Hysterectomy

Author: Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey

Introduction

Hysterectomy is the most common non–pregnancy-related major surgery performed on women in the United States. This surgical procedure involves removal of the uterus and cervix, and for some conditions, the fallopian tubes and ovaries.

Reasons for choosing this operation are treatment of uterine cancer and various common noncancerous uterine conditions such as fibroids, endometriosis, prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Although this procedure is highly successful in curing the disease of concern, it is a surgical alternative with the accompanying risks, morbidity, and mortality that an operative procedure carries and it leads to sterility in women who are premenopausal. The patient may be hospitalized for several days and may require 6-12 weeks of convalescence. Complications, such as excessive bleeding, infection, and injury to adjacent organs, also may occur.

History of the Procedure

In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. In 1929, Richardson, MD, performed the first total abdominal hysterectomy (TAH), in which the entire uterus and cervix were removed.1

Problem

Epidemiology of fibroids

Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of gynecological visits, and they create an annual cost of $1.2 billion.2 ,3 They are benign uterine tumors that increase in size and frequency as women age but revert in size postmenopausally.4 ,5 Factors that have proven to contribute to fibroid growth include estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and transforming growth factor-beta.6

The frequency of fibroid appearance in African American women is 2-3 times higher than in white women. Women who are obese or experience menarche when younger than 12 years are at increased risk of fibroid development due to prolonged exposure to estrogen. Women who have had children are at a lesser risk for fibroid development than women who have never been pregnant.7

Each fibroid arises from a single monoclonal cell line from the smooth-muscle cells of the myometrium.8 Most (60%) fibroids are chromosomally normal. The rest have nonrandom chromosomal abnormalities that can be separated into 6 cytogenic subgroups, which are trisomy 12, translocation between chromosome 12 and 14, rearrangements of the short arm of chromosome 6 and the long arm of chromosome 10, and deletions of chromosomes 3 and 7.9

Asymptomatic fibroids are relatively slow growing and characterize most of the tumors found in patients. Previously, uterine size (consisting of asymptomatic fibroids) equivalent to 12 weeks' gestation (280 g) had been the standard threshold for recommending a hysterectomy. Thus, asymptomatic fibroids of smaller size were handled via observation, with an annual pelvic examination and/or transvaginal ultrasonography.

Currently, surgical procedures are not recommended for fibroids based on uterine size alone in the absence of symptoms. According to Reiter et al, no increased incidence in perioperative morbidity existed posthysterectomy in those women with a fibroid uterus larger than 12 weeks' gestational size compared to those women with a fibroid uterus smaller than 12 weeks' gestational size.10 They concluded that hysterectomy for a large asymptomatic fibroid uterus may not be needed as a means of preventing increased operative morbidity associated with future growth, unless a sarcomatous change is observed.

In patients who experience symptoms with fibroids, the symptoms are related to the size, location, and number of fibroids within the uterus. As many as one third of patients with symptomatic uterine fibroids experience abnormal bleeding, cramping, and prolonged and heavy menstrual periods, which can result in anemia. The growth of fibroids to large sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic pain or pressure, pain during sexual intercourse, reduced urinary capacity due to increased bladder pressure, constipation due to increased colon pressure, and infertility or late miscarriages.6

Epidemiology of endometriosis

Endometriosis is responsible for approximately one fifth of hysterectomies, and it affects women during their reproductive years.11 It is a disease in which tissue similar to the endometrium is present outside the endometrial cavity (in other areas of the body). Such sites include all the reproductive organs, bladder, intestines, bowel, colon, and rectum. Other sites may include uterosacral ligaments, the cul-de-sac, pelvic sidewalls, and surgical scars. This ectopic endometrial tissue responds to monthly hormonal stimulation and, thus, breaks down and bleeds into the peritoneal cavity when located there, causing internal bleeding, inflammation of the surrounding areas, and formation of scar tissue. Scar tissue then can become bands of adhesions that are capable of distorting internal anatomy. Patients also may experience symptoms of pelvic pain; pain during bowel movements, urination, and sexual intercourse; and infertility or miscarriages.12

Currently, no cure exists for endometriosis. Although many women seek hysterectomy for pain relief, it does not provide a definite cure because some women in whom one or both ovaries are preserved may continue to experience problems with endometriosis that was left behind.

Epidemiology of pelvic relaxation

Genital prolapse is the indication for approximately 15% of hysterectomies. Various stresses on the pelvic muscles and ligaments can cause significant weakening and, thus, uterine prolapse. The prime cause of insult to the pelvic support structures is childbirth. Therefore, multiple pregnancies and vaginal deliveries increase the risk for uterine prolapse. A few less dramatic causes of increased pelvic pressure include straining during bowel movements, chronic coughing, and obesity. Also, significant pelvic structure weakening occurs postmenopause because estrogen, which pelvic tissues need to maintain their tonicity, is not present in significant amounts after menopause.

Women with mild pelvic relaxation may be free of symptoms. However, patients with moderate-to-severe relaxation may experience symptoms that include heaviness and pressure in the vaginal area; low back pain, leakage of urine, which can worsen during heavy lifting, coughing, laughing, or sneezing; urinary tract infections; retention of urine; and problems with sexual intercourse.11 Although several techniques that provide temporary improvement and control of pelvic relaxation exist, in moderate-to-severe situations, hysterectomy may provide a more functional and longer-lasting results.

Epidemiology of cancer of reproductive organs

Cancer of the uterus, or endometrial cancer, is the most common gynecological cancer in the United States, with an estimated 36,100 new cases in 2000.13 It affects women aged 35-90 years, with a mean age of 62 years. Cancer begins in the lining of the endometrium and can spread to other reproductive organs and to the rest of the body.

Stage 1 endometrial cancer is confined to the corpus, or body, of the uterus. Symptoms may include bleeding between periods or, as is in most cases, spotting in patients after menopause. Stage 1 endometrial cancer is very slow growing and highly curable. A hysterectomy is the preferred method of treatment. Not only is the uterus removed, but the ovaries and fallopian tubes also are removed because ovaries are a possible site for more cancer, or they may secrete hormones that play a synergistic role in the growth of the cancer. Only in  cases of early endometrial cancers in women who are in their second or early part of the third decade of life are attempts made to preserve the ovaries.

In stage 2 endometrial cancer, the cancer has spread to the cervix. Approximately 12,800 new cases of cervical cancer diagnoses occur annually in the United States.14 Symptoms of cervical cancer include bleeding between periods, bleeding postmenopause, or bleeding after sexual intercourse. In some cases, radical hysterectomy (removal of the uterus, cervix, top portion of vagina, ovaries, fallopian tubes, and tissues in the pelvic cavity surrounding cervix) may be the treatment of choice, along with chemotherapy or radiotherapy if needed.

In stage 3A endometrial cancer, the cancer has spread to the ovaries and fallopian tubes. This may be treated with a TAH and bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries), along with chemotherapy or radiotherapy if needed. In stage 3B, the cancer has spread to the vagina. In this case, a vaginectomy or radical hysterectomy must be performed, along with chemotherapy or radiotherapy if needed. By stage 3C, the cancer has entered the lymph nodes. In this case, lymph node dissection and hysterectomy is the treatment of choice, along with chemotherapy or radiotherapy if needed.

Frequency

Approximately 600,000 hysterectomies are performed annually in the United States, with a cost of approximately $5 billion per year.

The US Centers for Disease Control and Prevention (CDC) estimated 3.1 million US women had a hysterectomy from 2000-2004.

  • The hysterectomy rate decreased slightly from 5.4/1000 in 2000 to 5.1/1000 in 2004.
  • From 2000-2004, rates of hysterectomy differed by age. Overall rates were highest among women aged 40-44 years and lowest among women aged 15-24 years. Hysterectomy rates among women aged 50-54 years decreased significantly from 8.9/1000 in 2000 to 6.7/1000 in 2004.
  • Hysterectomy rates also differed by geographic region. The overall rate was highest for women living in the South (6.3/1000) and lowest for those in the Northeast (4.3/1000). Hysterectomy rates in the Northeast decreased from 4.9/1000 in 2000 to 3.7/1000 in 2004.
  • From 2000-2004, the most common medical reasons for undergoing a hysterectomy included benign fibroid tumors, endometriosis, and uterine prolapse. Uterine cancer was not as common but is an important reason for undergoing a hysterectomy.
  • The proportion of hysterectomies with an indication of uterine leiomyoma decreased from 44.2% in 2003 to 38.7% in 2004.

The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13% in 1995 and then steadily declined to 3.9% in 2003 (p for trend <0.001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (p for trend <0.001).

Presentation

Preoperative evaluation includes the following:

  • Complete history and physical: Evaluate, in detail, any comorbid conditions such as diabetes mellitus, hypertension, cardiac disease, or asthma.
  • Medication history such as use of aspirin, oral hypoglycemics, heparin, or warfarin
  • PAP smear, endometrial sampling, ultrasonography, CBC count, blood type and cross match, and, depending upon age and risk factors, ECG and chest radiograph.
  • In case of malignancy, preoperative staging can be determined with the help of biopsies, CAT scans, IVP, cystoscopy, barium enema, etc.

Indications

Reasons for choosing hysterectomy are treatment of uterine cancer , ovarian cancer , some cases of cervical cancer , and various common noncancerous uterine conditions like fibroids, endometriosis , uterine prolapse that leads to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

Relevant Anatomy

  • Total abdominal hysterectomy involves removal of the uterus and cervix through an abdominal incision.
  • Supracervical or subtotal hysterectomy is removal of the uterus through an abdominal incision, while sparing the cervix.
  • Radical hysterectomy is extensive surgery that, in addition to removal of the uterus and cervix, might include removal of lymph nodes, loose areolar tissue near major blood vessels, upper vagina, and omentum.
  • Oophorectomy and salpingo-oophorectomy: Oophorectomy is the surgical removal of the ovary and salpingo-oophorectomy is the removal of the ovary and the fallopian tube.
  • Vaginal hysterectomy is removal of the uterus and the cervix through the vagina.
  • Laparoscopy-assisted vaginal hysterectomy is vaginal hysterectomy with the help of laparoscopy.

Contraindications

Vaginal hysterectomy is contraindicated in only 10-20% of cases, eg, uterine size greater than 280 g15 , previous multiple abdominal or pelvic surgeries, advanced uterine or cervical malignancies, and ovarian malignancies.

Workup

Laboratory Studies

Lab studies related to hysterectomy include CBC count, Papanicolaou test, endometrial sampling, ultrasonography, blood type and cross match, and, in some cases, chest radiography, ECG, CAT scan, MRI, cystoscopy, barium enema, IVP, blood chemistry, tumor markers.

Treatment

Medical Therapy

Although hysterectomy is often the definitive treatment for many pelvic pathologies, nonsurgical alternatives should always be attempted in elective cases.
 
Hormonal therapy, gonadotropin-releasing hormone antagonists, progesterone-containing IUD, endometrial ablation, focused ultrasonographic surgery, cryotherapy, and uterine artery embolization have been used with success.

In the 6 states studied, the diffusion of endometrial ablation has had a varying impact on hysterectomy rates among women with benign uterine conditions. However, endometrial ablation is used as an additive medical technology rather than a substitute.

Surgical Therapy

Abdominal hysterectomy

In November 1843, Charles Clay performed the first hysterectomy in Manchester, England. The earliest hysterectomies were supracervical, or subtotal, hysterectomies. The body of the uterus was removed while the cervix remained intact. In 1929, Richardson, MD, performed the first TAH, in which the entire uterus was removed.1

Prior to an abdominal hysterectomy, the patient undergoes a regional or general anesthetic. A patient remains awake during a regional anesthetic, with only part of the body being numbed to prevent pain. When given a general anesthetic, the patient is unconscious.

The abdominal hysterectomy begins via a surgical incision 6-8 inches long, made either vertically, running from the navel to the pubic bone, or horizontally, running along the top of the pubic hairline. The cut exposes the ligaments and blood vessels surrounding the uterus. These ligaments and blood vessels then are separated from the uterus and cervix. In the process, the blood vessels are tied off to prevent bleeding and to help in healing. The uterus and cervix are then cut off at the superior portion of the vagina and removed. The top of the vaginal cuff is closed with sutures, and the surgical wound is closed in layers.

An abdominal hysterectomy may be performed in conjunction with a salpingo-oophorectomy, in which the adnexa are removed, if needed. Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, chronic pelvic pain, endometriosis, adenomyosis (endometrial tissue that has infiltrated the myometrium), uterine prolapse, cancer of the reproductive organs, or pelvic inflammatory disease.

Vaginal hysterectomy

In a vaginal hysterectomy, the uterus is removed through the vaginal introitus. Prior to surgery, the patient is given a regional or a general anesthetic and the skin surrounding the vagina is prepped with an antibacterial solution. A surgical incision is then made in a circular fashion around the cervix and through the upper vagina to expose the tissue and blood vessels around the cervix and uterus. The tissues and vessels are cut and tied off for the uterus and cervix to be removed from the top of the vagina. The upper part of the vagina, where the surgical incision was made, is then sutured.

Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Often, colporrhaphy (reconstructive surgery) is performed to repair or prevent cystocele, rectocele, and/or vaginal vault prolapse.

Candidates for this surgery include those who have fibroids, abnormal or heavy bleeding, adenomyosis, uterine prolapse, early-stage cancer of the reproductive organs, or precancerous conditions of reproductive organs.

Laparoscopically assisted vaginal hysterectomy

Laparoscopically assisted vaginal hysterectomy (LAVH) is a procedure that uses laparoscopic surgical techniques and instruments to remove the uterus, cervix, and/or fallopian tubes and ovaries through the vagina. Prior to surgery, the patient is usually given a general anesthetic and the abdomen and vagina are prepared with an antibacterial solution.

LAVH begins with several small abdominal incisions inferior to the belly button, which allow the insertion of the laparoscope and other surgical tools. In order for the surgeon to observe the inside of the body clearly, the peritoneal cavity is inflated with gas (usually carbon dioxide), and a camera, which is attached to the laparoscope, captures and produces a continuous image that is magnified and projected onto a television screen.

Using the laparoscopic surgical tools, the tissues and vessels surrounding the uterus are cut and tied off. The uterus and cervix are then removed through the vagina, and the top of the vaginal cuff is sutured. The fallopian tubes and ovaries also may be removed during this surgical procedure.

Possible complications include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; nerve damage; and urinary tract infection. Candidates for this surgery include those who have had previous abdominal surgery, large fibroids, chronic pelvic pain, endometriosis, or pelvic inflammatory disease, or those who want an oophorectomy. Today, robotic laparoscopic surgery, such as procedures involving the da Vinci Surgical Robot, is also being refined to evaluate the performance of LAVH.

Laparoscopic hysterectomy

Laparoscopic hysterectomy (LH) is a procedure in which the uterus and cervix are dissected and ligated from ligaments, tissues, vagina, and blood vessels and removed entirely from small abdominal incisions with the help of instruments like the morcellator. This procedure requires good surgical technique, intra and extracorporal sutures, and different hemostatic devices.

Supracervical hysterectomy

Supracervical hysterectomy is defined as removal of the uterine corpus with preservation of the cervix and can be performed through abdominal, laparoscopic, or robotic approaches.
During supracervical hysterectomy, removal of the corpus is at or below the internal os along with ablation of the endocervical canal. During laparoscopic and robotically assisted hysterectomy, morcellation of the uterine fundus is performed to facilitate its removal through the port site incisions.

Women with known or suspected gynecological cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure.

Evidence regarding the potential benefits of this procedure like less blood loss, shorter operating time, and fewer complications are limited to retrospective series. Patients should be counseled about the need for long-term follow up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy; hence, it should not be recommended by the surgeon as a superior technique for hysterectomy for benign diseases.16

Robot-assisted hysterectomy

Da Vinci surgical system was approved for use in gynecological surgery by FDA in 2005. Da Vinci hysterectomy involves a robotic system in which the surgeon's hands are naturally positioned while his or her fingers grasp the controls below the display, and movements are transferred in real time to surgical instruments inside the patient. This system is useful when the surgery involves dissection in a difficult situation, such as near the ureters, bladder, or blood vessels.

The current system consists of 4 components: (1) console where the surgeon sits and views the screen and controls the robotic instruments, (2) robotic cart with interactive arms, (3)camera and vision system, (4) wristed instruments with computer interfaces.

Advantages are 3-dimensional visualization with improved depth of perception, improved dexterity, less blood loss, shorter hospital stay, less pain, and less risk of wound infection.
Disadvantages include high cost, increased operating time associated with set up and docking, lack of tactile feedback, inability to reposition the patient once the robotic arms are attached, and the bulkiness of the system.17

Comparisons of hysterectomy procedures

With the various hysterectomy procedures available, physicians must limit healthcare dollars associated with these surgical procedures while maintaining quality health care for patients. Various studies have been performed to decide which surgical procedure is most suitable in terms of economics and patient health.

The severity of the pathological disorder must be the key standard in selecting the type of hysterectomy, in order to maintain optimum surgical practice. In studies performed in the United States, France, and the United Kingdom in which strict guidelines based on the severity of the pathological disorder have been implemented, most patients underwent successful vaginal hysterectomy without abdominal or laparoscopic assistance.18

In a study by Gimbel et al subtotal hysterectomy is faster to perform, has less perioperative bleeding, and seems to have less intra- and postoperative complications.19 However it does have a slightly high rate of urinary incontinence and cervical stump problems.

Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH; however, the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically. Also, laparoscopic approaches require greater surgical expertise.20

Postoperative Details

Early feeding (oral intake of fluids or food within 24 h of surgery, irrespective of bowel sounds) after major abdominal gynecological surgery is safe and associated with reduced length of hospital stay but increased nausea. Further studies should focus on the cost effectiveness, patient satisfaction, and other physiological changes.21

Follow-up

After the surgery, it takes 4-6 weeks to recover. Recovery is earlier in cases of vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy.

No lifting anything heavy for 6 weeks after the surgery.

In case of oophorectomy in premenopausal women, patients experience menopausal symptoms like hot flashes, vaginal dryness, and mood disturbances.

Return to normal sexual activities is expected after 6 weeks of surgery.

Complications

Possible complications of hysterectomy include surgical wound infection; excessive bleeding; injury to the bowel, bladder, ureter, or major blood vessel; urinary tract infection, nerve damage, postoperative thromboembolism, atelectasis, early onset of menopause, and loss of ovarian function.

Future and Controversies

As more pharmacologic and invasive radiologic interventions become available, the number of hysterectomies performed in the United States and abroad will continue to decrease.

Compared with hysterectomy, uterine artery embolization (UAE) was associated with higher rates of minor postprocedural complications such as vaginal discharge, postpuncture hematoma, and postembolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge. No evidence shows a benefit of UAE over surgery(hysterectomy/myomectomy) for satisfaction. Currently, the ongoing trials REST (UK) and EMMY have yet to report on the long-term follow-up.22

Not only will surgical techniques continue to be updated and improved, but preoperative and postoperative interventions will improve morbidity, mortality, and quality of life.

Because the uterus is associated with femininity, some women experience a sense of loss after a hysterectomy. However, some women find a hysterectomy enhances their quality of life because it provides relief of symptoms and definite contraception.

Hysterectomy, whether total or subtotal, may improve quality of life and psychological outcome.23

References

  1. Johns A. Supracervical versus total hysterectomy. Clin Obstet Gynecol . Dec 1997;40(4):903-13. [Medline] .

  2. Lepine LA, Hillis SD, Marchbanks PA. Hysterectomy surveillance--United States, 1980-1993. Mor Mortal Wkly Rep CDC Surveill Summ . Aug 8 1997;46(4):1-15. [Medline] .

  3. Zhao SZ, Wong JM, Arguelles LM. Hospitalization costs associated with leiomyoma. Clin Ther . Mar 1999;21(3):563-75. [Medline] .

  4. Goodwin SC, Wong GC. Uterine artery embolization for uterine fibroids: a radiologist's perspective. Clin Obstet Gynecol . Jun 2001;44(2):412-24. [Medline] .

  5. Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health . Feb 1996;86(2):195-9. [Medline] .

  6. Guarnaccia MM, Rein MS. Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy. Clin Obstet Gynecol . Jun 2001;44(2):385-400. [Medline] .

  7. Demello AB. Uterine artery embolization. AORN J . Apr 2001;73(4):790-2, 794-8, 800-4 passim; quiz 809-14. [Medline] .

  8. Townsend DE, Sparkes RS, Baluda MC. Unicellular histogenesis of uterine leiomyomas as determined by electrophoresis by glucose-6-phosphate dehydrogenase. Am J Obstet Gynecol . Aug 15 1970;107(8):1168-73. [Medline] .

  9. Gross KL, Morton CC. Genetics and the development of fibroids. Clin Obstet Gynecol . Jun 2001;44(2):335-49. [Medline] .

  10. Reiter RC, Gambone JC, Lench JB. Appropriateness of hysterectomies performed for multiple preoperative indications. Obstet Gynecol . Dec 1992;80(6):902-5. [Medline] .

  11. Lee NC, Dicker RC, Rubin GL. Confirmation of the preoperative diagnoses for hysterectomy. Am J Obstet Gynecol . Oct 1 1984;150(3):283-7. [Medline] .

  12. Weir E. The public health toll of endometriosis. CMAJ . 2001;164(8):1201.

  13. Greenlee RT, Murray T, Bolden S. Cancer statistics, 2000. CA Cancer J Clin . Jan-Feb 2000;50(1):7-33. [Medline] .

  14. Sawaya GF, Brown AD, Washington AE. Clinical practice. Current approaches to cervical-cancer screening. N Engl J Med . May 24 2001;344(21):1603-7. [Medline] .

  15. Kovac SR. Which route for hysterectomy? Evidence-based outcomes guide selection. Postgrad Med . Sep 1997;102(3):153-8. [Medline] .

  16. ACOG Committee Opinion No. 388 November 2007: supracervical hysterectomy. Obstet Gynecol . Nov 2007;110(5):1215-7. [Medline] .

  17. ACOG Technology Assessment in Obstetrics and Gynecology No. 6: Robot-assisted surgery. Obstet Gynecol . Nov 2009;114(5):1153-5. [Medline] .

  18. Kovac SR. Guidelines to determine the role of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol . Jun 1998;178(6):1257-63. [Medline] .

  19. Gimbel H. Total or subtotal hysterectomy for benign uterine diseases? A meta-analysis. Acta Obstet Gynecol Scand . 2007;86(2):133-44. [Medline] .

  20. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev . Apr 19 2006;CD003677. [Medline] .

  21. [Best Evidence] Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev . Oct 17 2007;CD004508. [Medline] .

  22. [Best Evidence] Gupta JK, Sinha AS, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev . Jan 25 2006;CD005073. [Medline] .

  23. Thakar R, Ayers S, Georgakapolou A, Clarkson P, Stanton S, Manyonda I. Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy. BJOG . Oct 2004;111(10):1115-20. [Medline] .

  24. Farquhar CM, Naoom S, Steiner CA. The impact of endometrial ablation on hysterectomy rates in women with benign uterine conditions in the United States. Int J Technol Assess Health Care . Summer 2002;18(3):625-34. [Medline] .

  25. Jacobson GF, Shaber RE, Armstrong MA, Hung YY. Hysterectomy rates for benign indications. Obstet Gynecol . Jun 2006;107(6):1278-83. [Medline] .

Fri, 23 Jul 2010 @00:36

Kategori
Artikel Terbaru
Arsip

Komentar Terbaru
SLINK
Buat nama web sesukanya

Cek Nama Domain ?

image

Ask2obgyn

ask2obgyn@gmail.com

Mesin penerjemah
FACEBOOK
KUNJUNGAN

Daftar link
Video dan Gambar
Copyright © 2017 Bung Kemas · All Rights Reserved