leiomyomas -- these can cause pain, excessive bleeding, or both.
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• Uterine prolapse -- most often the result of vaginal birth, as a woman becomes a little older, the uterus and bladder (and sometimes rectum) begin to hang lower in the vagina. This can contribute to symptoms of pelvic pressure and discomfort or pain with intercourse.
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• Endometriosis -- this is a chronic condition where the tissue that usually lines the uterine cavity begins to grow on the surface of pelvic and abdominal organs. Although symptoms are highly variable, pain and infertility are common problems associated with this condition.
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• Abnormal uterine bleeding -- every woman is an individual. In my experience, one woman may tolerate, without complaining, persistent heavy bleeding, which keeps her dangerously anemic, while another may be upset by slight changes in regularity and duration of menstruation. (I am certain, however, that all women are more tolerant than men would be in similar circumstances.)
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• Abnormal Pap Smears -- Again this category covers a wide range of conditions of varying severity. Women who have completed their childbearing and who have precancerous lesions of the cervix may be advised by their gynecologist to have a hysterectomy.
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Most of the patients who eventually undergo hysterectomy could conceivably be managed using more "conservative" alternatives. For example, abnormal bleeding may be controlled with birth control pills or other hormonal therapies. It may also be controlled using conservative surgical approaches such as D&C or endometrial ablation. A woman who wishes to purse conservative options should be encouraged to do so if her physician does not believe this places her at unnecessary risk. But if she wishes to have a hysterectomy it should not be the job of the gynecologist to persuade her that conservative options are "better".

At present, however, most insurance companies insist on conservative treatments first, even though there is no evidence that these are better for the patient.

If a woman has a hysterectomy for abnormal periods she is guaranteed to have no more periods. This is not true for any conservative management approach. Often women will have a D&C or endometrial ablation and later find that they need a hysterectomy anyway, either for bleeding or for an unrelated reason.

A woman who has a hysterectomy for benign reasons is protected lifelong against uterine and cervical cancer. If her ovaries are removed at the same time she is also protected against ovarian cancer.

Many gynecologists believe that a woman who has a hysterectomy for benign reasons does not need routine pap smears.

A woman who chooses hysterectomy for the management of a benign gynecologic condition also does not need further birth control -- this is also not true for most conservative treatments.

A woman in the menopausal years who is taking hormones is very likely to have vaginal bleeding if she retains her uterus. And she will have to take both estrogen and progesterone. A woman who has had a hysterectomy will need only estrogen and will be guaranteed no bleeding.