Hysterectomy (benign indications): Patient-important issues and surgical complications

INTRODUCTION — Hysterectomy has evolved into multiple types of procedures, each with its own benefits and limitations. Beyond the traditional open abdominal approach (ie, laparotomy), hysterectomy can be performed vaginally or laparoscopically, and the development of robot-assisted systems has added variations to each. Selection of hysterectomy as a treatment is influenced by nonsurgical issues as well as potential operative complications.

This topic review will discuss patient-reported nonsurgical outcomes and surgical complications associated with hysterectomy, regardless of approach. Topics on selection of a surgical route for hysterectomy and specific techniques are reviewed separately.

●(See "Hysterectomy (benign indications): Selection of surgical route".)

●(See "Hysterectomy: Vaginal".)

●(See "Hysterectomy: Laparoscopic".)

●(See "Hysterectomy: Abdominal (open) route".)

●(See "Prophylactic vaginal apex suspension at the time of hysterectomy".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-diverse individuals.

HYSTERECTOMY INDICATIONS AND ALTERNATIVES — Patients are offered a hysterectomy in several scenarios, including:

●When medical or other therapeutic interventions fail to alleviate symptoms

●There are no alternative effective therapies for their condition (eg, cancer)

●Medical treatment is contraindicated

●After informed counseling, the patient and surgeon choose surgical intervention over medical treatment

Once the decision has been made to proceed with hysterectomy, the patient and physician select the surgical approach. The approach to selection in presented in related content. (See "Hysterectomy (benign indications): Selection of surgical route", section on 'Hysterectomy indications and alternatives'.)

PATIENT-REPORTED OUTCOMES — Hysterectomy has been associated with improvements in physical and mental quality-of-life measures, body image, and aspects of sexual activity, with few differences reported among surgical routes [1,2]. The nonsurgical outcomes of hysterectomy can be assessed in terms of symptom relief, psychosexual issues, and patient satisfaction.

Symptom relief — Hysterectomy generally improves the most common symptoms that lead to surgery, including problematic vaginal bleeding, pelvic or back pain, limitation of activity, sleep disturbance, fatigue, urinary incontinence, and vaginal bulging.

Two studies from one prospective multicenter study of 1299 women who underwent hysterectomy reported [3,4]:

●Substantial reduction of symptoms across these variables, and symptom reductions persisted at two years of follow-up (table 1).

●Ninety-six percent of patients indicated the surgery had somewhat or completely resolved the symptoms for which they underwent surgery.

●The individuals who had at least as many problematic symptoms after surgery as they did prior to surgery were more likely to have had low income or depression compared with women who reported symptom improvement.

●While bilateral oophorectomy was associated with lack of symptom relief at 24 months after surgery, lack of data regarding symptom type and treatments that may have been offered, such as hormone therapy for vasomotor symptoms, limit the utility of this study for educating patients. Discussions of bilateral oophorectomy and subsequent health outcomes are presented separately. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy".)

Psychosexual issues — Hysterectomy is unlikely to make sexual function or quality of life worse. Prospective studies have described positive effects on mood and quality of life. Studies on sexual function following hysterectomy, with or without oophorectomy, have reported neutral to positive outcomes, presumably because the symptoms that lead to the hysterectomy, such as abnormal uterine bleeding or pelvic pain, have resolved [2,5-10]. These significant positive effects on postoperative sexual function and quality of life occur regardless of surgical technique used [2].

While older studies reported adverse psychosocial outcomes from hysterectomy [11,12], conclusions are limited by confounding factors [12-14]. As above, newer data do not support this position.

Patient satisfaction — A posthysterectomy survey in which US patients were asked whether the surgical procedure solved their prehysterectomy problems reported that 85 percent of women were completely satisfied, 11 percent mostly satisfied, 3 percent somewhat satisfied, and less than 1 percent were not satisfied [4]. Overall, approximately 70 percent reported much better health after the surgery. However, among premenopausal patients, some regret at loss of fertility is common [15].

Risk of occult malignancy — Despite appropriate preoperative assessment, occult uterine malignancy can be diagnosed at the time of hysterectomy for what was presumed to be benign disease.

●Overall cancer incidence – Two retrospective reviews reported occult cancer rates of 0.19 to 0.82 for individuals undergoing hysterectomy for benign indications [16,17]. Detailed discussion of occult malignancy, particularly sarcoma, in patients undergoing fibroid surgery is presented separately. (See "Uterine fibroids (leiomyomas): Differentiating fibroids from uterine sarcomas".)

●Types of gynecologic cancer – In the biggest study to date, a secondary analysis of the 2014-2015 American College of Surgeons National Surgical Quality Improvement Program dataset that included over 24,000 women undergoing benign hysterectomy, 1.4 percent of women had uterine cancer (ie, cancer of the uterine corpus), 0.60 percent had cervical cancer, and 0.19 percent had ovarian cancer [18]. Additionally, prevalence rates of uterine cancer varied by surgical route, from a low of 0.23 percent for laparoscopic supracervical hysterectomy to a high of 1.89 percent for total laparoscopic or laparoscopic-assisted vaginal hysterectomy. This variation in cancer rate by procedure may reflect differences in the underlying surgical indications, differential patient selection by surgeons, or other factors. In the study, the majority of uterine and ovarian cancers were stage I (uterine, 80 percent and ovarian, 61 percent [18]).

●Impact of hysterectomy indication – The surgical indication for hysterectomy impacts the relative risk of occult malignancy. Hysterectomy for pelvic organ prolapse (POP) repair is at the lower end of the risk spectrum while prophylactic hysterectomy for cancer syndromes is at the higher end.

•Pelvic organ prolapse repair – A meta-analysis of patients undergoing hysterectomy for POP repair reported a pooled prevalence of occult uterine malignancy of 0.22 percent (95% CI 0.11-0.35, 8 studies, 35,880 patients) [19]. A different study of patients who underwent sacrocolpopexy with hysterectomy reported no uterine cancers (0 cancers in 238 patients) [20].

•Hysterectomy for all benign indications – A retrospective cohort study of patients undergoing vaginal hysterectomy for benign indications reported an occult malignancy rate of 0.82 percent [17].

•Prophylactic hysterectomy for cancer syndromes – Patients undergoing presumed benign prophylactic hysterectomy for cancer syndromes have increased rates of occult malignancy. In a study of patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer), 13 percent (3 cancers in 23 patients) were diagnosed with occult endometrial cancer [21]. In a study of 413 individuals undergoing prophylactic hysterectomy for multiple types of hereditary cancer syndromes, 4.6 percent were diagnosed with malignancy or premalignancy [22].

●Age as a risk factor – In multivariate regression analysis, age ≥55 years, compared with age 40 to 54 years, was associated with a more than sixfold increased risk of uterine cancer, more than a threefold increased risk of ovarian cancer, and nearly twice the risk of cervical cancer [18]. We find these data helpful in counseling our patients, particularly women age 55 and older.

●Abnormal uterine bleeding – The evaluation of females with abnormal uterine bleeding, a common risk factor for uterus malignancy, is reviewed elsewhere.

•(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

•(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)

Decreased ovarian function or earlier menopause — Hysterectomy appears to reduce ovarian function and result in earlier onset of menopause despite ovarian conservation [23-27]. While the studies below demonstrate reduced ovarian function after hysterectomy, it is not clear how much of the decreased ovarian activity is directly attributable to the surgery versus the underlying disease process for which the surgery was indicated. One potential explanation for decreased ovarian output after hysterectomy is alteration of the ovarian blood supply, even if the ovaries are retained [28].

●Elevated follicle-stimulating hormone (FSH) – Removal of the uterus, without concomitant oophorectomy, appears to reduce ovarian reserve and cause earlier cessation of ovarian function.

•Reduced ovarian function – In a prospective cohort study including over 850 women, women who underwent hysterectomy had nearly twice the risk of reduced ovarian function (defined as FSH ≥40 international units/L) compared with women with intact uteri [26]. While the risk of decreased ovarian function was greater for women who had one ovary removed (adjusted hazard ratio [HR] 2.9) than for women who retained both ovaries (HR 1.7), both groups had significantly reduced ovarian function.

•Earlier menopause – In a prospective study of over 500 women who were followed for five years, women who underwent hysterectomy reached menopause, defined as FSH ≥40 international units/L, nearly four years earlier than control women who did not undergo hysterectomy [24].

●Decreased anti-müllerian hormone (AMH) – In a planned secondary analysis of the above study that measured anti-müllerian hormone (AMH) levels one year after hysterectomy, women who had undergone hysterectomy had a 23 percent reduction in overall AMH levels, a greater median percentage decrease in AMH levels, and a higher proportion of women with undetectable AMH compared with control women who did not undergo hysterectomy, despite both groups having similar baseline AMH levels [27]. This study suggests that the ovarian damage associated with hysterectomy is unrelated to baseline ovarian reserve.

Cardiovascular and metabolic morbidity — Large observational studies have reported hysterectomy is associated with a small but significant increased risk of cardiovascular morbidity, independent of oophorectomy [29-35]. In a 2017 cohort study with a median of 21.9 years of follow-up, when compared with matched women who did not undergo hysterectomy, women who underwent hysterectomy with ovarian conservation had slightly increased risks of de novo hyperlipidemia (HR 1.14, 95% CI 1.05-1.25), hypertension (HR 1.13, 95% CI 1.03-1.25), obesity (HR 1.18, 95% CI 1.04-1.35), cardiac arrhythmia (HR 1.17, 95% CI 1.05-1.32), and coronary artery disease (HR 1.33, 95% CI 1.12-1.58) [32]. These effects were particularly pronounced for women who underwent hysterectomy at age ≤35 years, as these women had a 2.5-fold increased risk of coronary artery disease and a 4.6-fold increased risk of congestive heart failure compared with reference women. It is biologically plausible that small changes in cardiovascular risk factors could have a cumulative impact over time and result in greater risk for women who undergo hysterectomy at younger ages.

It is not known if the association between hysterectomy without oophorectomy and cardiovascular disease is causal, and if so, the mechanism(s) by which these changes may occur. Prior studies have documented altered ovarian function (eg, decreased levels of AMH) after ovary-sparing hysterectomy, which may be a contributing factor. In addition, the cardiovascular impact of the underlying disease that resulted in hysterectomy is not understood, as the risk for cardiovascular and metabolic outcomes differed by surgical indication in the above cohort study [32]. (See 'Decreased ovarian function or earlier menopause' above.)

Osteoporosis — Studies have reported an increased risk of osteoporosis following hysterectomy, regardless of ovarian conservation or removal [36,37]. (See "Screening for osteoporosis in postmenopausal women and men".)

All-cause mortality — Bilateral oophorectomy, but not hysterectomy alone, appears to increase the risk of all-cause mortality when performed in younger individuals [38]. A detailed discussion is presented elsewhere. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy", section on 'All-cause mortality'.)

SURGICAL COMPLICATIONS — General complications of hysterectomy are discussed here. Procedure-specific complications are discussed separately in the topic reviews on each type of hysterectomy.

●(See "Hysterectomy: Vaginal".)

●(See "Hysterectomy: Laparoscopic".)

●(See "Hysterectomy: Abdominal (open) route".)

Overall — In an Australian population-based study of almost 80,000 hysterectomies performed for benign indications, complications were reported at the following rates [39]:

●Hemorrhage – 2.4 percent (see "Management of hemorrhage in gynecologic surgery")

●Genitourinary disorders (eg, pelvic organ prolapse [POP], urinary retention, renal or ureteral injury) – 1.9 percent (see "Complications of gynecologic surgery")

●Urinary tract infection – 1.6 percent (see "Acute simple cystitis in adult and adolescent females")

●Other infections – 1.6 percent (see "Fever in the surgical patient")

Urinary tract injury — In a systematic review and meta-analysis of 79 studies of benign gynecologic surgeries, the rates of intra- and postoperative urinary tract injury per 1000 hysterectomies in which cystoscopy was not routinely used ranged from <1 to 4 percent for ureteral injury and 5 to 17 percent for bladder injury [40]:

●Abdominal approach

•Ureteral injury: 2.6

•Bladder injury: 5.8

●Vaginal approach

•Ureteral injury: 0.4

•Bladder injury: 5.1

●Laparoscopic approach

•Ureteral injury: 3.1

•Bladder injury: 7.3

●Robot-assisted approach

•Ureteral injury: 4.1

•Bladder injury: 16.5

Data for laparoscopic hysterectomy included both laparoscopic-assisted vaginal and total laparoscopic hysterectomy. Several studies suggest that the incidence of urinary tract injury, and major complications in general, during laparoscopic hysterectomy is decreasing with time, which may reflect improved technology and increased surgical experience [41,42]. Some of the variation in the injury rate range is due to the underlying pathology, degree of anatomic abnormality, surgeon experience, and sample size (particularly for robot-assisted laparoscopic hysterectomy).

Adnexal surgery at the time of hysterectomy does not significantly increase the prevalence of urinary tract injury. In a retrospective study of a national database, urinary tract injury occurred in approximately 3 per 1000 hysterectomies that included adnexal surgery (route of hysterectomy not specified) [43]. When adnexal surgery was performed alone, the prevalence of urinary tract injury was lower at 1 per 1000 surgeries.

Urinary incontinence — Studies have reported a variable impact of hysterectomy on urinary incontinence [44-46]. Until definitive data are available, we counsel patients that hysterectomy may increase the risk of urinary incontinence over time. However, it is not clear if the surgery itself or other preoperative factors determine the likelihood of posthysterectomy urinary incontinence. Potential study confounders include the presence of baseline urinary symptoms and other pelvic floor disorders, different study methodologies, multiple indications for the hysterectomy, different surgical techniques, and varied length of follow-up.

As examples:

●Increased urinary incontinence risk – Three large retrospective cohort studies reported hysterectomy was associated with increased risk of subsequent surgery for stress incontinence [46,47] and increased incidence of both urge urinary incontinence and stress urinary incontinence [48] compared with women who had not undergone hysterectomy.

●Mixed risk of urinary incontinence – In a retrospective cohort study of over 16,000 women who underwent hysterectomy and were followed for one year, 8.5 percent reported de novo urinary incontinence, 13.3 percent reported remission of prior urinary incontinence, and 16.1 percent reported continued urinary incontinence [49]. Obesity (body mass index [BMI] ≥30 kg/m²), prior vaginal delivery, and preoperative daily urinary urgency without incontinence were associated with increased risk of de novo posthysterectomy urinary incontinence while BMI <25 kg/m², prolapse, fibroids, or lack of daily urge without incontinence were associated with remission of urinary incontinence symptoms.

●No difference in risk – Lastly, a small longitudinal cohort study that followed 661 women for 10 years reported no difference in incidence proportions of stress and urgency incontinence among women who underwent hysterectomy and women in the control groups (laparoscopic cholecystectomy and transcervical endometrial resection) [50]. In all groups, the prevalence of stress and urgency urinary incontinence increased with time, and women in all three groups changed their status from continent to incontinent and vice versa. While this study group was much smaller than the others, the study provides 10-year prospective data.

Risk of pelvic organ prolapse — Studies have reported mixed results on the role of hysterectomy in the development of subsequent pelvic organ prolapse (POP) [51-62]. This discordancy likely reflects differences in patient populations (ie, proportion of patients with preexisting prolapse, age, menopausal status), surgical technique (ie, type of cuff closure and incorporation of support ligaments), lack of standardized outcome criteria, and differing lengths of follow-up. The controversy surrounding the impact of hysterectomy on subsequent prolapse and discussion of the role of apical repair to prevent prolapse are presented in detail in related content.

Briefly, examples of the conflicting data include:

●Earlier cohort and case control studies generally reported the risk of future prolapse was highest when hysterectomy was performed in women with existing prolapse [58-61], while the risk in women with normal pelvic support was less clear.

●A 2018 retrospective cohort study including over 42,000 individuals who underwent hysterectomy with the index prolapse repair reported hysterectomy at the time of initial POP surgery reduced the risk of future POP surgery by approximately 30 percent [62].

●In a 2020 observational study of 406 individuals that compared laparoscopic and vaginal hysterectomy, 17 percent overall were treated for subsequent POP; similar rates of prolapse occurrence were reported between the laparoscopic and vaginal nonprolapse groups (apical vault prolapse 4.4 versus 5.8 percent) [63]. Prolapse after vaginal hysterectomy was more common in individuals whose surgical indication was prolapse (apical vault prolapse 23 percent).

Pelvic organ fistula — In resource-rich countries, pelvic surgery such as hysterectomy is the most common cause of lower urinary tract fistula development. A case-control study of over 180,000 women reported a fourfold higher rate of subsequent surgery to repair a pelvic organ fistula in women who had undergone hysterectomy than in the control group [64]. This differs from resource-limited countries in which pelvic organ fistulas are most commonly related to obstetric injury.

Vaginal cuff dehiscence — Vaginal cuff dehiscence, or separation of the previously closed vaginal cuff, can occur following hysterectomy by any route. Robot-assisted hysterectomy appears to be associated with the highest risk. Risk factors, diagnosis, and management of vaginal cuff dehiscence are presented elsewhere.

Persistent opioid use — Approximately 5 percent of patients report continued opioid use after benign hysterectomy, although the rates vary with the study population and definition used [65,66]. A meta-analysis including over 370,000 patients undergoing hysterectomy for benign indications reported risk factors for continued opioid use included younger age, smoking history, alcohol use, back pain, and fibromyalgia [65]. The route of hysterectomy did not impact risk. (See "Use of opioids for postoperative pain control".)

SUMMARY AND RECOMMENDATIONS

●Patient important outcomes – Hysterectomy has been associated with improvements in physical and mental quality-of-life measures, body image, and aspects of sexual activity, with few differences reported among surgical routes. (See 'Patient-reported outcomes' above.)

•Symptom relief – Hysterectomy generally improves the most common symptoms that lead to surgery, including problematic vaginal bleeding, pelvic or back pain, limitation of activity, sleep disturbance, fatigue, urinary incontinence, and vaginal bulging. (See 'Symptom relief' above.)

•Psychosexual function – Hysterectomy is unlikely to make sexual function or quality of life worse. Studies on sexual function following hysterectomy have reported neutral to positive outcomes, presumably because the symptoms that lead to the hysterectomy have resolved. (See 'Psychosexual issues' above.)

•Patient satisfaction – The vast majority of patients who elect hysterectomy report satisfaction with the improvement in their preoperative symptoms. However, some regret at loss of fertility is common. (See 'Patient satisfaction' above.)

•Risk of occult malignancy – Despite appropriate preoperative assessment, occult uterine malignancy can be diagnosed at the time of hysterectomy for what was presumed to be benign disease. Risk of occult cancer varies based on the type of malignancy and indications for surgery. (See 'Risk of occult malignancy' above.)

•Decreased ovarian function and earlier menopause – Hysterectomy appears to reduce ovarian function and result in earlier onset of menopause even with ovary conservation. It is not known how much of the decreased ovarian activity is directly attributable to the surgery versus the underlying disease process for which the surgery was indicated. (See 'Decreased ovarian function or earlier menopause' above.)

•Cardiovascular and metabolic morbidity – Studies have reported hysterectomy is associated with a small but significant increased risk of cardiovascular morbidity, independent of oophorectomy. It is not known if the association between hysterectomy without oophorectomy and cardiovascular disease is causal, and if so, the mechanism(s) by which these changes may occur. (See 'Cardiovascular and metabolic morbidity' above.)

●Surgical complications – In addition to routine surgical complications, hysterectomy may contribute to the development of urinary incontinence and pelvic organ prolapse (POP). (See 'Surgical complications' above.)

•Urinary incontinence – Studies have reported a variable impact of hysterectomy on urinary incontinence. Until definitive data are available, we counsel patients that hysterectomy may increase the risk of urinary incontinence over time. (See 'Urinary incontinence' above.)

•Pelvic organ prolapse (POP) – Studies have reported mixed results on the role of hysterectomy in the development of subsequent POP. The risk of subsequent prolapse is greatest for patients who have underlying prolapse as the indication for the hysterectomy. (See 'Risk of pelvic organ prolapse' above.)