“Hysterectomy: What, Why, and How” – with Dr. Farnaaz Kia

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Dr. Kia, welcome back to the podcast. I just realized as we were speaking earlier, you haven’t been on in quite some time and that’s a crime. I’m very sorry for that to you and to all of our listeners. So, welcome back.

Dr. Kia: Thank you. Thank you for having me. Excited to be back.

Dr. Fox: And we’re going to be talking today about hysterectomy. And as I was telling you before, you know, someone I know had to undergo a hysterectomy and she was saying to me, you know, “I listened to your podcast every week and you haven’t done one on hysterectomy. Like, what the hell?” And I was ashamed and I said, “Yeah, that’s a good topic. We really should do that.” So, you know who you are. Thank you for making that recommendation. And I figured who better to talk about hysterectomy than Dr. Farnaaz Kia, hysterectomizer of the stars.

Dr. Kia: It is a good topic. It’s also a very common surgery that women have done. So, good to summarize kind of everything about it, what it is, why you might need it, that sort of thing.

Dr. Fox: Yes, I guess, let’s start with that. Let’s start with, just so everyone’s on the same page, what is a hysterectomy?

Dr. Kia: So, a hysterectomy is a surgery where one removes their uterus and then plus or minus different reproductive organs like fallopian tubes, ovaries are often can be included with the hysterectomy. But the term hysterectomy is just removable of the uterus itself.

Dr. Fox: Right. So, let’s actually start there. And I think that that’s one of the areas of this topic that’s a little bit confusing to people who don’t really know about it. So, hysterectomy, ectomy in medicine means removal of, right? You ever hear someone say that is something ectomy. It was removed like a colectomy is removal of the colon, tonsilectomies is the removal of your tonsils and so forth. So, hysterectomy for horrible reasons that we will not go into here. The uterus has the word hyster in front of it. And so that is sort of the word for uterus. So, like hysterectomy means removal of the uterus. Removal of the uterus does not mean necessarily removal of the ovaries, which produce hormones and the tubes. Sometimes they’re removed, sometimes they’re not at the same time. So, if someone has hysterectomy, they’re not always removed. Why would someone if they’re having their uterus removed also have ovaries or tubes or not have them removed?

Dr. Kia: Yeah, that’s a good question. So, nowadays we typically remove people’s fallopian tubes when they’re having hysterectomy because it reduces your risk for ovarian cancer by about 50%. And so once you’re removing someone’s uterus, the fallopian tubes, they don’t produce hormones or anything as you mentioned earlier that comes from your ovaries. And so they’re of limited utility and you’re removing the uterus, you’re not planning future pregnancy. So, you might as well remove the fallopian tubes to reduce your risk for ovarian cancer. Now, removal of the ovaries is a bit more of a complex decision to make. And that depends on a lot of different things. That depends on someone’s age, their risk factors for ovarian cancer, maybe the patient’s preferences, maybe their surgical history, the type of hysterectomy that they’re having done like the route of hysterectomy and that type of thing. And, you know, because when you remove someone’s ovaries, if they have not yet gone through menopause, then you’re essentially putting them through a surgical menopause because you’re removing the thing that produces estrogen for them.

Dr. Fox: Right. So, meaning if someone were, you know, let’s, just to make it pretty simple, if someone’s 28, then they need to have the uterus removed for one reason or another, which is unusual. But let’s say that were to happen, you’d be much less likely to remove the ovaries because basically you’re not only taking out a uterus, but you’re also, if you take out the ovaries, going to make her menopausal at age 28, which is pretty profound, right? Because that’s a very big difference from what’s going to happen naturally. So, unless there’s a really, really strong reason to take out the ovaries, you’d almost always leave them in. Whereas if someone is 78 and they’re having their uterus removed for some reason, almost always you are going to take out the ovaries because she’s already been through menopause, presumably if she’s 78, she won’t typically notice the difference if her ovaries are in or out and it would reduce her risk for ovary cancer and actually breast cancer moving forward. So, those are like the ends of the spectrum age-wise. And then if you’re in the middle, like let’s say you’re in your 40s or 50s or whatever it is and it’s a decision, you know, if someone has a high risk of ovary cancer or breast cancer, they’re more likely to remove it, versus if it’s a low risk versus if they already went through menopause or in the middle of menopause or worried about menopause, all those things go into that decision. But again, that’s a separate decision from the decision to remove the uterus.

Dr. Kia: Correct. Yeah. And there’s, you know, there’s different risks and benefits in that 40 to 50 age range, you know, kind of depends like why someone’s having the procedure in the first place. For instance, you know, if someone has like, let’s say endometriosis or they have chronic pelvic pain, you know, one might be more likely to remove the ovaries as those can be an area where endometriosis can infiltrate. Versus as someone’s having a hysterectomy for benign reasons like, you know, uterine fibroids like you’d be more likely to leave the ovaries at that point if they haven’t yet gone through menopause or in that early 40 to 50 range. Because, you know, removing them prematurely can have some long-term health consequences as well. So, you know, some of those long-term health consequences that we see with menopause like hot flashes, sleep disturbances, increased cardiovascular disease, osteoporosis, those types of things. So, really, you know, the risk-benefit discussion that you have with your provider to decide what is the best choice for you given your history, age, and kind of the reasons why you’re having the procedure in the first place.

Dr. Fox: Right. So, for this podcast, we’re going to focus on just the hysterectomy aspect and removal of the uterus. But sort of as an overarching theme, if someone is listening to this podcast and is about to undergo hysterectomy or might undergo hysterectomy, just remember that it’s a separate decision that is made between you and the surgeon of whether to also remove the ovaries at the time or to leave them in. And pretty much everything we’re going to talk about would allow for both leaving them in and for taking them out unless there’s some reasonable mention otherwise if it sort of makes them more technically challenging. But for all of these types of hysterectomies and reasons for hysterectomy, there’s a separate decision that will be made prior to surgery, potentially during the time of surgery about whether to remove the ovaries or leave them in. So, let’s go to hysterectomy. Why might someone need, or want or have a hysterectomy? What are the reasons that people have their uterus removed?

Dr. Kia: Right. Lots of different reasons. Fibroids is a big one. If someone has large fibroids or even small fibroids that are causing them pain, bleeding. They’ve tried different management options and they’re done with childbearing and they’re ready to just kind of get rid of the source of the bleeding for them. And so fibroids is a big reason. I kind of mentioned abnormal bleeding, you know, obviously cancer, pre-cancerous things, you know, if one were to have endometrial cancer, concerns for that, then, you know, having a hysterectomy would be the treatment. Different types of cancer as well, different reproductive cancers, pelvic organ prolapse, is another reason why people have hysterectomies. And, you know, sometimes we see this related to pregnancy as well, but kind of, you know, we obviously hope to avoid this as much as possible. But as a last resort, if a woman needs a hysterectomy to save her life in the setting of labor and delivery for, you know, uncontrollable bleeding or those types of things, then they would have a hysterectomy. Or, you know, if they have something called like a placenta or a credor or something like that, that would involve a hysterectomy.

Dr. Fox: I want to sort of break those into categories and we can do the last category first, which is one related to pregnancy. As you said, it’s often unplanned. Sometimes it’s planned, but that’s really a totally separate category because it’s to treat hemorrhage or prevent hemorrhage and it’s obviously not something typically people want, but it’s really like a life-saving type of thing. So, we’re going to put that aside for reasons for hysterectomy because that’s sort of a separate topic. Then the second bucket is when the uterus is getting removed, sort of not for a quality of life issue, but really because we’re worried about her health related to cancer or pre-cancer. And so there are certain gynecologic cancers or pre-cancers where it is recommended to remove the uterus. And that depends again on which type and how far advanced it is. And when that is happening, will also sometimes affect whether you’re taking out the ovaries or not based on the type of cancer we’re talking about, right?

Dr. Kia: Correct. Yes.

Dr. Fox: Right. So, the classic ones, endometrials usually if it’s pre-cancer, removing the uterus can sometimes just prevent cancer, treat and prevent it entirely if it’s pre-cancer. Same, rarely with cervical, though that’s much, much less common nowadays. And then if someone has suspected ovary cancer, usually when the ovaries come out, the uterus comes out as well. And so that’s like another bucket where there’s usually less discussion about whether to remove the uterus or not. And then it sometimes just goes into the root and what other things we have to do at that time. I think that the third bucket is the one that’s the most interesting from like a doctor perspective, but sometimes for a patient perspective. And those are all the ones, you mentioned bleeding, you mentioned pain, you mentioned fibroids, you mentioned pelvic or even prolapse. None of these things are life threatening. Is it just a quality of life decision for people? Like, would they rather have surgery and sort of stop having these symptoms versus not have surgery and maybe live through the symptoms or do other things with the symptoms? Is that really what it boils down to typically?

Dr. Kia: Sometimes. But, you know, like sometimes, for instance, like people that have fibroids that have really heavy bleeding, they might need hospital admissions, IV transfusions of blood, like their bleeding might be more threatening that a hysterectomy would almost be recommended at that point. Because if they failed other management options, then that would be a feasible next step to kind of help. Now, with this other issue of they have anemia, chronic anemia, and those types of things, metastasis can cause quite debilitating pain for people as well. So, yes, quality of life, but also it affects many facets of your quality of life. Prolapse could also make you more prone to recurrent infections and those types of things. So, they’re not necessarily like all elective reasons. There’s medical indications for them for all these separate categories as well that one might proceed with a hysterectomy.

Dr. Fox: You know, I think that’s fair. And I wasn’t suggesting that quality of life means like elective, like the term plastic surgery, type of thing. I mean, these are symptoms that bother people, right? Having pain, it’s not elective, right? I mean, it is. You don’t have to do it. But obviously, you’re not just doing it, you know, for the hell of it. Like, you want to not be in pain, right? But see like, I guess what I’m trying to ask is, when you’re having conversations with patients about hysterectomy and again, we’re not talking about cancer, we’re not talking about related pregnancy, but just for things like pelvic pain, prolapse, fibroids, things of that nature, how often are you saying to her, “You need a hysterectomy because your health is being affected, right? You’re getting blood transfusions, you’re anemic, you’re sick.” Versus, “Hey, these symptoms are really bothersome to you. Here’s one option. Here’s another option. And the last option, which is the most aggressive, but the most definitive is a hysterectomy.” Meaning, how often is the conversation, the first versus the second is what I’m really asking.

Dr. Kia: Yeah, you’re exactly right. It’s pretty rare where we’re like, “You need a… You know, there’s usually other management options. We tend to start with least invasive, you know, and generally in medicine, we want to start with the least invasive thing and then kind of work our way to, you know, hysterectomy as if it’s necessary and you’ve failed other management options. But most of these things that we’ve talked about, there are other management options that you can do before you get to the point of a hysterectomy. So, yes, I agree more times than not it’s, you know, “Let’s try these other things and see if that works.” And then you always have that as your definitive surgical management.

Dr. Fox: Right. Now, I presume if someone is planning on having children, they’ll do, you know, pretty much everything they can to avoid a hysterectomy, because if you have a hysterectomy, you can’t have children by caring. You’d have to have a surrogate, right? So, there isn’t really an option otherwise. So, in someone who’s not planning on having more children, what tends to be the reasons that people would do something other than a hysterectomy, like the alternatives? Is it, does it tend to be that they’re worried about the surgery? Is it because you think it’s very clear that the other treatments are going to work? I’m just trying to get a sense of like, why wouldn’t someone choose a hysterectomy? Again, assuming they’re not planning on carrying any more pregnancies.

Dr. Kia: Right. I mean, yeah, every surgery has its associated risks. And so there’s the surgical risk that comes with a hysterectomy. There’s many different types of hysterectomies that we can perform surgically. Each have their own set of risks and benefits. And, you know, it might require some time off from work and fitting the surgery into your schedule, that type of thing. So, just kind of the nature of surgery itself. And there might be some other management options that are easier and convenient for people.

Dr. Fox: Right. What you didn’t mention, and I’m curious because I know that people talk about this. How often is it someone’s just, they feel that there’s something different about them if they don’t have a uterus, their identity as a woman, like whatever it might be, sort of that generic category of something about wanting to hold on to your uterus. Do people tell you that? Have you heard it? I’ve heard that like myself. And so I’m just curious, how often have you heard that?

Dr. Kia: Absolutely. Yeah, absolutely. I think, you know, we see that a lot with women as well that are needing mastectomies, right? Like, there is, it’s a reproductive part of your body. And, you know, in the setting of a hysterectomy, sometimes we see that a lot with the decision to remove your cervix or not. And so definitely something that you hear and is a concern for people.

Dr. Fox: You know, it’s interesting. I think that sometimes and listen, however, people feel, that’s how they feel. Like, you know, that’s great. You know, God bless. I think that some of it is sometimes born out of a misunderstanding of what happens when the uterus is removed, and what exactly is getting removed, and whether… You know, because someone’s not going to look different externally if they had a hysterectomy versus didn’t have a hysterectomy or obviously a mastectomy, they will. If you’re removing the uterus and not removing the ovaries, they really shouldn’t feel different in terms of, you know, hormones or menopause and things like that. They won’t get their period anymore, which many people that’s a pleasant side effect of having hysterectomy. And I guess people ask a lot probably about sexual function afterwards and, you know, whether it’s going to affect anything related to sex afterwards. And how do you respond to that?

Dr. Kia: Yeah, so the data doesn’t show that there is a change in sexual function that happens after hysterectomy or even, you know, removal of the cervix or not. You know, anecdotally, people always feel different things that may not be supported by the data or not. So, I think that you just have to hear everyone out. It’s definitely a concern for a lot of people when they’re pursuing a hysterectomy that their sex life is going to change. You know, definitely, if you do have the ovaries removed and are put into a surgical menopause, then, you know, you will have a change in your sexual function likely because you’ll experience some of those menopausal symptoms. But, you know, really the data thus far has not shown that there is a change in sexual function after a hysterectomy.

Dr. Fox: All right. That’s reassuring. Now, in terms of the options, so let’s say someone has made a decision to have a hysterectomy or they’re deciding whether to do it and they want to know, like, what the surgery is going to entail. So, let’s talk about the types of hysterectomies surgically, because I think people don’t realize there’s many different ways to do this operation. And for each of them, we’ll sort of talk about what happens from the surgical side, sort of why might someone choose this route, you know, the pros and the cons of this particular route. And then sort of what from the patient and what would they expect like before, during, and after surgery, just so people can get a flavor. They won’t, you know, be experts, obviously, but get a flavor for what each type of hysterectomy entails. And we can start with any of the types you want, you pick.

Dr. Kia: Okay, we’ll start with like the most minimally invasive, I guess. I mean, in general, if…

Dr. Fox: Well, I’m curious what you’re going to say is the most minimally invasive. This is going to be very interesting because you’re younger than me. So, I’m curious. What is the most minimally invasive?

Dr. Kia: Well, actually, the preferred route for hysterectomy is a vaginal hysterectomy.

Dr. Fox: Oh, God bless you. You were trained well. All right.

Dr. Kia: It’s, you know, where you remove the uterus through the vagina. So, you know, there aren’t any incisions on your abdomen or anything like that. So, very minimally invasive. And people traditionally have been trained very well on vaginal hysterectomy and can do it pretty fast. It has a lower complication rate. People return to normal activities much faster, reduce hospital stay, shorter off time, lower blood loss, all those things. But the downside of like nowadays, what we’re seeing is the people that were once experts in vaginal hysterectomy, it’s not as common anymore. And so it’s kind of, in my opinion, phasing out. Now, if you have a provider that is good at them and can do them and you’re a good surgical candidate for them, then, you know, that is, you know, the preferred route for hysterectomy. There’s other types of minimally invasive procedures. So, there’s total laparoscopic hysterectomy, which, you know, I have more experience in my training with total laparoscopic hysterectomy is over vaginal hysterectomy. And so the total laparoscopic hysterectomy is where it’s a laparoscopic surgery.

So, minimally invasive. You people that may have had laparoscopic surgery for other indications as well in the past, like gallbladder, that type of thing. But a couple of small incisions that are about a centimeter that go, you know, one in the belly button and a couple on the sides. You place a camera inside the abdomen and use instruments to detach the uterus and then either remove the uterus vaginally or through, you know, a smaller incision on the abdomen. It has a lot of the same benefits as vaginal hysterectomy, lower postoperative pain. You go home the same day, lower risk for infection, lower risk for blood clots, that type of thing. Some of the disadvantages of laparoscopic surgery is, you know, there’s the higher risk of urinary tract injuries. It might take one no longer amount of time to perform the surgery, those types of things. And then there’s laparoscopic-assisted vaginal hysterectomy, or it’s essentially you part of the hysterectomy vaginally and part of it laparoscopically. And remove the uterus vaginally. So, that’s kind of a combo of the both, the two prior things that I’ve mentioned.

Dr. Fox: So, let’s break that down for a second. So, for the vaginal hysterectomy, which is basically all the surgery is done vaginally, right? So, for that operation, the patient is totally asleep, right? She’s under general anesthesia, so no pain to her. We do all the surgery vaginally. The uterus is removed. The cervix has to be removed if you’re taking out vaginally. I mean, you can’t leave the cervix in and take out the uterus vaginally. That’s not technically possible. And you have the option to take the ovaries out or leave the ovaries in with that surgery. And when you said it’s fast, I mean, it could be under an hour. I mean, a vaginal hysterectomy. And then typically, is that something where the patient stays overnight in the hospital? And if so, for how long?

Dr. Kia: You know, it depends if vaginally, if it goes very smoothly, then no, you don’t need. You know, they could go home the same day. If they do, maybe one night.

Dr. Fox: Yeah, it’s a pretty low-risk procedure in that sense. And then generally, the recovery is, you know, pretty good. Pain is not crazy. There tends to be less pain when you have an incision vaginally inside as compared to on your belly. So, the recovery tends to be pretty quick for that. Technically, it’s easier to do if someone’s had children before because the uterus tends to be a little bit more mobile, that easier for us to sort of move around vaginally. And also, if you’re not removing a uterus that’s very, very large, right? Because then there’s just a geometry issue of trying to get vaginal. So, people who have like very huge fibroids. It’s very hard to do that vaginally. But if it’s been done for bleeding and it’s a small uterus, it tends to be pretty straightforward. When you said that fewer people do them nowadays, which is true, is it just because fewer people are adept at vaginal surgery or that there’s just fewer hysterectomies overall? And so this kind of vaginal surgery is less trained?

Dr. Kia: I think a combination of both things. I think that the training in vaginal surgery is less because a combination of, you know, maybe not as many people that you’re learning from are doing them as frequently as they once used to do with the introduction of more laparoscopic surgery. And yeah, you’re right. We’re also doing fewer hysterectomies with multiple other treatment management options for all of these other indications.

Dr. Fox: Right. And then moving up the laparoscopic-assisted vaginal hysterectomy. So, why would someone have that? Like, why would you add the laparoscopic assistance as opposed to doing the vaginal hysterectomy just on its own? Is it just for technical surgical reasons or are there other reasons why you would do that?

Dr. Kia: Let’s say you wanted to look inside someone’s abdominal cavity. So, like with a vaginal hysterectomy, you don’t really get to see inside their abdominal cavity. So, for instance, let’s say someone had endometriosis where you wanted to evaluate the endometriosis, look at the other adjacent organs and if someone has bad pelvic adhesions, those types of things. And laparoscopic surgery can be more beneficial for you because you can put a camera inside, look around, take biopsies if you need. And then you can see from above as well. So, I would say that was another big reason why people do this laparoscopic surgery.

Dr. Fox: And then if someone has a laparoscopic-assisted vaginal hysterectomy, I presume the recovery is pretty similar, but maybe slightly more pain because they also have incisions, I mean, small ones, but they have some incisions on their belly and their belly was filled with gas, which tends to give people some shoulder pain. So, it’s probably like a vaginal plus a little bit, I would assume, yes?

Dr. Kia: Correct. Yeah.

Dr. Fox: Okay. Now, what is the difference between that and you said a total laparoscopic hysterectomy?

Dr. Kia: The difference between a laparoscopic-assisted and total laparoscopic. So, total laparoscopic is everything is done laparoscopically. So, the uterus, the anatomy is kind of divided into an upper portion or lower portion where, you know, like the fallopian tubes, ovaries, some oligomens, those types of things for laparoscopic assisted, are taken down laparoscopically and then one, the surgeon would go down below and then remove the uterus vaginally and detach the lower portion of the uterus vaginally. Versus a total laparoscopic hysterectomy, everything is done laparoscopically. And then the uterus is removed, you know, then one would decide if their cervix is staying or not, and then remove the uterus through a smaller incision on the abdomen.

Dr. Fox: So, if someone wanted to keep their cervix for whatever reason, and you wanted a minimally invasive approach, you’d have to do a total laparoscopic hysterectomy and remove the uterus through an incision on the belly.

Dr. Kia: Correct.

Dr. Fox: Got it. And I assume the recovery for that is pretty similar to any laparoscopic operation.

Dr. Kia: Correct. Yeah.

Dr. Fox: Got it. And so that is the one that I think is much more common now than when I was training. There were very few total laparoscopic hysterectomies, you know, 20 years ago, and now it’s a very common operation. Would you agree?

Dr. Kia: Yes, very much so.

Dr. Fox: Okay. Now, why would someone need the more aggressive type of surgery, which we call an abdominal hysterectomy? And what exactly is that?

Dr. Kia: Yeah. So, an abdominal hysterectomy is no laparoscopic instruments involved. There’s an incision on the abdomen that’s made. Typically it’s, you know, we can usually do this like a C-section incision very rarely, depending on why someone is having a hysterectomy would you need a vertical incision on the skin. But, usually, people are able to do it like via like a C-section incision, a fan-cell incision. So, like one bigger incision rather than a couple of small ones. And that really just depends on the indication. So, if someone has a very large uterus, like let’s say, their uterus is 25 centimeters large because they have these giant fibroids. It’s going to be really hard to get that uterus out vaginally. And it’s also going to be very hard to get that uterus out laparoscopically. So, one would need an abdominal hysterectomy to remove a very large, you know, if someone has that anatomy. Also, if someone has a lot of prior surgeries where they have, you know, really dense scar tissue, adhesions, those types of things where it’s going to be hard to visualize laparoscopically or hard to remove the uterus vaginally, you know, then one might resort to abdominally or for some of the other cancer indications that we discussed earlier.

Dr. Fox: Now, for the abdominal hysterectomy, what is that typically like from the patient end in terms of recovery?

Dr. Kia: So, you know, it’s a bigger surgery, so more pain and then usually a couple of nights in the hospital. So, we try to fast-track people as much as possible and, you know, get their pain under control and get them up and moving and that type of thing. But usually a couple of nights, like two nights in the hospital.

Dr. Fox: Yeah. And that’s really, you know, when you make the laparoscopic incisions, you know, they’re big enough to fit maybe your pinky inside. They’re just, you know, five millimeters, you know, sometimes slightly more, sometimes slightly less. And they’re basically like a puncture, right? Whereas if you do an abdominal hysterectomy, you’re actually like opening up the skin, opening up the layers below. There’s a lot more inflammation underneath and sutures underneath that we have to put every layer back together. And so it tends to be more painful. Some of that is proportional to the size of the incision, right? A smaller abdominal incision is going to hurt less than a bigger abdominal incision. Some of it’s not. Some of it’s just, you know, having you open and closed is painful for people. And so I guess the most similar that people might get is like a C-section. It tends to be less than a C-section because, you know, when the uterus is removed, you don’t have cramping like the uterine cramping doesn’t happen. It’s really just a surgical.

And obviously, you’re not as sleep-deprived because you don’t have a newborn to take care of. And you’re not, you know, nursing or, you know, there’s a lot less going on in that sense. So, it’s probably a quicker recovery than a C-section, but it’s definitely a harder recovery than a vaginal hysterectomy or a laparoscopic hysterectomy. You know, take us through that conversation. If someone’s having a hysterectomy, let’s say for fibroids and bleeding, right? How does that conversation go? And a decision’s been made to do it, right? So, we sort of pass that decision. And then let’s say she’s, you know, 41 and she’s leaving her ovaries inside. Okay, so it’s just about the hysterectomy. How do you make a decision with her about whether to do vaginal, laparoscopic vaginal, total laparoscopic or abdominal? Like, what are the factors that you want to know and what are the factors that you’re going to sort of put on her to decide?

Dr. Kia: So, I think a lot of it just starts by getting a good medical history, you know, seeing how many prior. If she’s had any prior vaginal deliries, if she’s had any prior surgeries, if we expect there to be adhesions, if she’s had prior C-sections, that can cause adhesions or scar tissue on the inside. So, just getting a good, thorough history of that. My preference is to always do things the least invasive if possible. And so, you know, then it goes down to why she’s having the hysterectomy, as we discussed with fibroids. And I would take a look at, like, where are the fibroids on the uterus? How big are the fibroids? You know, how does her uterus feel on the exam? Do I think that it’s going to be able to come out vaginally? You know, and then sometimes with that, then that kind of makes your decision for you. Like, if it’s too big to perform laparoscopically, then you’re with abdominal. The other thing to consider, too, is if it’s, you know, if you feel like it can be done laparoscopically, then you kind of talk about the different options for laparoscopic removal.

But a lot of it boils down to your surgeon’s preference on which route, you know, like, which route does your surgeon feel most confident? You know, what is their preferred method when it comes to, you know, laparoscopic-assisted vaginal or total laparoscopic or that type of thing, or a vaginal hysterectomy? And so you know, discussing the risks and benefits with each different route, and they’ll kind of present you with what they think is best from that standpoint. We also have specialists as well, like minimally invasive gynecologic specialists that can perform these surgeries very well as well, you know, if one has large fibroids that maybe their surgeon doesn’t feel comfortable removing laparoscopically, but does feel like it’s within the scope of having a laparoscopic surgery. Then might refer you to the minimally invasive surgeons to see if it’s something that they could accomplish as well.

Dr. Fox: One decision we didn’t talk about much is whether to take out or leave in the cervix. And obviously, with some of the routes, the cervix has to come out, anything that’s vaginal, basically. And with the total laparoscopic and the abdominal, you can choose to leave the cervix in or take the cervix out. How do you help people make that decision? Or do you always recommend one versus the other?

Dr. Kia: I typically recommend removing the cervix at the time of hysterectomy because, as, you know, I kind of alluded to earlier, there isn’t strong data to show that it’s going to… There isn’t a difference in, you know, urinary bowel, sexual function, recovery from surgery, you know, those types of things with retaining the cervix. And then the downside of retaining the cervix is that you’re going to need continued cervical cancer screening, and you might continue to have, you know, cyclical vaginal bleeding that comes from the cervix as well. And so at that point, if, you know, since there isn’t benefit in keeping the cervix, I typically recommend having it removed now. With that being said, obviously, a decision that you discuss with the patient and see what the patient’s preference is and kind of through shared decision making, reach a conclusion.

Dr. Fox: Right. I mean, anecdotally, some people, like you said, will report that leaving the cervix in sort of leaves them with better sexual function or maybe less risk of prolapsing. And I agree that data doesn’t really support that, but sometimes that’s a concern that patients have and they’ll want the cervix to remain behind, which is fine, technically. Are there people who you would really push back against that? I guess, someone with abnormal pap smears might be someone like, you know, who you would do that.

Dr. Kia: Exactly. So, if someone’s had a history of, you know, abnormal pap smears and particularly like higher grade lesions or those types of things, then I would strongly recommend the cervix be removed so it doesn’t have a potential for cervical cancer in the future.

Dr. Fox: Got it. So, to review, hysterectomy is still a pretty common procedure, but it’s still a very common operation. There are some reasons that are related to cancer, pre-cancer, again, less common, and some related to pregnancy, much less common. And then all the other ones, a lot of them it’s just a decision about how bad are the symptoms, what are the options. And if you’re having a hysterectomy or planning to have a hysterectomy, a discussion with the surgeon about what the optimal route would be for both of you, right? For you, the patient, what’s the one you want? What’s the sort of, in terms of the best option for you and also something that the surgeon is comfortable with? Terrific. Did I miss anything? Do we miss anything, Dr. Kia?

Dr. Kia: I think we’re good. That was great.

Dr. Fox: Thank you so much for doing this. Thanks for coming on the podcast. Really good one. And I will try to be better about inviting you more frequently.

Dr. Kia: Thanks so much. I appreciate it.

Dr. Fox: All right. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.