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Removal of Uterus (Hysterectomy): Partial or Total?

G, 45, had heavy menses with cramps for the past five years. She was married with two grown up children. In her late 30s, she noticed that her menstrual periods were getting heavier with clots. The bleeding was getting worse when she was 40. At times, her clothes were soiled. She became light headed and felt very tired during menses in spite of taking oral iron tablets regularly.

She began to experience menstrual cramps after about a year. It was accompanied by backache a day before and during the first 2 days of her menses. Initially, the pain was bearable but the intensity gradually increased so that it could only be relieved with a pain killer, hot pad and rest.

G was diagnosed with multiple fibroids at the age of 39. She was offered surgical management which she was not mentally prepared for. She was then treated conservatively with tranexamic acid, a medication that blocks the breakdown of blood clots, which prevents bleeding, Ponstan, a pain killer as well as oral iron therapy.

As G’s symptoms did not respond well to conservative treatment and her quality of life was severely affected, she decided to have her uterus removed after suffering for the past 5 years. “I am too old to have another baby and the uterus has caused me so much suffering,” she said.

Types of hysterectomy To remove uterine fibroids, there are two types of hysterectomy. · Total hysterectomy – the womb and cervix (neck of the womb) are removed. · Subtotal hysterectomy – the main body of the womb is removed, leaving the cervix in place.

Choice of total or partial (subtotal) hysterectomy Total hysterectomy (TH) involves removal of the body and the neck (cervix) of the womb, while partial or subtotal hysterectomy (SubTH) concerns the removal of only the body of the womb, leaving the cervix behind.

The cervix is the lowest portion of the uterus. It contains lots of glands that produce mucus forming clear vaginal discharge. The mucus is secreted under the influence of the hormonal changes of the menstrual cycle, becoming more profuse at the time of ovulation.

Hysterectomy disrupts the intimate anatomical relationship between the uterus, bowel, bladder and vagina

Bladder function: Hysterectomy involves separation of the bladder from the womb. This is more extensive in TH than in subTH. It has been reported that symptoms of incomplete emptying of bladder, urinary incontinence and frequency of passing urine improve better with subTH than TH.

Urinary tract infections are less common following a subTH.

Bowel function There has been no significant difference in bowel symptoms following either subTH or TH.

Sexual function: Studies have shown an improvement in sexual activity following either type of hysterectomy as the symptoms which patients have previously suffered from have been removed and there is no worry of becoming pregnant. However, hysterectomy may interfere with lubrication and orgasm.

With subTH, patients will not experience vaginal dryness or have a shortened vagina and sexual satisfaction may be better than post TH.

With subTH, the duration of operation, bleeding and injuries to the bladder and ureters are less. There are also fewer wound infections and haematomas (collections of blood under the wound).Thus, hospital stay and recovery are shorter.

After discussing the pros and cons of both types of hysterectomy, G opted for subTH which was carried out successfully via laparoscope. She was discharged well the next day. She was reminded to have regular checks with pap smear on her cervix for early detection of cancer.

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