Cervix, Keep it or Remove it?

Located in Hysterectomy (click link to see other articles).

A hysterectomy refers to the removal of a women’s uterus (womb) and possibly the cervix.  Hysterectomy is one of the most common surgeries in the United States, with approximately 600,000 performed annually [1].  Reasons for performing a hysterectomy include pelvic pain, heavy vaginal bleeding, fibroids, pelvic organ prolapse and cancer.  There are two main types of hysterectomies: total and supracervical.  A total hysterectomy refers to removal of the uterus and the cervix (It is a common misconception that a total hysterectomy includes removal of the ovaries.  If the ovaries are to be removed, your surgeon will refer to that as a bilateral salpingoophorectomy or BSO.).  A supracervical hysterectomy refers to removal of just the uterus with the cervix being left in place.  Your surgeon may give you the option to keep or remove your cervix, but in some circumstances removal of the cervix is medically warranted.  Hysterectomies that are performed for treatment of cancer generally will involve removal of both the uterus and cervix.  Women having a hysterectomy for any of the first three reasons may elect to have either a total or supracervical hysterectomy (Figure 1).   If the hysterectomy is for pelvic organ prolapse, the cervix may or may not need to be removed based on the type of prolapse repair that you need.  In the United States in 2003, six percent of all hysterectomies performed were supracervical [2].

Since pelvic pain, heavy vaginal bleeding, and fibroids are the most common indications for hysterectomies, many women are faced with the choice of having their cervix removed versus keeping it at the time of their surgery.  Quite a few factors can go into making this decision; the most common being cyclic bleeding (similar to a period but generally lighter), sexual function, prolapse (the top of the vagina becoming lower), incontinence (the loss of urine) and the need for continued Pap-smears after surgery [3,4].

After a supracervical hysterectomy a woman may continue to have small amounts of monthly bleeding or spotting.  This happens because the cervix can contain some of the cells that are responsible for the monthly menstrual period.  When the cervix is left behind, some of these cells may also be left behind and continue to bleed monthly.  If the cervix is removed (total hysterectomy), the patient will not have any vaginal bleeding after the surgery.  The likelihood of bleeding after a supracervical hysterectomy has been reported to be between 11-17% [4].  Some women may find this symptom bothersome and may require a second surgery to remove the cervix to stop the bleeding.

Improved sexual function has often been cited as one of the primary reason to not remove the cervix at time of a hysterectomy.  Multiple studies have been performed and they showed no clear benefit to sexual satisfaction from either removal or preservation of the cervix [3,4].  These studies looked at multiple factors, such as sensation during intercourse, ability to achieve orgasm, and pain with intercourse and did not show that a supracervical hysterectomy is better than a total hysterectomy when it came to these factors.

Pelvic organ prolapse is a condition where the uterus, bladder or intestines may create a bulge in the vagina (patients are often told that their “organs have dropped”).  One proposed benefit of leaving the cervix in place after a hysterectomy is to reduce the risk of this happening.  Research has demonstrated that this is untrue and that removing the cervix does not predispose patients to a higher risk of prolapse[5].  Urinary incontinence is the involuntary loss of urine that can occur when a woman sneezes, laughs or coughs.  Similar to pelvic organ prolapse, numerous studies have shown that the rate of incontinence is not worse following a total hysterectomy than a supracervical hysterectomy [3,4].

All women planning to undergo a hysterectomy should have a Pap smear performed prior to their surgery.  Pap smears are performed to detect precancerous changes to the cervix.  Women who have a total hysterectomy with no history of severely abnormal Pap smears within the past 20 years do not need Pap smears after their surgery.  Women who have a supracervical hysterectomy and are less than 65 years of age will need to continue having Pap smears since their cervix is still in place [6].  Even if the cervix is removed and Pap smears are not necessary, it is still important to see your gynecologist every year for an annual exam.

The decision to remove or retain your cervix as part of a hysterectomy is a decision that should be made in conjunction with your gynecologist.  Our hope is that you will be able to discuss some of the issues raised with them in order to make the best possible decision for you prior to your surgery.

References

1. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu Y, Neugut AI, Hershman DL.   Nationwide Trends in the Performance of Inpatient Hysterectomy in the United States. Obstet Gynecol. 2013 August ; 122(2 0 1): 233–241. oi:10.1097/AOG.0b013e318299a6cf.
2. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG.  Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110(5):1091.
3. Lethaby A, Ivanova V, Johnson N. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane  Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004993. DOI: 10.1002/14651858.CD004993.pub2.
4. ACOG Committee opinion, number 338. Supracervical hysterectomy. November 2007, reaffirmed 2013
5. AAGL Practice Report: Practice Guidelines for Laparoscopic Subtotal/Supracervical Hysterectomy (LSH). Journal of Minimally Invasive Gynecology (2014) 21, 9–16
6. ACOG Practice Bulletin, number 131.  Screening for Cervical Cancer.  November 2012.