In 1975, the number of hysterectomies was reported to be as high as 1 million, which demonstrates the highest reported incidence. Following such prevalence, the procedure received high visibility in the news. In the late 1980s, the media went so far as to warn women against consenting to this surgery without clear medical indication and a second opinion.

In 1986, one report labeled the incidence of hysterectomy a crisis, estimating that 32% to 39% may have been unnecessary.³

After that time, the number of hysterectomies gradually came down in the late 1980s and leveled off into the 1990s to the current rate of 600,000 hysterectomies each year.2 Along with a decrease in the rate of hysterectomies is a trend toward a significant decrease in the morbidity of the procedure, a faster recovery after it, and a shorter postoperative hospital stay. From 1964 to 1994, the average length of stay (LOS) for a woman having a hysterectomy declined from 12.2 to 4.5 days for an abdominal hysterectomy and 2.5 days for a vaginal hysterectomy.^2,4 And now laparoscopic hysterectomies (laparoscopic assisted vaginal hysterectomy, commonly referred to as LAVH; laparoscopic supracervical hysterectomy or LSH; and total laparoscopic hysterectomy or TLH) are not only performed in hospitals, but also in ambulatory settings located in hospitals or freestanding outpatient surgery centers.^5-9

The shortest recovery and the lowest morbidity are associated with an LSH.^6-9 This procedure preserves the cervix and does not interrupt the integrity of the vaginal wall. This contributes to a decrease in intraoperative and postoperative morbidity, including a faster postoperative recovery, earlier resumption of sexual activity, and better pelvic support. Following an LSH, patients return home with less discomfort more than 90% of the time and generally resume their usual activities within one to two weeks.^6-9

Regardless of the type of hysterectomy a patient has, postoperative stay is decreased and nurses have much less time to care for their patients in the hospital. As a result, thorough preoperative and postoperative instructions provided to patients and their families by the nurses become critically important.^10-12

From cause to effects

The most frequent cause or causes for having a hysterectomy are uterine leiomyomata (fibroids), pelvic pain (generally caused by endometriosis or adenomyosis and/or adhesions), pelvic organ prolapse, dysfunctional uterine bleeding (DUB), and malignancy.^1,2 The severity of the symptoms and how they affect a woman’s quality of life are vitally important in the determination of whether a hysterectomy is necessary.

Many women may have DUB, pelvic pain, or uterine prolapse; however, the severity of their symptoms will often dictate whether surgical intervention is necessary. In most cases, medical therapy will be attempted initially, and if the symptoms continue to be severe, surgery is oftentimes necessary. For example, in the case of a patient with DUB causing menorrhagia, which is defined clinically as total blood loss exceeding 80 mL per cycle or menses lasting longer than seven days, the patient may become anemic.¹³

If medical therapy does not reduce the bleeding to a manageable level and the anemia is not resolved, this condition could become life-threatening if it were to continue. This is a situation that would require immediate surgical intervention.¹³

A hysterectomy is the removal of the uterus, which can be performed through a single large incision on the abdominal wall (abdominal hysterectomy); three to four small, 5 mm to 10 mm incisions on the abdominal wall (laparoscopic hysterectomy); or through the vagina (vaginal hysterectomy).^2,14,15 Currently, the technique used most often remains an abdominal hysterectomy. The ratio of abdominal hysterectomies to laparoscopic and vaginal approaches will likely decrease in general gynecology as more physicians become comfortable with performance of laparoscopic and vaginal hysterectomies.¹⁵ A vaginal hysterectomy is done with or without the assistance of laparoscopy. In more recent years, LAVHs have increased from 13% to 28%, and studies have found that women who had this surgery had less blood loss and pain, a decreased LOS, and shorter convalescence when compared to those having abdominal hysterectomies.^2,14,15 The number of LSHs are increasing rapidly due to their decrease in postoperative morbidity and possibly a decrease in potential surgical risks, such as damage to the ureters and bladder.^6-9,16

During the period from 1994 to 1999, 55% of hysterectomies included removal of the ovaries and fallopian tubes.² The current trend is to preserve the ovaries if possible to maintain hormonal integrity, particularly if the patient is premenopausal. Nurses need to know the exact procedure performed in order to determine if surgically induced menopause should be expected and to ensure appropriate follow-up.

Currently, the recommendations after hysterectomy when the cervix is preserved (supracervical or subtotal hysterectomy) are as follows:^17,18

1.         Women under 30 should have annual pap smears.

2.         Women over 30 may have a pap smear performed every two to three years if they meet the following criteria:

• Three consecutive negative pap smears AND no history of CIN II or III
• No immunocompromise (transplant, steroid use, autoimmune disease)
• No HIV infection
• No history of in utero DES (diethylstilbestrol) exposure

3.         Women with a history of CIN II or III should be screened annually until they have three negative consecutive tests, at which time they may continue annual screening or proceed with less frequent screening.

4.         There is no consensus regarding the upper age limit for cervical cytology testing. The American Cancer Society stated that women age 70 or older may elect to stop cervical cancer screening if they have had three consecutive negative pap smears and no abnormal test results within the prior 10 years.

After a total hysterectomy (uterus and cervix removed), recommendations for screening depend on indications for the hysterectomy:^17,18

1. Women with invasive cervical cancer require frequent follow-ups initially and then annual screening.
2. Women with current CIN II or III need cytology screening of the vaginal epithelium and inspection of the vulvar and perianal epithelium at four to six month intervals until three consecutive results are negative, and then annually. Annual screening should be performed until negative results have been achieved for three years. Then the women may proceed with less frequent testing or stop screening as indicated based on individual risk factors. 
3. Cytologic screening is not indicated for women with benign indications for a hysterectomy, and those with no history of CIN II or III may stop pap smear testing.
4. Screening should be continued in women with in utero DES exposure.

Pelvic examinations should still be performed annually for detection of additional pelvic pathology.

Physical complications associated with hysterectomies are related to the surgical procedure performed. Following an abdominal hysterectomy, the potential complications are similar to other types of pelvic and/or abdominal surgery, which include atelectasis, pneumonia, ileus/intestinal obstruction, thromboembolism, wound dehiscence and/or separation, urinary retention, and infection.^5,19 Potential injuries associated with pelvic and abdominal surgeries include injuries to the bowel, bladder, ureters, and major pelvic vasculature.^1,19 Vaginal hysterectomies pose less risk for complications; however, excessive bleeding and urinary tract complications are possible.⁵ Laparoscopic techniques involve the same risk of injury.¹⁵

Psychological complications may occur, and depression is the most often reported reaction. ⁵ Those who experience depression and/or decreased or depressed sexual function preoperatively are at greater risk for a postoperative reaction. Hormone deficiency may potentiate such risks if the ovaries have been removed.¹⁶ Other possible reactions include perceived loss of femininity, which can be temporary and related to the postoperative discomfort and presence of a surgical incision.⁵

Routine Care

With today’s earlier discharges and same day surgery, much of the nursing care once received in the hospital now takes place at home. However, routine in-house postoperative care is still the first step to recovery.

Following a hysterectomy, patients need the usual postoperative care and instructions that are required by any patient after major abdominal surgery. The goal is to facilitate the return of normal body functions.

Respiratory function: Coughing, deep breathing, and incentive spirometry to prevent respiratory complications, such as atelectasis, are paramount. Women usually have a sequential compression device applied to the lower extremities throughout the abdominal surgery and immediately postoperatively for both abdominal and vaginal hysterectomies to prevent thromboembolism.

Bowel Function: Early ambulation not only prevents venous stasis and respiratory complications, but it promotes the return of bowel functioning. Intestinal manipulation during abdominal hysterectomies, combined with anesthesia, can slow the bowel and cause ileus. In the past, women were not discharged until they had a bowel movement. Now many surgeons discharge patients if active bowel sounds are present, heightening the necessity of instructing patients about signs and symptoms of bowel dysfunction. Women should immediately report any anorexia, nausea, vomiting, or worsening of abdominal distention, abdominal pain, or absence of flatus on day three following surgery. Patients undergoing a vaginal or laparoscopic hysterectomy may resume a regular diet postoperatively on the day of surgery.

Urinary function: Providers insert a urinary catheter in women having hysterectomies to keep the bladder empty and out of the way, thus protecting it from injury and allowing better access to the uterus. The catheter is usually removed the day after surgery.

Due to earlier ambulation and ease of recovery, catheters can be removed earlier during the postoperative period following vaginal or laparoscopic hysterectomies. This can generally be performed postoperatively on the day of surgery. Besides the signs and symptoms of urinary infection, nurses should inform their patients that they might experience incisional pain when a full bladder exerts pressure against the incision. It is important to encourage patients to void at regular intervals, especially when their fluid intake is being increased, which may prevent this incisional discomfort.

Respiratory and cardiovascular concerns: Increases in intraabdominal and intrathoracic pressures associated with pneumoperitoneum are well tolerated by healthy patients, but may present a challenge in patients with significant cardiovascular and pulmonary compromise. Elevation in these pressures decreases pulmonary compliance, vital lung capacity, cardiac output, and central venous pressure, and elevates systemic vascular resistance and capillary wedge pressure. The Trendelenburg position, frequently used in a laparoscopy and vaginal hysterectomy may increase cardiac preload and afterload. Knowledge of a patient’s medical history helps in the control of perioperative risk factors.

Learning needs during hospitalization

Because many women who have hysterectomies have had other surgical procedures, they are familiar with their own postoperative concerns. Research has identified common learning needs.²⁰

Incision: The foremost learning need concerns the incision and postoperative discomfort. Some women cannot bear to look at the wound immediately postop, while others are anxious to see it as soon as possible. When the patient is ready, using a simple hand or compact mirror can help.

Nevertheless, caregivers should encourage all patients to inspect their incisions at least once before discharge to establish a baseline for later inspection for infection. Patients need to report drainage or erythema, increasing induration, and pain at the site of incision. Also, the incision area must remain dry (this is especially important in obese individuals).

An advantage of vaginal and laparoscopic surgery includes low maintenance of abdominal incisions or no abdominal incision at all in the case of vaginal surgery. This is especially important in patients who are obese, diabetic, or immunocompromised. Additionally, with the rare exception of umbilical herniation there is little risk of abdominal wall herniation following laparoscopy. Most laparoscopists agree that it is important to close the fascia for any incisional site larger than 5 mm. Numerous companies make products to facilitate closure of the fascia during a laparoscopy.^15,21

The presence and removal of sutures, staples, and/or incisional closure tape can be anxiety producing. Even though suture removal may not occur until after discharge, nurses should explain this procedure while the patients are still in the hospital. Providers, sometimes nurses, remove staples and sutures four to five days postop.

Incisional pain is foremost on patients’ minds. Explaining options and providing and maintaining adequate analgesia reduces anxiety and facilitates early mobility. Nurses can instruct patients in the use of other adjuncts, such as splinting the incision with a small pillow while coughing and deep breathing. Analgesia administered before suture removal or the car ride home can prevent unnecessary discomfort; and when discharged, using a small pillow over the abdomen, beneath the seat belt, can also protect the incision during the car ride home.

Level of activity postoperatively: The second most commonly identified learning need involves complying with the appropriate level of activity during convalescence. Patients need to be encouraged to ambulate as soon as possible while still in the hospital, and even showering is frequently permitted after the abdominal dressing is removed. Early ambulation is a good opportunity to provide information about proper body mechanics for lifting and bending and about how the abdominal muscles can provide support against other injuries, such as the back, and stimulate the early return of bowel function.

Early ambulation can prevent thromboembolism.¹⁹ Modern women are at higher risk for thromboembolism due to sedentary lifestyle, increased incidence of diabetes, increasing obesity, increasing age, and age-related medical conditions. Induction of general anesthesia is associated with general muscle relaxation, which decreases venous circulation substantially not only during the course of the procedure, but also for about two weeks postop. Muscular activity from early ambulation promotes circulation and reduces venous stasis and the risk of thrombosis.

Because of restrictions in activity, women may also have concerns about being dependent and burdensome to family and friends after discharge. Nurses can help patients to identify resources and modify living arrangements before they leave the hospital to ease recovery. Simple tips, like having family members move heavy kitchen items, such as pots and pans, to waist-height cabinets can eliminate unnecessary lifting and stretching during convalescence.

Menopausal and vaginal concerns: The extent of the surgical procedure may raise questions about menopause. For example, if a bilateral oophorectomy was performed, surgically induced menopause can occur, and hormone replacement therapy may be appropriate. Sometimes an estrogen patch may be placed during the surgery to prevent postoperative menopausal symptoms. The subject of HRT use remains currently controversial.^22-26 The United States Preventive Services Task Force and the International Menopause Society Guidelines publish guidelines that reflect combined estrogen/progesterone and estrogen only branches of the Women’s Health Initiative (WHI) and the Heart and Estrogen/ Progestin Replacement Study I and II (HERS). Both branches of the WHI study were discontinued prematurely, with the estrogen-only branch being stopped in February 2002. These guidelines are somewhat controversial. The decision to start HRT needs to be made carefully between a patient and clinician. This decision should be individualized based on a careful balance of the risks, benefits, and alternatives for a specific woman. In general, healthy perimenopausal women should be reassured that using estrogen for the management of menopausal symptoms is safe. Duration of therapy has not yet been established. However, estrogen therapy should be used for the shortest duration of time, taking into account symptoms and quality of life.^22-26

For women who had severe endometriosis observed during surgery, HRT may be delayed for six months to prevent immediate endometriosis production from hormonal stimulation.

Discussions about menopause can lead to questions about anatomy. Even though the surgeon may have discussed the procedure with the patient preoperatively, additional questions may arise. Pictures can promote understanding of what organs were removed and why symptoms, such as vaginal spotting of red or brown (old) blood, can occur immediately posthysterectomy. One to two weeks after surgery, the development of bloody vaginal discharge may alarm or confuse a patient whose uterus has been removed. This bleeding, which should not be as heavy as normal menses, can be attributed to the dissolving of vaginal cuff sutures. Patients need to know that spotting is expected after a hysterectomy regardless of the approach. However, they need to know to inform providers about significant bleeding, especially when accompanied by lightheadedness, dizziness, and significant abdominal pain.

Diet: While some physicians advise that patients can resume their diet immediately as tolerated, others wait until bowel sounds or even flatus are present. However, providers are in common agreement that fluid intake needs to be increased to prevent infection and to aid in the return of peristalsis.

Learning needs at home

Several hysterectomy-related issues may continue after discharge.

Incision: Women focus on the incision between the first and second postoperative weeks, when incisional pain is waning. They may be concerned about the flab or sagginess around the abdominal incision.^10,15,27 This condition, which is caused by residual edema, subsides by the eighth postoperative week. Patients may also experience temporary or permanent numbness around the incision from nerves being cut or compressed during surgery. Generalized itching may occur due to allergic reaction, and if this occurs, patients need to notify their healthcare provider.

Fever: Occasionally, a fever with no other specific symptoms, such as incisional drainage, occurs. Nurses should instruct patients to assess their temperature twice daily for the first week after discharge. Instructions about reading a thermometer may be necessary, and in fact, some patients may not even own one. Thermometers can generally be purchased for less than $10. Patients need to notify the physician’s office if they develop a temperature above 101 F.

Activities: Women’s activities will vary with the physical layout of their houses, domestic obligations, and career demands. Generally, patients can climb stairs once a day for the first week, twice a day for the second week, and then as tolerated. If the bathroom is located downstairs, a woman may want to come downstairs after her morning hygiene routine and stay down until after dinner to reduce the isolation of her room from family. Driving, especially a standard stick-shift car, is usually restricted until after the first postop exam, which is scheduled between four to six weeks after surgery. If it is necessary to drive before that time, women need to protect the incision by wearing a small pillow under a seat belt, driving at less busy times of the day, starting out with short trips, and avoiding conditions, such as icy roads, that could require quick movement.

Patients should not drive while using narcotics. In general, the key concern is that patients can react quickly and push on the brake with ease when necessary. These abilities reflect a patient’s level of pain and physical ability to perform these functions.

When patients undergo vaginal or laparoscopic surgery, concerns of the seat belt and other functions are greatly reduced after these surgical approaches in contrast to abdominal hysterectomies.^10,15,19

Fatigue after major abdominal surgery is normal and can persist for up to three months^.5 Encourage rest periods during the day, especially during the first and second weeks postdischarge. However, if sleeping at night is problematic, daytime napping should be limited or eliminated. Exercises — short walks one week after hospitalization and later, as well as longer walks or jogging — can enhance energy and nighttime sleep. Usual guidelines allow women to lift about five pounds after discharge, with heavier lifting or more strenuous exercise delayed until after the surgeon’s postoperative exam. The American Physical Therapy Association (APTA) has a pamphlet, For Women of All Ages, which provides guidelines about maintaining and restoring physical health and stamina throughout a woman’s life, including postoperative events. It’s available at www.aptva.org, the organization’s website. You can also contact the APTA at (800) 999-2782 or 1111 North Fairfax Street, Alexandria, VA 22314-1488.

Sexual activity: Patients will have questions about the resumption of sexual activity, and care should be taken not to avoid this topic, even if it is awkward for the patient or the nurse. And do not assume that every woman is involved in a heterosexual relationship.

Providers do not recommend sexual intercourse or douching until examination of the vaginal cuff or cervix at the postop visit. When sexual intercourse is resumed, the woman may wish to assume the superior position to control the depth of penetration to reduce pressure on the incision and discomfort. The inferior position, which uses less abdominal muscles and where a splint can be laid over the incision, may be better for others. Each woman will need to experiment to determine which position is most comfortable. Patients who experience diminished estrogen production from a bilateral oophorectomy may be especially in need of information about lubricants or possibly estrogen cream.

Emotional and physical issues: Hysterectomies can affect women psychologically, and reactions may occur within the first three months or up to three years postoperatively.⁵ Hormonal changes may induce menopausal symptoms of mood swings or hot flashes posthysterectomy, with or without oophorectomy. Women experiencing surgically induced menopause will need information about HRT, vitamin supplements, and the importance of discussing menopausal concerns with their provider.^22-26 Women who experience symptoms due to manipulation of the ovaries during surgery need to know that unless they became coincidentally perimenopausal, these problems will eventually subside without treatment.

Patients may be apprehensive about other potential effects of a hysterectomy, such as changes in body image. Even though many effects never materialize, encourage patients to discuss their feelings and fears that could have an impact on their femininity, libido, relationships with significant others, and religious or cultural orientations.

Health maintenance: Most women are not ready to learn about health maintenance issues, such as pap tests, breast exams, and mammograms immediately after surgery, but the four to six weeks postoperative visit affords an excellent opportunity. Keep in mind that with laparoscopic surgery, the postoperative visit may be as early as two weeks; however, all of the same issues need to be discussed at that time regardless of the type of hysterectomy. For recommendations on cervical cancer screening, please refer to previous guidelines mentioned earlier in this article.^16-18 With the incidence of breast cancer rising, monthly breast self-exams continue to be a vital part of health maintenance. Some women will continue to recognize monthly cycles even though bleeding is no longer present, and the optimal time for a breast examination is seven to ten days after menses would have occurred. The breasts are generally less tender and lumpy at that time. When teaching breast self-exams, nurses should encourage women to inspect their breasts on the same day every month. The American Cancer Society, American College of Radiology, American Medical Association, and American College of Obstetrics and Gynecology recommend starting routine screening for breast cancer and annual mammograms at age 40. If the patient has a personal or family history of cancer, mammograms are recommended sooner.²⁸

Nutrition: A less frequently explored learning need is nutrition. Strongly encourage women not to diet at this time because more nutrients, especially protein, are necessary for healing. They should drink at least eight 8-ounce glasses of fluid per day. Vitamin supplements, such as vitamin C and vitamin group B are beneficial, but women need to be cautioned not to overdose. For example, a woman may decide to take vitamin B6 and B12 to alleviate menopausal vasomotor symptoms of night sweats and hot flashes, while on a regimen of vitamin B and a multivitamin, which also contains vitamin B. Neurotoxicity can occur when too much vitamin B is taken. A simple multivitamin that includes vitamin B may be sufficient. Foremost, a well balanced diet should be maintained.

We stated earlier that 600,000 hysterectomies are performed in the U.S. annually.² Currently, 77% of women undergoing hysterectomies are likely to be employed.²⁹ Our goal as nurses and health care providers is to aid patients in a safe, rapid recovery as well as to facilitate their resumption of preoperative jobs along with their personal and family responsibilities. Additionally, we need to pay close attention to lending support as well as providing adequate education not only to the patient but also to her family, friends, and/or significant other.

Nurses can pave the way for a more effective convalescence by dealing with a woman’s special learning needs during the perioperative process and then doing everything possible to ensure comprehensive follow-ups for patients at home.