Navigating Hysterectomy: From Diagnosis to Recovery

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're focusing on hysterectomies. If you've been told you might need a hysterectomy or you're supporting someone who has, you may be feeling a mix of emotions, relief at the idea of finally getting answers, but also worry, grief, or uncertainty about what this surgery means for your body and your future. I'm joined by minimally invasive gynecologic surgeon, Dr. Tarangi Sutaria to discuss what a hysterectomy is, why it's done, the different procedures that are available, and what recovery looks like. Most importantly, we want to help you feel informed and supported as you consider your choices.

Thank you so much for joining me on the podcast, Dr. Sutaria.

Tarangi Sutaria, MD:

Thank you so much for having me, Dr. Newlin. Thank you.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in Cleveland Clinic and about your background?

Tarangi Sutaria, MD:

Absolutely. Thanks again for having me today. I really appreciate your time and your projects here. I'm a minimally invasive gynecologic surgeon over here in Weston, Florida. In this role, I help women overcome complex benign gynecologic issues through medical treatments or surgery. The surgeries I perform typically involve laparoscopic, robotic, hysteroscopic, and vaginal techniques.

So I completed my training in obstetrics and gynecology at the George Washington University in Washington, D.C. Then I transitioned to Atlanta, Georgia where I participated in a fellowship in lower anogenital screening and treatment at Emory University. There I learned and honed in on my skills to evaluate the treatment of pre-cancers as well as other complex conditions that affect the lower genital tract.

After that, I completed a fellowship in minimally invasive gynecologic surgery at Cleveland Clinic Florida. I decided to join the team here at Cleveland Clinic Florida, where I serve a dynamic and incredible South Florida community.

Erica Newlin, MD:

Great. Let's start by defining what a hysterectomy actually is.

Tarangi Sutaria, MD:

Sure. So a hysterectomy is a surgical procedure to remove the uterus. There are a variety of reasons why someone may need a hysterectomy. Sometimes the hysterectomy is a medically necessary procedure to save someone's life, such as when there's severe uncontrolled bleeding or cancer of the uterus, cervix, or ovaries. In other cases, a hysterectomy can be performed to improve someone's overall health and quality of life when other treatments don't work or aren't safe options. This can happen when someone experiences abnormal bleeding, fibroids, adenomyosis, endometriosis, pelvic organ prolapse, severe infection, and sometimes even pre-cancers of the uterus and cervix.

Erica Newlin, MD:

And can you walk us through the different types of hysterectomies and some of that terminology?

Tarangi Sutaria, MD:

Absolutely. A total hysterectomy is the removal of the uterus and cervix. What's interesting is that many people believe that total hysterectomy is a complete removal of all female reproductive organs, including the fallopian tubes and ovaries. But this isn't the case. Medically, the total hysterectomy refers to the uterus and cervix alone. Some patients undergo partial hysterectomy, and this refers to the removal of the uterus without the cervix. This is also known as a supracervical hysterectomy, which means above the cervix.

There are also radical hysterectomies which involve removal of the uterus, cervix, the upper portion of the vagina, and some surrounding tissue. This is done to treat cancer in most cases. And at the time of hysterectomy, most surgeons would recommend removing the fallopian tube to reduce the lifetime risk of developing ovarian cancer, even when the ovaries remain in the body. The removal of the fallopian tubes alone is called a salpingectomy.

When the fallopian tubes and the ovaries are removed, this is referred to as a salpingo-oophorectomy. And the removal of the ovaries alone is called an oophorectomy. This will cause someone to enter menopause if they haven't already. While all these terms combined describe the different structures that can be removed in the different types of hysterectomy.

Erica Newlin, MD:

Yeah. I feel like in my pre-op counseling, that's what comes up the most. And that terminology can be really confusing for patients. I have so many people come to me and say, "Oh, I had a partial hysterectomy," meaning that they still have their ovaries, but when we talk about that, we mean leaving the cervix behind. Can you talk a little bit about when we choose to leave the ovaries in versus not and how that guidance has changed and how we go back and forth on that quite a bit?

Tarangi Sutaria, MD:

Yeah, absolutely. And it's a conversation that is so important to have because the ovaries are the hormone producing structures that sometimes fuel the problems that lead women to want a hysterectomy in the first place. And so typically, when someone is pre-menopausal, especially below the age of 50, we recommend leaving the ovaries in the body at the time of a hysterectomy.

And the reason for this is because we want to have patients avoid going into premature menopause or going through and experiencing the consequences of premature menopause. So when we remove the ovaries, we'd reduce the levels of estrogen in one's body as well as progesterone. And this can lead to an increased risk of what's called all-cause mortality for women or death for many reasons. Now, that includes the risk of osteoporosis, stroke and heart attack, early onset memory loss. And so that's the reason why we usually encourage those under the age of 50 to keep their ovaries.

Above the age of 50, it's definitely a shared decision making point. We work with our patients to see what their goals are. And if that goal is to never have to go through surgery again, then we might say, "Okay, it makes sense to remove the ovaries, especially if they keep forming cysts." Some people just have that gift. But other times, patients will say, "Just take what you need to help me feel better." And that may not include the ovaries at that time.

Erica Newlin, MD:

Another big part of surgical counseling is surgical approach. Can you talk about the different approaches to a hysterectomy?

Tarangi Sutaria, MD:

The main surgical approaches for hysterectomy are abdominal, laparoscopic, and vaginal. An abdominal or open hysterectomy involves a large incision on the abdomen. This incision can be horizontal in the bikini line similar to a cesarean scar or vertical along the middle of the abdomen. Another approach is the laparoscopic hysterectomy. This involves making small incisions usually less than one centimeter in size.

Your surgeon would inflate the abdomen with gas and pass a camera through the central incision or the middle incision, typically at or above the belly button to look inside the abdomen while instruments are inserted through side incisions to allow the surgeon to perform the procedure. Sometimes laparoscopic hysterectomies are performed with the help of a robot, which serves as another instrument for the surgeon.

The third approach is a vaginal hysterectomy. This is completed vaginally. This type of hysterectomy involves no abdominal scars, and the surgeon performs the procedure through an incision that's made near the top of the vagina by the cervix.

Erica Newlin, MD:

Loaded question. Which approach is best?

Tarangi Sutaria, MD:

Using the best hysterectomy approach, whether abdominal, laparoscopic, or robotic or vaginal really depends on a combination of patient factors, disease factors, a patient's anatomy, and also the surgeon's expertise. It's a great question because it can vary so broadly. For instance, an abdominal or open approach may be recommended when a patient has a uterus that is extremely large. This is because the size of their uterus makes seeing and accessing key structures during the surgery more challenging without an open incision.

A vaginal hysterectomy may be recommended when there's a good amount of space and the uterus moves freely, meaning it's not stuck in place by scar tissue. Other times, a laparoscopic approach is best. If the patient's expected to have a lot of scarring from prior surgeries, infections, or endometriosis. This technique also is favorable when there are other procedures that also need to be accomplished at the same time, such as removal of an ovarian cyst or the appendix, because it improves access to those structures.

Erica Newlin, MD:

While a hysterectomy can offer significant relief and improved quality of life, like any surgery, it does have risk. Let's break down what someone should know ahead of time. What are the potential benefits of a hysterectomy with chronic symptoms like heavy bleeding or pelvic pain?

Tarangi Sutaria, MD:

For people with chronic quality of life limiting symptoms like heavy bleeding or pelvic pain, a hysterectomy can truly be definitive treatment because it removes the force of the problem, which is the uterus itself. The most immediate and dramatic benefit is a complete and permanent relief from heavy bleeding. Periods will stop completely, so there are no more flooding accidents, clots, or unpredictable bleeding episodes. This is also a way to stop anemia caused by chronic blood loss, and it removes the need for hormonal therapy, iron supplements, and repeat procedures in the long term. It can be liberating for most.

Erica Newlin, MD:

How quickly do patients typically notice improvement after their surgery?

Tarangi Sutaria, MD:

Patients who have a hysterectomy due to heavy bleeding or bulk symptoms from fibroids, for instance, typically notice improvements within days. As the patient's recovery progresses, they may notice less pelvic discomfort than before, improved bowel and bladder function and increasing energy levels over about two to six weeks. Most patients will feel the most benefit after one to three months once their anemia improves significantly and their energy levels return.

Erica Newlin, MD:

What are the risks or complications people should be aware of when deciding on a hysterectomy?

Tarangi Sutaria, MD:

Similar to other surgeries, the risks with hysterectomy involve bleeding, infection, clots, complications from anesthesia and injuries to nearby structures. These nearby structures can include bowel, bladder, blood vessels, nerves, and the ureters, which connect the kidneys to the bladder.

Erica Newlin, MD:

How common are these complications?

Tarangi Sutaria, MD:

Such a great question. While we don't have a lot of newer data on the complication rates and hysterectomy in recent years, we do see that high volume surgeons demonstrate reduced complications during shorter operative times and reduced blood loss for benign gynecologic surgery. The surgeons are also more likely to use minimally invasive techniques, which offer patients faster recovery time. But whenever we're thinking about complications, it's really important to consider, will the risks of a surgery outweigh the benefit of the surgery? Is the hysterectomy really going to be worth the risks in order to improve the conditions that we seek to treat?

Erica Newlin, MD:

And then when someone's preparing for a hysterectomy, is there a best way to prepare physically and mentally going into surgery?

Tarangi Sutaria, MD:

Yes. What patients do before surgery can make a big difference in how quickly and smoothly they can recover afterwards. It's really important to optimize one's fitness for surgery prior to the big day. This can involve quitting smoking, bringing down blood sugar, improving anemia, and incorporating regular exercise leading up to the surgical date. Typically, blood work and medical exams are completed prior to a hysterectomy to make sure it's safe to proceed.

Regarding mental preparations, knowledge is power. It's so important for someone undergoing a hysterectomy to share their personal goals for surgery and make sure they're on the same page with their surgeon. It's also crucial for patients to understand the surgical plan, what organs are to be removed, what will remain after the surgery is complete. Talking to the surgeon about any concerns, whether it's regarding physical recovery, time away from work, or emotional concerns regarding the plan is so important.

Now, a hysterectomy may or may not involve a hospital stay depending on the surgical approach and the condition being treated. It's important to discuss what types of support will be needed in the early days of recovery. This way, patients can build their support systems and have comfort items in place. Some helpful steps include preparing meals in advance, arranging help with childcare, pets, or chores, placing commonly used items at waist height so there's no bending or excessive reaching and avoiding the need to lift heavy objects. This can allow patients to focus on healing, which pays off long-term.

Erica Newlin, MD:

Fantastic. Recovery can look a little different for everyone depending on the type of surgery. Let's discuss the general milestones and expectations patients can expect post-surgery. What does a typical recovery timeline look like following a hysterectomy?

Tarangi Sutaria, MD:

I usually tell most of my patients that the first two to three days after hysterectomy are the hardest. After that, they'll start to feel like they made the right choice. But the thing is that you can expect them intense abdominal pain and pelvic cramping in those first few days. Those who undergo laparoscopic surgery may also experience gas-related shoulder pain, but after those first few days, patients can expect to impress themselves with their day-by-day recovery.

By the second week of recovery, most patients feel well apart from some soreness with movement. By four weeks after surgery, most patients feel fully recovered and are itching to get back to their regular exercise routine, though some may take a few more weeks to regain their normal energy levels.

Erica Newlin, MD:

Should most patients expect to stay in the hospital or go home following their surgery?

Tarangi Sutaria, MD:

It really depends on the approach. For a laparoscopic hysterectomy, most patients can expect to go home on the same day of surgery or have a one-night observation period. For abdominal hysterectomies, most patients need to stay two or three days to recover sufficiently before going home.

Erica Newlin, MD:

Great. And what restrictions or precautions do most patients need to follow after surgery?

Tarangi Sutaria, MD:

Activity recommendations for most patients typically include no heavy lifting for six to eight weeks to prevent the risk of hernia and openings incisions. No pool, beaches, especially here in South Florida, hot tubs or intercourse for six weeks to keep all incisions cleaned and closed, and then no driving for typically 10 to 14 days. Walking is encouraged as bedrest can lead to physical deconditioning and increase the risk of blood clots.

Erica Newlin, MD:

Can you speak briefly as to what medications someone may expect to go home with or things that might help with pain?

Tarangi Sutaria, MD:

Most people go home with a toolkit for success for pain control. That usually includes extra strength acetaminophen and extra strength ibuprofen. Those are for baseline pain control, which patients can typically use for the first 72 hours routinely, and then as needed after that. A lot of patients also need to go home with a narcotic medication, which can help with the stronger pain that they may feel in the first few days.

We also send patients home with a bowel regimen, which includes a couple of stool softeners to prevent straining in those first few days after the surgery, as well as a medicine for nausea. This toolkit for success is to keep the patient comfortable and to help them achieve their comfort levels that allow them to be able to walk and move and regain their strength soon after they go home.

Erica Newlin, MD:

Great. In the longer term, how might a hysterectomy affect sexual health?

Tarangi Sutaria, MD:

A hysterectomy shouldn't affect sexual health or function. If one enters menopause as a result of a hysterectomy, they may experience symptoms like low sex drive and vaginal dryness. However, the ability to engage in penetrative intercourse or to participate in intimate relations doesn't change after the hysterectomy. It's really important to let the surgeon or healthcare provider team know if you're experiencing uncomfortable side effects of menopause or any other pain type symptoms after a hysterectomy, because there are opportunities to treat these conditions.

Erica Newlin, MD:

I feel like this was more of a hot topic around 10, 15 years ago, but can you talk about whether or not leaving the cervix versus taking the cervix away affects sexual pleasure?

Tarangi Sutaria, MD:

Whether the cervix is removed or not is definitely something to discuss with a provider, and it all comes down to understanding how an individual experiences pleasure and generates an orgasm. Most of the time, that's through clitoral stimulation, but a good portion of our community experiences orgasms through stimulation of the cervix, and this can guide the decision to perform or not to perform a total hysterectomy.

Erica Newlin, MD:

Great. Thanks for commenting on that. I feel like it's been a controversy and definitely a discussion worth having in pre-op discussion with patients. When is it safe to resume sexual activity? When can someone expect to go back to their sex life?

Tarangi Sutaria, MD:

I typically encourage patients to wait at least six weeks before resuming sexual activity. This gives the incision at the top of the vagina enough time to heal.

Erica Newlin, MD:

Great. And as you mentioned, if anyone is having pain or discomfort or things feel different afterwards, that's definitely worth talking about with your surgeon because I think repeating that it's not normal and there are things that we can do to help, for sure. What about if the ovaries are removed? How does that affect menopause or hormone levels?

Tarangi Sutaria, MD:

If the ovaries are removed in someone who's pre-menopausal, meaning they haven't completed the transition to menopause, this will cause a sudden drop in estrogen and progesterone leading to symptoms of perimenopause or menopause. Because the hormone change is abrupt instead of a gradual natural process that occurs over time, symptoms can feel stronger and stark quickly, often within days to weeks.

Some symptoms of surgical menopause include hot flushes and night sweats, sleep disruptions, mood changes, vaginal dryness and discomfort, decreased libido, brain fog, and joint aches. For patients who are already perimenopausal, they may feel no different, though some may experience worsening of perimenopausal symptoms such as hot flashes, mood changes, and low libido. It's really a spectrum and hard to predict how one's body's going to respond.

Erica Newlin, MD:

Not to delve into another controversial topic, but can you talk about whether a hysterectomy when leaving the ovaries behind, does that hasten transition to menopause or should someone expect to have menopausal symptoms if they have a hysterectomy, but leave the ovaries?

Tarangi Sutaria, MD:

Oftentimes, in order to remove the uterus without the ovaries, we have to cut what's called the utero-ovarian ligament, and that ligament brings some blood flow from the uterus to the ovaries. The ovaries themselves, when they are left in the body, have their own blood supply from what are called the gonadal vessels. And so sometimes with that shift in blood flow, patients who keep their ovaries who are premenopausal can experience a temporary change in their hormones.

And so that manifests as symptoms of perimenopause or menopause with hot flashes, mood changes, decreased libido, oftentimes that will resolve after four to six weeks. That's in the short term. Now when we think about taking out the uterus and the fallopian tubes without the ovaries in someone who's before menopause. There's some evidence to show that the transition to menopause may occur sooner, but we're still learning about this process.

We're still learning exactly how the uterus and the blood supply and the organs that we typically don't think of as hormone producing impact the body in the long term. So I think that we're going to learn more about this in upcoming years and have more to add to the discussion.

Erica Newlin, MD:

Great. Thanks for commenting on that. Another thing that patients often ask about is risk of prolapse after hysterectomy. I think a lot of patients in counseling ask me, "Well, is my vagina going to fall out without the uterus there?" Can you comment on prolapse or suspension in the hysterectomy process?

Tarangi Sutaria, MD:

Absolutely. So it's a great question and it's a question that is really patient dependent. Now, when I say that, I mean, some patients have a quality in their tissue that makes them have a higher likelihood to develop prolapse in the future. There might be a genetic component to this. There might be just the way we are type of components to it, but those patients may develop prolapse in the future, whether or not they have a hysterectomy.

Now, it's in our standard practice to close the top of the vagina and stitch it to what's called the uterosacral ligaments. The ligaments that suspend the uterus typically, which is removed, to the sacrum or the pelvic bones. And so that helps to keep the top of the vagina suspended or heightened or pulled, if you will, to the structures that would typically support the uterus and helps to decrease the risk of prolapse. That being said, it's not a guarantee that someone won't develop prolapse in the future.

If pelvic organ prolapse already exists at the time of a hysterectomy, it may improve, but there are also opportunities to collaborate with surgeons who place slings or repair prolapse at the same time as the hysterectomy, which is why the question of prolapse is such a good one and can really offer patients a multidisciplinary approach to their care where there are opportunities to work on prolapse at the same time as removing a uterus for a hysterectomy for fibroids or pelvic pain, for instance. And that collaborative and patient centered decision making is key for success.

Erica Newlin, MD:

Now that we've covered surgery and recovery, let's talk about choosing the right time and understanding alternatives. This is a big question, but can you just briefly discuss whether there are alternatives to hysterectomy for conditions like fibroids or abnormal bleeding?

Tarangi Sutaria, MD:

Definitely. For conditions like fibroids or abnormal bleeding, there are several effective alternatives to hysterectomy depending on the symptom severity, fibroid size, and location, patient's age, and whether future fertility is desired. Many patients can get excellent relief without removing the uterus. Treatment options can include hormonal and non-hormonal options through medication, as well as uterine sparing procedures such as myomectomy, which is where you remove fibroids alone, uterine artery embolization performed by an interventional radiologist, and radiofrequency fibroid ablation.

Erica Newlin, MD:

And then how can someone know when it is the right time to seriously consider a hysterectomy?

Tarangi Sutaria, MD:

Deciding whether to seriously consider a hysterectomy is a deeply personal medical decision. It often comes after trying other options when symptoms significantly affect the quality of life. Medical necessity can often move a person toward hysterectomy, such as when there's uncontrolled bleeding, causing anemia, severe unrelenting pelvic pain, or a gynecologic cancer diagnosis, but other considerations may include fertility as a hysterectomy should only be considered in patients who do not wish to become pregnant in the future.

Surgery can be physically and emotionally demanding, so one may wish to consider hysterectomy once they're comfortable with the permanence of the procedure. Finally, if symptoms are persistent or continue, they're debilitating or worsening, it may be a sign to seriously think about removing the uterus.

Erica Newlin, MD:

What misconceptions or fears do people commonly have about a hysterectomy?

Tarangi Sutaria, MD:

Some of the misconceptions I often hear in the office are concerns like, "I'll lose all my hormones or I'll immediately go through menopause with a total hysterectomy." And it's important to remember the terminology that we discussed before. The total hysterectomy only involves removal of the uterus and cervix. It has nothing to do with the ovaries, which produce the hormones that decline with the transition to menopause.

Though we did talk about how we're still learning about how removal of the uterus affects hormones long term. It's so important to understand the terminology and its implications on one's health. Another misconception that I hear is, "I will gain weight." Weight gain is not a direct result of hysterectomy, though lifestyle factors like diet, exercise and age, as well as hormonal changes can play a big role in this weight gain scenario after hysterectomy.

One of the other misconceptions I hear is, "Well, this is what everyone else in my family has, so I need to have one too." This isn't necessarily the case. This is where you and your gynecologist can work together to figure out what's best for you as an individual. There's been so many advances in modern medicine that allow patients to receive a variety of treatments that weren't available to generations past. So hysterectomy is not the only solution anytime, and we just have to work together to figure out what's the right solution for our patients.

Erica Newlin, MD:

Great. This has been such an informative conversation. Before we wrap up, let's leave our listeners with a final piece of guidance. For someone considering a hysterectomy, what's one key message you want them to take away from today's discussion?

Tarangi Sutaria, MD:

The biggest takeaway from today's discussion is that this deeply personal decision to have a hysterectomy is not one that a patient has to make on their own. Gynecologists and other healthcare providers can be sources of information, guidance, and counseling when we can work together to achieve goals.

A hysterectomy can provide lasting relief when uterine conditions cause pain, heavy bleeding, or other serious symptoms, and it's a very safe and effective option, especially when other treatments haven't helped. The choice is the right one when it's made centered around a patient's health, needs, and priorities. So I just want to empower patients to take control of their wellbeing, to have honest, frank conversations with their providers so they can work together to achieve their goals.

Erica Newlin, MD:

Dr. Sutaria, thank you so much for joining me on the podcast today. For more information, visit clevelandclinic.org/hysterectomy. That's clevelandclinic.org/hysterectomy. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your treatment options is the best way to feel empowered in making informed decisions about your health.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.