Introduction

Hysterectomy simply means the surgical removal of the uterus. Having a hysterectomy can be devastating for some women, especially those who find difficulty in accepting an end to their fertility. For others, however, it is seen as offering a welcome relief from pain or discomfort, or debilitating heavy blood loss. An important part of the nurse's role in caring for a woman undergoing hysterectomy is to assess the effect that this surgery will have on the women, her partner and her family and to respond appropriately.

A woman faced with this operation needs information (Coulter 1994, Scriven and Chesterton 1994, Young et al 1994). She needs to know exactly what surgery is planned - what parts of her anatomy are to be removed and why. She needs to explore if other options are available and be involved in making an informed decision. She needs to know what effect the surgery will have on her body, particularly in relation to her reproductive cycle, and how this will affect her sexuality. She also needs expert and sensible advice about her hospital stay and convalescence and her eventual return to a normal lifestyle. Equally important is her need to be given time and space to explore her feelings and emotional response to the hysterectomy, and in this the nurse can act as a source of comfort and be a sympathetic counsellor (Corney et al 1992, Haslett 1985, Jones 1993).

To fulfil these roles effectively, the nurse needs to be knowledgeable about and have an understanding of:

• The reasons for performing hysterectomy and the potential of other possible options (Haslett 1992).
• The types of hysterectomy performed and the rationale for deciding the most appropriate form of surgery (Haslett 1992, Kovac 1995, Llewellyn-Jones 1986).
• Care during the pre- and post-operative periods in hospital.
• Appropriate advice regarding convalescence following discharge, including information on Hormone Replacement Therapy (HRT).
• The woman's emotional needs and the anxieties of her partner and family.
• Availability of support organisations and additional reading material which may be useful.

Reasons for performing hysterectomy and possible options

Disorders of menstruation, dysfunctional bleeding or menorrhagia

Hysterectomy is often an 'end of the road' decision for women who may be debilitated from months of heavy and prolonged bleeding. Other treatments and investigations may have been tried unsuccessfully. Initial optional treatments include:

• Drug therapy - various hormonal and non-hormonal drug therapies may be used.
• Hysteroscopic transcervical resection of the endometrium (HTRCE). This relatively new and minimally invasive procedure has largely replaced dilatation and curettage as a diagnostic procedure and may also be an effective alternative to hysterectomy where appropriate (Rees 1993).

Table 1. Reasons for performing hysterectomy

Fibroids or other tumours

These may be benign or malignant. Fibroids are almost invariably benign, being bundles composed of muscle and fibrous tissue, which develop most commonly in the myometrium. They can vary enormously in size and number, and produce both menorrhagia and pressure symptoms such as frequency of micturition. Surgical removal of the fibroid(s) (myomectomy) may be a valid option for premenopausal women who wish to retain their fertility, but it is important to note that fibroids frequently recur. Small fibroids may successfully be removed by hysteroscopic resection.

Malignant tumours such as carcinoma can occur within the cervix, the body of the uterus, or ovaries. Hysterectomy is usually essential in the treatment of malignancy, in conjunction with chemotherapy and/or radiotherapy. The surgery is invariably radical and a Wertheim's or extended hysterectomy may be performed. Other options are not likely to be offered at this stage, although local diagnostic surgical procedures such as hysterectomy, endometrial biopsy, laser treatment, cone biopsy or oophorectomy may already have been performed.

Endometriosis

This condition denotes the spread of endometrial tissue to areas other than the lining of the womb, most commonly within the pelvic cavity. It can be extremely painful and may be associated with infertility. Hormone therapy, such as Goserelin, may be an option for a woman hoping for an eventual pregnancy, as it may be effective in suppressing the endometrial function and relieving the symptoms.

Pelvic inflammatory disease (PID)

This painful, often recurrent condition results from infection of the Fallopian tubes and other pelvic organs. Hysterectomy is usually offered when other options such as repeated courses of antibiotics have been given and the disease has become chronic. Fertility may be drastically reduced due to tubal adhesions, but a sensitive preparation for hysterectomy may still be necessary.

Prolapse

A utero/vaginal prolapse occurs when the supporting 'sling' of ligaments and pelvic floor muscles are no longer strong enough, allowing the uterus to descend into the vagina.

Alternative options to hysterectomy depend on the degree and severity of the prolapse, the woman's age and general state of health, and her willingness to have her uterus removed. A polythene ring pessary can be fitted, but this tends to be less effective than surgery. Repair surgery alone may be possible, but in the case of severe utero/vaginal prolapse, it is often performed in conjunction with a vaginal hysterectomy.

Emergency surgery

This usually follows either haemorrhage (for example, following childbirth) or perforation of the uterus during surgery. In either case, hysterectomy is the life-saving procedure with no other appropriate alternative options. The women concerned may need skilled help to come to terms with surgery as radical as hysterectomy without prior preparation.

Types of hysterectomy

These vary according to the route by which the surgery is performed and the extent of the organs or tissue removed (LLewellyn-Jones 1986). The types and classifications of hysterectomy are shown in Table 2.

Abdominal

The surgery is performed through an abdominal incision. This may be vertically midline (often used when the patient is obese), or more commonly, transverse or 'bikini-line'. Abdominal surgery is particularly preferred when the uterus is enlarged with large fibroids, or when organs other than the uterus need to be inspected or removed.

Types

• Abdominal
• Vaginal
• Laparoscopically assisted

Classifications

• Total
• Sub total
• Total, plus salpingo-oophorectomy
• Extended.

Table 2. Types and classifications of hysterectomy

Vaginal

The uterus is removed via the vaginal route. This is obviously the method of choice where the uterus has prolapsed, or when vaginal repair surgery is also required. Women who find scarring distasteful may also ask if the vaginal route is a viable option for cosmetic reasons.

Laparoscopically assisted

This method has been used most commonly in assisting vaginal hysterectomy and has obvious advantages in reducing surgical trauma (East 1994, Harris and Olive 1994, Wood et al 1994), resulting in a much speedier recovery. The costs involved, however, and a lack of suitably trained surgeons prevents laparoscopic hysterectomy being a viable option for some women at present.

The type of hysterectomy also varies according to the organs or amount of tissue removed.

Total hysterectomy

Is the removal of the body of the uterus and the cervix, but with the Fallopian tubes and ovaries retained. It is most commonly performed in benign disease such as fibroids and dysfunctional bleeding.

Subtotal hysterectomy

Is the removal of the body of the uterus only, with the cervix being retained. Although many gynaecologists feel that it is preferable to remove the cervix and thus avoid the risk of cervical cancer, some women may wish to retain their cervix, and would prefer this method if feasible. It is important for these women to be aware of the need to continue with regular cervical smear tests.

Total hysterectomy plus salpingo-oophorectomy (single or bilateral)

Involves removal of the uterus and one or both Fallopian tubes and ovaries. The extent of the surgery may depend on whether the woman is pre- or post-menopausal with functioning ovaries, and the presence of co-existing disease such as ovarian cysts, endometriosis or PID.

Extended hysterectomy

Involves a total hysterectomy plus bilateral salpingo-oophorectomy with removal of a vaginal cuff, and is performed because of malignancy. More radically, some pelvic tissue (including lymph nodes) may be removed and the cuff extended to involve the upper third of the vagina (Wertheim's hysterectomy).

Nursing care

Many gynaecology units now recognise the importance of pre-operative information giving. This is usually undertaken by nursing staff in a variety of settings, for example, pre-operative support groups or access to a nurse counsellor.

The care plan for a woman undergoing hysterectomy should reflect her emotional needs and the nurse's awareness of her anxiety levels, as well as the physical care required (Gould 1990).

On admission, in addition to carrying out routine procedures such as checking vital signs and performing urinalysis, the nurse should ascertain that the patient is fully informed about the extent of the surgery planned, understands her anatomy and the implications of the surgery, and is appropriately prepared, knowing what to expect immediately post-operatively and in subsequent days.

Post-operative care will depend on the extent and type of surgery carried out. Patients are mobilised as soon as possible, but will probably receive intravenous fluids and subcutaneous drainage for at least 24 hours, and will require analgesics to control pain. A urinary catheter and vaginal pack may also be present initially, particularly if extensive vaginal surgery has been performed.

Vaginal sutures are normally soluble, but sutures or clips closing abdominal incisions will need removal; clips usually on the second or third day after surgery, sutures on the fifth.

Pre-menopausal women who have a hysterectomy need to understand clearly that the removal of the uterus means there will be:

• No more periods
• No risk of pregnancy
• No need for contraception (except in relation to reducing the chances of contracting sexually transmitted diseases).

It is important to reassure such women that they will still be able to pursue an active, enjoyable and fulfilling sex life, and will still be able to achieve orgasm.

Women whose ovaries remain should understand that the natural production of the female hormones (oestrogen and progesterone) and dependant cycle changes will continue until the menopause is reached and ovarian function ceases, although ovarian failure does tend to occur earlier in women who have had a hysterectomy. Women who have both ovaries removed, however, are likely to be advised to accept hormone replacement therapy (HRT). The nurse can play a vital role in providing information on HRT, how it works and why, and explaining why it is so important to the maintenance of general health.

Hormone replacement therapy

HRT is a means of replacing the oestrogen no longer produced naturally when ovaries either cease to function or are surgically removed (women who have not had a hysterectomy will also need some progestogen to protect the endometrium). It is most commonly offered to pre-menopausal women who have had a hysterectomy accompanied by bilateral oophorectomy.

Oestrogen is given to prevent or relieve the distressing and/or debilitating consequences of oestrogen deficiency. In particular, it helps to control or prevent:

• Osteoporosis
• Neurovascular disorders, such as hot flushes and night sweats
• Vaginal dryness, atrophy and urethral syndrome
• Skin and hair texture change, with loss of collagen and elasticity to skin and fading of colour and dryness of hair
• Coronary artery disease and strokes.

Doses of HRT vary according to need and may be administered by the following routes:

• Orally, in tablet form, commonly presented in a calendar pack similar to the oral contraceptive pill, although HRT contains a much smaller dose of natural oestrogen.
• Transdermally, via absorption from 'patches' supplied as adhesive discs which the woman applies to a fatty area below the waist (usually buttock or thigh) and renews twice weekly, although a seven day patch is currently being developed.
• Subcutaneously, by implant. This involves a minor surgical operation under local anaesthetic during which a slow release pellet is positioned under the skin through a small incision in either the buttock or lower abdomen. The pellet is renewed approximately every six months, but this may vary depending on the individual's metabolism.
• Vaginally, as a treatment for local symptoms with oestrogen-based creams or pessaries.

Convalescence and recovery

Women (and their families) require practical advice about the convalescent period and appreciate very specific information. The recovery rate is affected by the extent of the surgery, the woman's general state of health, her chosen lifestyle and her willingness to adjust her activity levels appropriately in the initial convalescent period.

The nurse can give practical advice on several issues and can also take advantage of the opportunity to offer some useful health education advice and promotion, for example:

Smoking

If the woman gave up smoking prior to the anaesthetic (or because the hospital has a no smoking policy), strongly encourage her not to start again by emphasising the general benefits that accrue from not smoking, particularly in reducing the risk of respiratory, cardiovascular and gastrointestinal disorders.

Diet

Emphasise the importance of healthy eating, particularly in reducing intake of fats and increasing fibre to avoid constipation and weight gain (Webb and Wilson-Barnett 1983a).

Rest and exercise

Both are important factors in the convalescent period. Women should be warned that they will tire easily at first and will need to rest between activities. Exercise, however, is also important and should be undertaken as recommended by a physiotherapist (Haslett and Jennings 1992).

Vaginal bleeding or discharge

A slight vaginal discharge is normal for a few weeks following surgery, but women should be warned to seek medical advice if this becomes offensive, bright red or heavy with clots. They should also be reminded that the discharge may contain threads from dissolvable internal sutures. The importance of using a sanitary pad, not tampons (because of the risk of infection) should be stressed.

Hygiene

It may be appropriate to emphasise the benefits of appropriate hygiene measures, but it is important to point out that vaginal douches are not advised.

Housework/lifting

It may seem obvious that the woman should not be regularly lifting heavy weights during this period, but it is safer to discuss it with her and, importantly, her partner and family, who must be encouraged to undertake the heavier chores.

Return to work

It is impossible to generalise on this, as advice will vary with the nature of the work, how much travelling is involved and the individual's rate of recovery. Most employers are happy to grant three months sick leave for women undergoing hysterectomy. Women whose work involves heavy lifting may need this period of time, however many other women are ready to return to work much earlier.

Driving

This may be resumed when women feel that it would not cause physical discomfort, and that they have the confidence and concentration to do so. They should also check their cover with their insurance company in relation to surgery.

Sexual activity

Women and their partners appreciate reassurance and specific advice on resuming sexual activity. Many couples prefer to wait until the post-operative check has confirmed that the vaginal vault is completely healed before resuming vaginal intercourse. It may also be helpful to recommend initial use of a lubricant such as KY jelly. There are no specific contraindications to non-penetrative activities, although masturbation to orgasm should be delayed until the vault is healed. Also reassure women that their own sexual response should be very little changed by this operation, and experiencing orgasm will still be possible.

It is also important to stress to partners that women need love and affection at what can be an emotionally traumatic time, and that resumption of sexual activity may have to be preceded by the woman coming to terms with her altered sense of body image and, in some cases, her perceived change in femininity (Webb and Wilson-Barnett 1983b).

Emotional needs

Some women have enormous fears associated with hysterectomy - many based on misinformation and 'old wives' tales'. They need constant reassurance that there is no reason for them to gain weight, become hirsute or lose their hair, or experience depression or loss of libido (Webb and Wilson-Barnett 1983a). A very real fear for many women is a perceived loss of femininity - the fact that they will no longer be a 'whole woman'. They see the womb as the core of their womanhood and find difficulty in coming to terms with the end of fertility. Even women who did not particularly want a child resent the removal of this option and the finality of hysterectomy.

Certain ethnic groups find this operation particularly hard to accept, and nurses should be aware of the impact hysterectomy may have on different cultures and communities. West Indian women see menstruation as a cleansing act, ridding the body of impurities, and may find hysterectomy difficult to accept. Some also fear they will be 'less of a woman' in the eyes of their men, who may then be tempted to look for another 'whole woman'. The cultural role of Muslim women is dependant on their fertility, and again it may be difficult for both partners to come to terms with this form of surgery.

It can, therefore, be of value for the nurse to find time for discussion with the husband or partner and other members of the family. When people are anxious or distressed, they absorb only a small amount of information, so the nurse should always reinforce advice by offering some written back-up material wherever possible (Haslett and Jennings 1992, Haslett and Jennings 1995). It is also useful to offer information on additional reading material and the location of support organisations if these would be more appropriate.

Conclusion

This article has set out to help nurses gain an understanding of the complex physiological and emotional issues which are involved in hysterectomy. The indications for and the routes by which hysterectomy is performed have been explained, and the nurse's role in pre- and post-operative care described, particularly in relation to explaining the benefits of HRT and advising on convalescence. The crucial role of the nurse in helping the woman come to terms with the loss of her womb, a loss which is compounded by various cultural and religious beliefs, has been emphasised. Sensitive and empathic nursing care can do much to help women who have undergone hysterectomy to rebuild a normal and productive life; nurses must first anticipate the likely problems, however, then use their skills to help the woman and her family overcome then.

© Sally Haslett RGN, RM, RHV, FPCert. (1996) Nursing Standard 10, 38, 49-55.

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Further Reading

• Butterworth J (1995) Hysterectomy: A Reassuring Guide to Surgery Recovery and Your Choices. London, Thorsons.
• Coope J (1988) The Menopause: Coping with the Change. Revised edition. London, Macdonald Optima.
• Cooper W (1987) No Change. London, Arrow Books.
• Dickson A, Henriques N (1992) Menopause: The Woman's View. London, Quartet.
• Family Planning Association (1994) The Menopause. London, FPA.
• Hawkridge C (1996) Living with Endometriosis. London, Vermilion.
• Hayman S (1986) Hysterectomy. London, Sheldon Press.
• Smart F, Campbell S (1993) Fibroids. London, Thorsons.
• Smart F, Colvert T (1992) The Woman's Guide to Surgery. London, Thorsons.
• Webb A (1989) Experiences of Hysterectomy. London, Macdonald Optima.
• Westcott P (1993) Hormone Replacement Therapy: Making Your Own Decision. London, Thorsons.