There are many types of hysterectomy. This page talks about complete removal of the uterus and cervix. It does not discuss subtotal or supracervical hysterectomy where the cervix stays behind. (there are many nerves in the cervix and they may give rise to persistent pain in some clinical presentations of chronic pelvic pain (Lieng, 2008)).
Hysterectomy (keyhole, abdominal or vaginal) will remove the bulk of abnormal nerves in women with chronic pelvic pain or endometriosis. Not necessarily all of them since there may be injuries to retroperitoneal, uterosacral or vaginal nerves which may give rise to persistent pain after surgery. Conserving the ovaries mean there will be changes in blood supply in the lower pelvis that may continue to cause increases in pain though for the most part, most women notice a marked improvement in symptoms after the operation. For many women with chronic pelvic pain vaginal hysterectomy is technically feasible because there has been injury to the supoprts of the uterus following a difficult delivery; in women with advanced endometriosis and extensive adhesions, a large abdominal incision may be necessary.
Pain may recur for a number of reasons. If there are continuing problems with straining during defaecation then the pain will recur quickly owing to recurrent nerve injuries in the remaining tissues. If the abnormal nerves have been there for a long time then there is registration of these abnormalities in the brain (“central sensitisation”) that may contribute to recurrent pain some years later. There may be other reasons that contribute to recurrence rates of 10-50% at five years in women with chronic pelvic pain with, or without, endometriosis (Namnoun, 1995; MacDonald, 1999, Martin, 2006).
Long term consequences are in another category. Hysterectomy cuts adjacent nerves which will grow back after the operation. Over 10-15 years women may experience symptoms such as “my insides are falling out” (without physical signs of genital prolapse) and “I am sitting on a tennis ball” (aberrant reinnervation in the vaginal vault that is similar to a “phantom limb”). These symptoms are rarely as troublesome as the original pain; they are delayed afte the event and a full explanation usually deals with them.
Alway the biggest question for a woman with chronic pelvic pain is whether or not to have her ovaries removed. As noted in the autonomic denervation view, the ovaries produce oestrogen that increases blood flow in the second half of the menstrual cycle that contributes significantly to worsening pain where different patterns of abnormal nerves are present. The “rule of thumb” regarding oophorectomy in gynaecology is conserve ovaries in women under 40 years (risks of loss of hormones) and remove ovaries in women over 45 years (cancer risk). In most situations a woman should have hormone replacement therapy until the age of menopause (50 years). Difficult questions arise in younger women with chronic pelvic pain with, or without, endometriosis. The mantra among endometriosis surgeons is that in advanced endometriosis (stage 4) then removal of ovaries improves the situation. In other situations the position is less clear cut. Each woman needs individualised advice based on the cause of her symptoms, the site of her neural injuries and how they might respond to surgery.
There have been no studies of putting nulliparous women on proper diets, reducing transit times, increasing stool weights and avoiding straining during defaecation. Clearly this is critical in some nulliparous women. There are long term studies of GnRH agonists in women with chronic pelvic pain over 18 months without significant side effects, though the cost and side effects of these drugs mean they are restricted to six months courses in many units (Al-Azemi, 2009, Pierce, 2000). Given that we now know the source of neural injury in many women with chronic pelvic pain, this decision is now a very subtle and sophisticated, one for many of these women. It is important to have the full facts for her individual situation and her decision-making.
The good news in the autonomic denervation view of chronic pelvic pain is that it is usually possible to dientify the cause and extent of chronic pelvic pain, and, put in place preventive measures, or, tailor treatment to reduce the need for surgical treatment. If surgical treatment is necessary then vaginal hysterectomy will be appropriate for many women with chronic pelvic pain, and, women will be aware of all the parameters of the decision together with risks of recurrence of symptoms.