Hysterectomy Procedure

Reference # GAC 62

Hysterectomy Procedure
Lefebvre G, Allaire C, Jeffrey J, Vilos G, Arneja J, Birch C, et al. SOGC clinical guidelines.
Hysterectomy. Journal of Obstetrics & Gynecology Canada: JOGC. 2002 Jan;24(1):37-61; quiz
74-6
Rating (out of 4):

Scope
This guideline summary is intended for gynaecologists.

Clinical Question

What are the indications for hysterectomy? What is an appropriate

Background
Hysterectomy is the most frequently performed major surgical procedure in gynaecology. Within
each province, the rate fluctuates significantly by region. No relationship has been established
between these differences and patient outcomes or satisfaction. In 1999-2000, the proportion of
vaginal hysterectomy had increased to 32 percent of all hysterectomies in Canada. While choice
of approach for the surgery is discussed in this document, ultimately it remains a decision for
the individual surgeon in concert with his or her patient. This guideline summary presents
considerations involved in the decision-making process of choosing hysterectomy or alternative
therapies for each of the more common indications.

Considerations
• Hysterectomy is the treatment of choice for certain gynaecologic conditions. The
predicted advantage must be carefully weighed against the possible risks of the
surgery and other treatment alternatives.
• The cost of the surgery to the health care system and to the patient must be
interpreted in the context of the cost of untreated conditions. The approach selected
for the hysterectomy will impact on the cost of the surgery.

Recommendations
Surgical Approach
• The vaginal route should be considered as a first choice for all benign indications.
The laparoscopic approach should be considered when it reduces the need for a
laparotomy. (III-B)

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 Hysterectomy Procedure
Reference # GAC 62
Benign Disease
• Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution
to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A)
• Abnormal uterine bleeding: Endometrial lesions must be excluded and medical
alternatives should be considered as a first line therapy. (III-B)
• Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms
with failure of other treatments and when fertility is no longer desired. (I-B)
• Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must
include pelvic supporting procedures. (II-B)
• Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence
that hysterectomy will cure chronic pelvic pain. When the pain is confined to
dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer
relief. (II-C)

Preinvasive Disease
• Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A)
• Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B)
• Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix
when invasive disease has been excluded. (I-B)

Invasive Disease
• Hysterectomy is an accepted treatment or staging procedure for endometrial
carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian,
and fallopian tube carcinoma. (I-A)

Acute Conditions
• Hysterectomy is indicated for intractable postpartum hemorrhage when conservative
therapy has failed to control bleeding. (II-B)
• Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be
treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-
C)
• Hysterectomy may be required for cases of acute menorrhagia refractory to medical
or conservative surgical treatment. (II-C)
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TABLE I
QUALITY OF EVIDENCE ASSESSMENT CLASSIFICATION OF RECOMMENDATIONS
The quality of evidence reported in these guidelines has been Recommendations included in these guidelines have been
described using the Evaluation of Evidence criteria outlined in adapt-ed from the ranking method described in the
the Report of the Canadian Task Force on the Periodic Classification of Recommendations found in the Report of the
Health Exam. Canadian Task Force on the Periodic Health Exam.

I: Evidence obtained from at least one properly random-ized A. There is good evidence to support the recommendation
controlled trial. that the condition be specifically considered in a periodic
health examination.
II-1: Evidence from well-designed controlled trials without
randomization. B. There is fair evidence to support the recommendation
that the condition be specifically considered in a periodic
II-2: Evidence from well-designed cohort (prospective or health examination.
retrospective) or case-control studies, preferably from
more than one centre or research group. C. There is poor evidence regarding the inclusion or
exclusion of the condition in a periodic health examination,
II-3: Evidence obtained from comparisons between times or but recommendations may be made on other grounds.
places with or without the intervention. Dramatic
results in uncontrolled experiments (such as the results D. There is fair evidence to support the recommendation

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 Hysterectomy Procedure
Reference # GAC 62
of treatment with penicillin in the 1940s) could also be that the condition not be considered in a periodic health
included in this category. examination.

III: Opinions of respected authorities, based on clinical E. There is good evidence to support the recommendation
experience, descriptive studies, or reports of expert that the condition be excluded from consideration in a
committees. periodic health examination.

Effective Date: May, 2004 Planned Review Date: May, 2007

Ontario Guidelines Advisory Committee

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