7/30/22, 2:11 AM Patient education: Vaginal hysterectomy (Beyond the Basics) - UpToDate

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Patient education: Vaginal hysterectomy (Beyond the

Basics)
Authors: Caroline E Foust-Wright, MD, MBA, Lori R Berkowitz, MD, MBA
Section Editor: Howard T Sharp, MD
Deputy Editor: Kristen Eckler, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2022. | This topic last updated: Nov 20, 2020.

Please read the Disclaimer at the end of this page.

INTRODUCTION

Vaginal hysterectomy is a procedure in which the uterus is surgically removed through the
vagina. One or both ovaries and fallopian tubes may be removed during the procedure as well;
removal of both ovaries and fallopian tubes is called bilateral salpingo-oophorectomy (BSO) (
figure 1). Removal of the fallopian tubes only is called a bilateral salpingectomy. A vaginal
(rather than abdominal) approach may be used if the uterus is not greatly enlarged. A vaginal
hysterectomy includes removal of the uterus and cervix, which is the lower portion of the
uterus; the upper portion of the uterus is referred to as the "uterine fundus."

Studies have shown that vaginal hysterectomy has fewer complications, requires a shorter
hospital stay, and allows a faster recovery compared with removal of the uterus through an
abdominal incision (abdominal hysterectomy). (See "Patient education: Abdominal
hysterectomy (Beyond the Basics)".)

FEMALE ANATOMY

A brief review of female reproductive anatomy may be of help in understanding hysterectomy (

figure 2).

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The uterus is a hollow, pear-shaped muscular organ located in the lower abdomen or pelvis.
One end of each fallopian tube opens into the side of the uterus, at the upper end, and the
other end of the fallopian tube lies next to an ovary. At its lower end, the uterus narrows and
opens into the vagina. The lower end of the uterus is called the cervix. The ovaries lie next to
and slightly behind the uterus.

REASONS FOR VAGINAL HYSTERECTOMY

A hysterectomy may be advised for a number of conditions. For some of these conditions, there
may be alternatives to hysterectomy, which are described below. (See 'Alternatives to
hysterectomy' below.)

Abnormal uterine bleeding — Excessive uterine bleeding, called menorrhagia, can lead to

anemia (low blood iron count) and fatigue, and contribute to missed days at work or school.
Menorrhagia is generally defined as bleeding that lasts longer than seven days or saturates
more than one pad per hour for several hours. (See "Patient education: Anemia caused by low
iron in adults (Beyond the Basics)".)

Irregular uterine bleeding, called metrorrhagia, can also occur in women with menorrhagia.
Metrorrhagia is defined as bleeding or spotting that occurs at times other than during the
expected menstrual period.

Menorrhagia and metrorrhagia are generally treated first with medication or other surgical
alternatives to hysterectomy (see "Patient education: Heavy or prolonged menstrual bleeding
(menorrhagia) (Beyond the Basics)"). However, abnormal uterine bleeding that does not
improve with conservative treatments may require hysterectomy.

Fibroids — Fibroids (also known as leiomyoma) are noncancerous growths of uterine muscle.

Fibroids may become larger during pregnancy, and typically shrink after menopause. They may
cause excessive and irregular uterine bleeding. Symptoms can include heavy uterine bleeding,
lower abdominal pain or pressure, or difficulty moving the bowels or emptying the bladder. (See
"Patient education: Uterine fibroids (Beyond the Basics)".)

Pelvic organ prolapse — Pelvic organ prolapse occurs due to stretching and weakening of the
pelvic muscles and ligaments. This allows the pelvic organs such as the uterus, bladder, rectum,
or a combination to drop down (or prolapse) and bulge into the vagina. Prolapse is usually
related to pregnancy, vaginal childbirth, genetic factors, chronic constipation, or lifestyle factors
(such as repeated heavy lifting over the lifetime). While there is nothing wrong with the uterus,

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removal of the uterus makes it easier to repair a prolapse and possibly reduces the likelihood
that the prolapse will return.

Cervical abnormalities — Precancer or carcinoma in situ (cervical intraepithelial neoplasia

[CIN] 3) of the cervix that does not resolve after other procedures (such as cone biopsy, laser, or
cryosurgery) may require hysterectomy. (See "Patient education: Follow-up of low-grade
abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade or
glandular cell abnormal Pap tests (Beyond the Basics)".)

Endometrial hyperplasia — Endometrial hyperplasia is the term used to describe excessive

growth of the endometrium (the tissue that lines the uterus). It can sometimes lead to
endometrial cancer. Although endometrial hyperplasia can often be treated with medication, a
hysterectomy is sometimes needed or preferred to medical therapy.

Chronic pelvic pain — Chronic pelvic pain can be due to the effects of endometriosis or
scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can also be
caused by other sources, including the gastrointestinal and urinary systems (see "Patient
education: Chronic pelvic pain in women (Beyond the Basics)"). It is important for a woman with
pelvic pain to ask about the probability that her pain will improve after hysterectomy.

PREOPERATIVE PLANNING AND EVALUATION

Before surgery, the woman and her surgeon decide whether the ovaries and/or the fallopian
tubes should be removed, and whether estrogen replacement therapy is needed.

Removal of ovaries — A hysterectomy does not involve removing the ovaries, but they may be
removed at the same time as hysterectomy; this procedure is known as oophorectomy. The
decision to remove the ovaries depends upon several considerations. Occasionally, it may not
be possible to remove the ovaries due to scar tissue or other factors that increase the risk of
removal. If the ovaries are removed at the time of the hysterectomy, the fallopian tubes will be
removed as well.

Premenopausal women may decide to keep the ovaries to provide a continued, natural source
of hormones, including estrogen, progesterone, and testosterone. These hormones are
important in maintaining sexual interest and preventing hot flushes and loss of bone density
loss. On the other hand, some women who have menstrual cycle-related migraines, epilepsy, or
severe premenstrual syndrome may have an improvement in symptoms when hormone levels
are reduced by removal of the ovaries. Individuals should discuss the risks and preferences with
a doctor before surgery.
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Older postmenopausal women are usually advised to have their ovaries removed because of a
small risk of developing ovarian cancer at some point during their lifetime. This benefit of
removing the ovaries appears to outweigh the benefit of continued hormone production, as
described above.

Women in the menopausal transition (called "perimenopause") and in earlier menopause,

typically between 45 and 65 years of age, should discuss with their clinician their individual risks
for keeping their ovaries versus having them removed. Increasing evidence suggests that the
small amount of hormones produced by the ovaries during this perimenopausal period may
improve heart as well as bone health.

Removal of fallopian tubes — It is possible to remove the fallopian tubes with the
hysterectomy but leave behind the ovaries. Removing the fallopian tubes may decrease the
small risk of later developing one type of ovarian cancer, while preserving the hormone
production of the ovaries. Occasionally, it may not be possible to remove the fallopian tubes
due to scar tissue or other factors that increase the risk of removal.

Estrogen therapy — Estrogen therapy (ET) may be recommended after surgery for women
who had their ovaries removed. Women who have not reached menopause may use ET to avoid
hot flashes, night sweats, and loss of bone density, which may occur when the ovaries are
surgically removed. Women who plan to use ET should talk with their clinician about the risks
and benefits, and about how long to use this treatment.

In younger women who retain their ovaries, ET may be needed at a later date if the ovaries stop
functioning earlier than expected.

Women who have completed menopause generally do not require ET after hysterectomy.
Vaginal ET is not a systemic replacement hormone therapy but rather a topical therapy to
improve the vaginal epithelium; this may be recommended even if the ovaries are left in place.
(See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)

Preoperative testing — Standard preoperative testing may include a physical examination,

electrocardiogram, chest x-ray, and blood testing, depending upon age and other medical
conditions.

VAGINAL HYSTERECTOMY PROCEDURE

Vaginal hysterectomy is performed in a hospital setting and generally requires one to two hours
in the operating room. If other procedures are also performed, such as treatment of prolapse,

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the procedure may take longer. Patients are given general or spinal anesthesia plus sedation so
that they feel no pain. Heart rate, blood pressure, blood loss, and respiration are closely
observed throughout the procedure. After surgery, patients are transferred to the recovery
room (also known as the post-anesthesia care unit) so that they can be monitored while waking
up. Many patients will be able to go home the same day as the surgery. Some patients may
need to remain in the hospital for one to two days, depending on their age, other medical
conditions, and other procedures that may have been done at the same time as their
hysterectomy. A vaginal hysterectomy includes removal of the cervix, which is the lower portion
of the uterus.

LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY

Laparoscopically assisted vaginal hysterectomy (LAVH) is done by some surgeons to assist with
the vaginal hysterectomy procedure. A laparoscope is a surgical instrument inserted through a
small incision in the abdomen and pelvis. Using the scope, the surgeon can more easily see the
uterus, ovaries, and the tissues that surround these organs within the pelvis ( figure 3).

In addition, instruments may be used, along with the laparoscope, to facilitate the removal of
the uterus through the vagina. LAVH might be recommended for a woman with an enlarged
uterus, history of prior pelvic surgery, endometriosis, or other factors that could complicate a
traditional vaginal hysterectomy. Women generally recover faster after a vaginal hysterectomy
or LAVH compared with women who have abdominal hysterectomy.

However, not all surgeons use laparoscopy since additional training, experience, and equipment
is necessary. Patients should talk to their surgeon regarding the best procedure for their
individual situation.

NEED FOR ABDOMINAL HYSTERECTOMY

After surgery has begun, the surgeon may find conditions, such as extensive scar tissue, that
require him or her to remove the uterus through abdominal incisions. Sometimes these
conditions are not apparent before surgery.

Abdominal hysterectomy can be done with a traditional incision or through very small incisions
that allow insertion of an operative camera (laparoscope) to remove the uterus. Laparoscopic
surgery may be done for women with a large uterus, prior pelvic surgery, concern for scar
tissue from prior infections, or need for other procedures to be performed at the same time.
The recovery from a total laparoscopic hysterectomy is similar to after a vaginal hysterectomy.
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Morcellation of the uterus (cutting the uterus into small pieces in the abdomen) may be done to
help remove the uterus through the vaginal opening or through a small laparoscopy incision.
This is usually done in a bag placed in the abdomen to prevent spread of uterine tissue in the
abdomen. Patients should talk to their surgeon about the procedure.

VAGINAL HYSTERECTOMY COMPLICATIONS

A number of complications can occur as a result of hysterectomy. Fortunately, most can be

easily managed and do not cause long-term problems.

Hemorrhage — Excessive bleeding (hemorrhage) occurs in a small number of cases. Excessive

bleeding may require a blood transfusion and/or a return to the operating room to find and
stop it.

Infection — Low-grade fever is common after hysterectomy, is not always caused by infection,

and usually resolves without treatment. However, a high or persistent fever may signal an
infection. Serious infection occurs in less than 5 percent of women and can usually be treated
with intravenous antibiotics. Much less commonly, patients require another surgical procedure.

Constipation — Constipation occurs in most women following hysterectomy, and can usually

be controlled with a regimen of stool softeners, dietary fiber, and laxatives. Narcotic (opioid)
pain medications taken following surgery can increase the likelihood of constipation.

Urinary retention — Urinary retention, or the inability to pass urine, can occur after vaginal
hysterectomy. Urine can be drained using a catheter until retention resolves, usually within 24
to 48 hours.

Blood clots — Pelvic surgery increases the risk of developing blood clots in the large veins of
the leg or lung. The risk is increased for approximately six weeks after surgery. Medications
may be given to some women to prevent blood clots. In addition, women taking oral
contraceptives or hormone replacement should ideally discontinue them one month prior to
surgery since they can further increase the risk of blood clots. Women who are sexually active
and premenopausal should use alternative methods of birth control (eg, condoms) to prevent
pregnancy before surgery. (See "Patient education: Deep vein thrombosis (DVT) (Beyond the
Basics)".)

Damage to adjacent organs — The urinary bladder, ureters (small tubes leading from the
kidneys to the bladder), and large and small intestines are located in the lower abdomen and
pelvis and can be injured during hysterectomy. Bladder injury occurs in 1 to 2 percent of

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women who have vaginal hysterectomy, while bowel injury occurs in less than 1 percent of
women. Injury can usually be detected and corrected at the time of surgery. If detected after
surgery, another operation may be needed.

Early menopause — Women who have undergone hysterectomy may experience menopause

earlier than the average age of menopause (age 51). This may be due to an interruption in
blood flow to the ovaries as a result of removing the uterus. Occasionally, one or both ovaries
may need to be unexpectedly removed during the surgery due to injury, bleeding, or an
abnormality found during the surgery.

RECOVERY AFTER VAGINAL HYSTERECTOMY

Fluids and food are generally offered soon after surgery. Intravenous fluids may be
administered during the first day, particularly if there is nausea or vomiting. Pain medicine is
given as needed, either intravenously, or by intramuscular injection or pill. Patients are
encouraged to resume their normal daily activities as soon as possible. Being active is
particularly important since it helps to prevent complications, such as blood clots, pneumonia,
and gas pains. Many patients are able to go home on the same day of their procedure or the
following morning.

More information about recovery from hysterectomy is available separately. (See "Patient
education: Care after gynecologic surgery (Beyond the Basics)".)

LIFE AFTER VAGINAL HYSTERECTOMY

Studies of women's response to hysterectomy show that most women are very satisfied with
their results ( table 1). Most reported improvement in symptoms directly related to the
uterus, including pain and vaginal bleeding.

Sexual function and enjoyment, interest in sex, and pain with sex were improved for most
women. However, this improvement may be dependent upon several factors, including the age
of a woman at the time of surgery, the reason for surgery, and history of any prior difficulties
with mood. Younger women may grieve after hysterectomy due to their loss of fertility. A
woman who has new feelings of sadness, anxiety, or depression after surgery should speak
with her health care provider. These feelings may be treated by talking with a therapist, with
antidepressant medication, or may resolve with time.

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ALTERNATIVES TO HYSTERECTOMY

Some women who wish to avoid or postpone hysterectomy may use medications or less
invasive surgical procedures. Medical and surgical alternatives to hysterectomy depend upon
the underlying disorder. The decision as to which treatment is "best" should be based upon a
woman's particular medical problem, all available treatment options, and the risks and benefits
of each type of treatment.

Some alternatives to vaginal hysterectomy include the following:

● Uterine artery embolization and myomectomy may be used to treat symptomatic

leiomyoma (fibroids). (See "Patient education: Uterine fibroids (Beyond the Basics)".)

● Pain clinics may be able to treat patients with severe and chronic pelvic pain without
surgery. (See "Patient education: Chronic pelvic pain in women (Beyond the Basics)".)

● Endometrial ablation, in which a clinician destroys or removes most of the endometrium

using an instrument inserted through the vagina and cervix and into the uterus. (See
"Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the
Basics)".)

● Medical therapy using hormonal medications, such gonadotropin-releasing hormone

(GnRH) analogs (for example, leuprolide) or progestins can help reduce the pain
associated with endometriosis. (See "Patient education: Endometriosis (Beyond the
Basics)".)

● Prolapse repair with uterine preservation may be performed by some specialized

surgeons. This can be done either vaginally or laparoscopically, depending on the location
and amount of prolapse.

● Cone biopsy (eg, cold knife cone), cryosurgery, laser surgery, or loop electrocautery (eg,
LEEP or LLETZ) are usually used to treat women with high-grade cervical intraepithelial
neoplasia or carcinoma in situ of the cervix. These procedures remove the abnormal part
of the cervix rather than the entire cervix and uterus. (See "Patient education: Cervical
cancer screening (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

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Your health care provider is the best source of information for questions and concerns related
to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related
topics for patients, as well as selected articles written for health care professionals, are also
available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials.

Patient education: Hysterectomy (The Basics)

Patient education: Uterine cancer (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are best for patients who want in-depth
information and are comfortable with some medical jargon.

Patient education: Abdominal hysterectomy (Beyond the Basics)

Patient education: Fertility preservation in early-stage cervical cancer (Beyond the Basics)

Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)

Patient education: Anemia caused by low iron in adults (Beyond the Basics)

Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)

Patient education: Uterine fibroids (Beyond the Basics)

Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)

Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the
Basics)

Patient education: Chronic pelvic pain in women (Beyond the Basics)

Patient education: Menopausal hormone therapy (Beyond the Basics)

Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)

Patient education: Care after gynecologic surgery (Beyond the Basics)

Patient education: Endometriosis (Beyond the Basics)

Patient education: Cervical cancer screening (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and
other health professionals up-to-date on the latest medical findings. These articles are
thorough, long, and complex, and they contain multiple references to the research on which

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they are based. Professional level articles are best for people who are comfortable with a lot of
medical terminology and who want to read the same materials their doctors are reading.

Abdominal hysterectomy

Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management

Laparoscopic hysterectomy

Oophorectomy and ovarian cystectomy

Causes of female genital tract bleeding

Hysterectomy for benign indications: Selection of surgical route

Peripartum hysterectomy for management of hemorrhage

Radical hysterectomy

Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation

Approach to the patient with postmenopausal uterine bleeding

Vaginal hysterectomy

Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation,

and approach to diagnosis

The following organizations also provide reliable health information.

● National Library of Medicine

(https://medlineplus.gov/healthtopics.html)

● The American College of Obstetricians and Gynecologists

(www.acog.org)

● United States Department of Health & Human Services, Federal Government Source for
Women's Health Information

(www.womenshealth.gov)

[1-4]

REFERENCES

1. Meeks GR, Harris RL. Surgical approach to hysterectomy: abdominal, laparoscopy-assisted,

or vaginal. Clin Obstet Gynecol 1997; 40:886.

2. Harris WJ. Complications of hysterectomy. Clin Obstet Gynecol 1997; 40:928.

3. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: I. Outcomes of
hysterectomy. Obstet Gynecol 1994; 83:556.

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7/30/22, 2:11 AM Patient education: Vaginal hysterectomy (Beyond the Basics) - UpToDate

4. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual
functioning. JAMA 1999; 282:1934.

This generalized information is a limited summary of diagnosis, treatment, and/or medication

information. It is not meant to be comprehensive and should be used as a tool to help the
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medical advice, diagnosis, or treatment of a health care provider based on the health care
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Topic 8414 Version 19.0

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GRAPHICS

Vaginal hysterectomy

In a vaginal hysterectomy, the uterus and cervix are removed through the vagina.
The top of the vagina is then sewn together. There are no visible scars. The ovaries
and fallopian tubes may also be removed (called "salpingo-oophorectomy") at the
same time, or may be left in place.

Graphic 71521 Version 4.0

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Female reproductive anatomy

These are the internal organs that make up the female reproductive system.

Graphic 80271 Version 6.0

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Laparoscopically assisted vaginal hysterectomy

In laparoscopically assisted vaginal hysterectomy, three small incisions are made

in the abdomen. The laparoscope is inserted through these incisions. The uterus
and cervix are removed through the vagina. The top of the vagina is then sewn
together. The ovaries and fallopian tubes may also be removed (called salpingo-
oophorectomy) at the same time.

Graphic 60328 Version 5.0

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Frequency of common, severe symptoms before and after hysterectomy

Symptom Frequency before, percent Frequency after, percent

Vaginal bleeding 59 <1

Pelvic pain 63 8

Back pain 43 17

Activity limitation 58 2

Sleep disturbance 41 21

Fatigue 70 25

Abdominal bloating 48 12

Urinary incontinence 20 8

Data from: Kjerulff KH, Langenberg PW, Rhodes JS, et al. Effectiveness of hysterectomy. Obstet Gynecol 2000; 95:319.

Graphic 68886 Version 2.0

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Contributor Disclosures
Caroline E Foust-Wright, MD, MBA No relevant financial relationship(s) with ineligible companies to
disclose. Lori R Berkowitz, MD, MBA No relevant financial relationship(s) with ineligible companies to
disclose. Howard T Sharp, MD No relevant financial relationship(s) with ineligible companies to
disclose. Kristen Eckler, MD, FACOG No relevant financial relationship(s) with ineligible companies to
disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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