During 1997-98, over 55,000 hysterectomies were performed in England on the NHS. One in five women aged 20 - 80 years faces a hysterectomy: in the UK it is the fifth most common operation. Most hysterectomies are performed on women aged 35 - 45.

Hysterectomy means the removal of the uterus - a pear-shaped muscular organ about the size of a closed fist, located in the middle of the pelvis. A hysterectomy can be performed through an abdominal incision , via a vertical mid-line incision, or, more commonly, through a transverse or 'bikini-line' incision or through the vagina.

Hysterectomy is a major surgical procedure. Although not as dangerous as it was 20 years ago, complications can sometimes arise and it is important that the woman and her partner are well informed. She needs to know exactly what type of surgery is planned, what effect it will have on her body and her sexuality. She should also be supported in exploring her emotional response to the hysterectomy.

Preparing for surgery

Experience and research in the USA has suggested that proper preparation and counselling can drastically improve the way women cope with hysterectomy (Dulaney et al 1990). For most women a hysterectomy is a frightening and emotional experience, bringing up many issues relating to their femininity. Women are faced with a number of personal crises in addition to surgery: they often re-evaluate their roles as career women, wives and mothers. They face never conceiving again.

Preparation prior to surgery is important. At Northwick Park Hospital, women usually know they need a hysterectomy many weeks ahead. Child care, home and work adjustments can be attended to. They also have the opportunity to attend a nurse-led presurgery information group where they can discuss their fears, assumptions and expectations.

As part of preparation for surgery, women attend a 'pre-clerking' day where the surgeon asks them about their medical history and arranges for routine investigations. The anaesthetist explains what they can expect from general or epidural anaesthesia and shows them how to use patient-controlled analgesia (PCA). The nature and type of surgery is discussed and written consent obtained.

Admission to the ward generally takes place the evening before surgery. Once again, the patient is encouraged to express any fears and anxieties and have her questions answered. The ward admission procedure is completed and a care plan is formulated with the patient using Roper's model of nursing.

Postoperatively, the usual care is given with vital signs, vaginal loss and wound dressing checked at half-hourly intervals, progressing to four-hourly as the patient improves. A pain chart is also recorded. If a PCA is not used the patient will require regular analgesia and its effect must be assessed. Anti-emetic drugs can be prescribed for severe nausea or vomiting.

Between the first and second postoperative day, the patient will have her urethral catheter removed, care being taken to check she voids regularly. Her intravenous infusion will be discontinued and she will be able to drink and slowly work up to a normal diet. Her PCA will be discontinued and the doctor will prescribe Diclofenac 50-100mgs three times daily for pain relief. It usually proves to be effective.

The wound dressing is removed on the second day and, providing there is no discharge from the wound, it is left uncovered and the woman asked to shower at least once a day. The wound and vaginal loss are checked regularly. Early mobilisation and deep breathing exercises are encouraged to prevent deep vein thrombosis and chest infection.

Reasons for hysterectomy

Dysfunctional uterine bleeding

Irregular, heavy prolonged bleeding can lead to iron deficiency anaemia causing severe tiredness.

Fibroids

Uterine growths of muscle and fibrous tissue. Non-cancerous, they cause heavy,painful periods and pressure on other organs, such as the bladder.

Endometriosis

A condition in which the endometrium (the lining of the uterus) grows elsewhere in the pelvic cavity. These cells build up and are shed during menstruation, causing chronic, painful cramps.

Prolapse

The uterus drops down into the vagina due to weakness in the muscles and ligaments supporting it. It can also occur due to a thinning of the muscles at the time of the menopause or as a result of slackening and stretching due to childbirth.

Pelvic inflammatory disease

Untreated pelvic infection can cause severe scarring of the fallopian tubes and ovaries, causing chronic pelvic pain, backache, low-grade fever, vaginal discharge and problems with menstruation.

Cancer

Of the vagina, cervix, endometrium, fallopian tubes or ovaries. Chemotherapy and/or radiotherapy is often used in conjunction with surgery when malignancy is confirmed by either ultrasound scan or local diagnostic measures.

Types of hysterectomy

Total hysterectomy

The commonest operation. The uterus, including the cervix, is removed.

Sub-total hysterectomy

The uterus is removed but the cervix is left in place. Most surgeons prefer not to perform this operation because the cervix is a potential site for cancer and women would need to continue to have regular smear tests.

Total hysterectomy with bilateral or unilateral salpingo-oophorectomy

Removes the uterus, cervix, fallopian tubes and one or both ovaries.

Wertheim's or radical hysterectomy (also known as an extended hysterectomy)

When the uterus, ovaries, tubes, peritoneum, upper part of the vagina, lymph glands and some fatty tissue are removed. This is a rarer type of surgery and only performed because of malignancy.

The patient is likely to be discharged between the third and fifth postoperative day and arrangements made for suture or staple removal (fifth day for transverse incisions and seventh day for vertical incisions) by either returning to the ward or liasing with the GP practice nurse.

Postoperative advice

Before discharge it is very important to give advice to the patient and her partner. The nurse is the ideal person to do this, as the medical staff do not always have the time or inclination to go into sufficient detail, especially with regard to emotional issues. Advice should include the following:

Pain

Women experience pain at different levels and in different ways. It helps to take some form of analgesia, such as paracetamol, when it occurs. Another cause of pain is flatus wind trapped in the bowel or under the rib cage and peppermint cordial dissolved in warm water can help with this.

Diet

Healthy eating should be encouraged, especially high fibre foods such as wholemeal bread, brown rice, fresh fruit and vegetables to prevent constipation.

Rest and exercise

Both are equally important. Everyone recovers at their own speed and for the first week or two it is normal to tire very easily. Some women experience 'blue' days and may cry for no reason. It is important to walk around, including up and down stairs, and to increase the amount of walking each day. Women should expect to be fully mobile in about four weeks but should leave any strenuous exercise until after the six-week check-up.

Lifting

Women should avoid lifting anything heavier than a kettle of water for at least four weeks and not lift heavy objects such as bin-bags, toddlers or shopping for at least three months.

Hygiene

A bath or shower should be taken each day. There is usually some vaginal discharge or bleeding for the first three weeks. Pads should be used rather than tampons, which could pose a risk of infection. Any sign of infection, such as lower back pain, frequency and pain on micturition or a foul-smelling discharge, needs to be reported to the GP.

Return to work

Provided the job is not strenuous, the woman can return to work once the postoperative check has taken place.

Sexual activity

Women are advised to refrain from penetrative sex for about six weeks following the operation as it could cause bleeding. It is normal to feel indifferent to sex after a major operation, but things should gradually return to normal and women's personal response should be very little changed by the operation: orgasm should be unaffected.

Hormone replacement therapy

If both ovaries are removed, oestrogen is usually commenced prior to discharge from hospital. Oestrogen varies in dosage and can be given orally in tablet form, transdermally in patch form (changed twice weekly), subcutaneously in implant form, vaginally in the form of a pessary or topically applied as a cream.

When malignancy has been diagnosed it can prove difficult for the woman to accept or see beyond the initial shock of diagnosis, and it is here that we need to be particularly sensitive in dealing with the patient, her partner and family. It is usual to refer the patient to the Macmillan team and the oncologist to offer further advice and support, especially if further treatment is prescribed.

Conclusion

Hysterectomy can be a positive experience for some women. However, it should be remembered that others see the uterus as the core of their womanhood and find it difficult to come to terms with the loss of their fertility. Certain ethnic groups find this operation particularly hard to accept and we need to be aware of the impact hysterectomy may have on women from certain cultures.

Every woman's experience of hysterectomy is different (Haslett and Jennings, 1998), but the majority of women return to a normal life and look forward to the years ahead.

© Veronica Moreira BA, RGN, RM (2000) Nursing Times 96; 20; 41-42.

References

• Dulaney P et al (1990) A comprehensive education and support programme for women experiencing hysterectomies. American Journal of Obstetricians and Gynaecology; 190; 4; 319-324.
• Haslett S, Jennings M (1998) Hysterectomy and vaginal repair. Beaconsfield: Beaconsfield Publishers.