Total/Subtotal Hysterectomy for the Treatment of Endometriosis: History
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Please note this is an old version of this entry, which may differ significantly from the current revision.
Contributor:
Ibrahim Alkatout
,
Afrooz Mazidimoradi
,
Veronika Günther
,
Hamid Salehiniya
,
Leila Allahqoli

Hysterectomy is associated with risks; the risk of complications is greater in women with endometriosis. The majority of hysterectomies include removal of the cervix, but the rate of subtotal hysterectomies with retention of the cervical stump has increased in the last few decades.

  • total hysterectomy
  • subtotal hysterectomy
  • supracervical hysterectomy

1. Introduction

Endometriosis and adenomyosis are the most commonly encountered benign gynecological conditions. The exact prevalence of the two entities is unknown. Globally, endometriosis is estimated to occur in 10–15% of women of reproductive age [1] and approximately 50% of infertile women [2]. The prevalence of adenomyosis varies between 5% and 70% [2][3][4]. With no intervention, the rates of those who can conceive are almost 50%, 25%, and a few women with mild, moderate, and severe endometriosis, respectively [5]. The three types of endometriosis are ovarian endometrioma, superficial peritoneal endometriosis, and deep infiltrating endometriosis [6]. Typical symptoms of endometriosis include dysmenorrhea, dyspareunia, chronic pelvic pain, and reduced fertility [7]. Adenomyosis is marked by menorrhagia, pelvic pain, and dysmenorrhea [8]. Women with endometriosis or adenomyosis suffer from a variety of problems, including poor quality of life (QoL) due to severe pain or abnormal uterine bleeding [9][10][11]. The treatment of these benign conditions is determined individually [12], depending on symptoms [13], age, the desire for children [14][15], and the stage of the disease [15]. Medical therapy is usually the first option [16]. However, when medical treatments have failed and family planning has been completed, hysterectomy is offered to the patient for the purpose of relieving or alleviating pain [17][18]. Hysterectomy is associated with risks; the risk of complications is greater in women with endometriosis [19][20]. The majority of hysterectomies include removal of the cervix, but the rate of subtotal hysterectomies with retention of the cervical stump has increased in the last few decades [21][22]. Supporters of subtotal hysterectomy suggest that removal of the entire cervix might affect urinary function, reduce sexual satisfaction during intercourse, and interfere with pelvic floor support [23][24]. Nevertheless, recent publications have contradicted these assertions and revealed that, compared with total abdominal hysterectomy, subtotal hysterectomy did not improve outcomes in terms of urinary or sexual function. Not surprisingly, women who underwent subtotal hysterectomy were more likely to experience postoperative vaginal bleeding from the cervical stump until one year after surgery compared with women who underwent total abdominal hysterectomy [25][26][27]. The potential development of carcinoma on the cervical stump is a further cause of concern. The presence of cancer can be determined with relative accuracy only during the procedure [25].
Although subtotal hysterectomy is easier to perform and involves less extensive surgery, shorter operating times, and less perioperative bleeding [25], it does bear the risk of persistent pain and repeat surgery [22][28][29][30]. Several studies advise against subtotal hysterectomy in women with endometriosis, pelvic pain, or dysmenorrhea [22][28][29]. However, investigations that showed a risk of pelvic pain after subtotal hysterectomy did not include representative control groups [29][31][32]. Several randomized controlled clinical trials (RCTs) have demonstrated that outcomes after subtotal or total hysterectomy did not differ between the groups [33][34][35]. A randomized blinded controlled trial by Berner indicated that women with endometriosis and/or adenomyosis achieve symptomatic relief and improved QoL, regardless of whether the cervix is removed [32].
Based on these data, it appears that endometriosis would not be a contraindication to subtotal hysterectomy, unless retention of the cervix compromises the removal of the endometriosis [28][36]. However, the consensus arising from the few randomized trials that examined long-term outcomes of the two hysterectomy techniques is that subtotal hysterectomy provides no benefit over total hysterectomy in terms of sexual function, pain, or urinary symptoms [24][37][38].

2. Hysterectomy Options for Endometriosis and Adenomyosis

The optimal surgical procedure for endometriosis or adenomyosis is controversially discussed. One of the main issues is removal of the cervix. The purpose of the present review was to evaluate and compare outcomes after total or subtotal hysterectomy in women with endometriosis or adenomyosis. The body of published data comparing the two approaches in women with endometriosis or adenomyosis is limited. After a comprehensive search, researchers found 35 published studies from 1988 to 2021. The eligible articles reported contradictory data with regard to surgical outcomes after total and subtotal hysterectomy [29][31][32][39][40][41][42][43][44][45][46][47][48][49][50].
Some authors state that preserving the cervix during subtotal hysterectomy in women with endometriosis increases the risk of persistent postoperative pain [28][31] or vaginal bleeding from the cervical stump [51][52], whereas others report no significant difference between the two procedures in terms of reducing cyclic pelvic pain at 12 months after surgery nor in the occurrence and persistence of postoperative pain [32][40].
Okaro and co-workers (2001) stated that subtotal hysterectomy “is not necessarily the right procedure for women with pelvic pain” and that this procedure should be viewed with extreme caution in women with endometriosis [29]. Berner et al. (2014) reported a major reduction in cyclic pelvic pain after subtotal hysterectomy in women with endometriosis as well as those with adenomyosis. The results of the latter study support the view of gynecologists who consider subtotal hysterectomy an adequate procedure in women with benign disorders [28][36].
Regardless of the type of surgery, persistent bleeding after hysterectomy has been reported in 0.92% to 25% of the cases [51][52]. The existing body of data is inconclusive with regard to risk factors for persistent postoperative cervical stump bleeding [43]. Although endometriosis was suggested as a risk factor for postoperative bleeding in 1999 [53], a recent report failed to show an association between postoperative bleeding and endometriosis [54]. Some authors have claimed that the higher incidence of bleeding after subtotal hysterectomy can be accounted for only by an inappropriate surgical technique [55]. However, postoperative bleeding appears to be related to the indication for surgery as well. When hypermenorrhea is the indication of surgery, postoperative spotting would be common. It should be noted that spotting after a hysterectomy does not require treatment. Preservation of the cervix bears the risk of cervical stump carcinoma. As cervical stump symptoms appear to be rather common after subtotal hysterectomy, women should be informed preoperatively of the risk of persistent menstrual bleeding and/or pain.
One of the outcomes addressed in the present review is the recurrence of endometriosis after total or subtotal hysterectomy. Endometriosis may recur after either surgical technique [52][55][56][57][58][59][60]. Some authors suggest that subtotal hysterectomy may be inadequate for the treatment of endometriosis, especially advanced endometriosis, and total hysterectomy should be considered in most cases [55][59]. Yet, some women who have undergone total hysterectomy need to undergo repeat treatment [52][55][56][57][58][59][60]. Although the exact incidence of persistent endometriosis after surgery is not known [46], some authors have suggested that preservation of the ovaries or aggressive excision of all endometriotic implants at the time of hysterectomy is the main factor in persistent endometriosis [61][62]. Namnoum et al. concluded that recurrent pain and the risk of reoperation due to endometriosis were higher in women who had ovarian preservation compared with those who did not [48]. However, in a study performed by Sandström and co-workers, the proportion of women with pelvic or lower abdominal pain was significantly reduced, but the reduction was seen independent of whether bilateral oophorectomy was performed [63]. Further research will be needed to evaluate the origins of recurrence and the risk factors associated with retreatment. Some authors have observed higher rates of retreatment in younger patients than in older ones [57][64]. It should be noted that all reported recurrences were clinically relevant; yet, other recurrences may have remained undetected due to asymptomatic disease [58]. On the other hand, the recurrence of pain does not necessarily imply recurrence of endometriosis [65].
Another important outcome evaluated in the present study was QoL and sexual function after total or subtotal hysterectomy in women with endometriosis. Contradictory data have been reported in this regard [32][66][67][68][69]. Some authors observed no inter-group differences in QoL or sexual function after subtotal or total hysterectomy [37]. Berner et al. registered no difference in total QoL scores in the long term between total and subtotal hysterectomy in women with or without endometriosis or in those with or without adenomyosis [32]. Although the above-mentioned reports mentioned no difference between the two procedures with regard to QoL or sexual function, either in the short or the long term [70][71], some authors did suggest a possible advantage for subtotal hysterectomy. In a retrospective study by Brucker et al. [40] and a randomized study by Ellström Engh et al. [72], women with endometriosis in the subtotal hysterectomy group experienced a more rapid improvement of their sexual activity and had less dyspareunia compared with women who underwent total hysterectomy. According to Lermann et al., women undergoing subtotal hysterectomy had the highest sexual function scores based on the Brief Profile of Female Sexual Function (B-PFSF) questionnaire compared with those who underwent total hysterectomy, but the difference was not statistically significant [40].
Differences in the reported outcomes of sexual function have been attributed to vaginal vault pain, vaginal shortening, changes in cervicovaginal innervation, and the absence of cervical mucus production in women who underwent total hysterectomy [73][74]. The interpretation of published data on this topic is limited by difficulties in the standardization of studies and the heterogeneity of patients. Any potential difference in QoL and sexual function after total or subtotal hysterectomy in women with endometriosis must be addressed in trials specifically designed for this purpose.
Patient satisfaction or regret after total or subtotal hysterectomy in women with endometriosis was investigated because of the paucity of published data on the subject. Although some prospective observational trials confirmed a high degree of patient satisfaction after subtotal hysterectomy [31][36][53], critics of subtotal hysterectomy expressed concerns about the risk of cervical stump symptoms, such as vaginal bleeding and pelvic pain, causing patient distress and eventually necessitating repeat surgery [31]. However, these concerns were not confirmed in other studies. Despite the prevalence of cervical stump symptoms after either surgical procedure, the degree of overall patient satisfaction after subtotal hysterectomy was reported to be high [41]. The frequent occurrence of vaginal bleeding and pelvic pain after subtotal hysterectomy also did not affect patient satisfaction [31][75]. However, the validity of this conclusion is limited by the absence of a reference group in some studies.
Due to the poor results of endometrial ablation or hormone treatment, uterine adenomyosis usually requires hysterectomy [76]. Since adenomyosis is related primarily to the uterine corpus, both total and subtotal hysterectomy are potential treatment options for this condition. However, the existing body of data on the long-term outcomes of these interventions is scarce. Compared with total hysterectomy, cervical retention was believed to be associated with fewer adverse surgical outcomes related to sexual or urinary function, and these factors did play a role in the patient’s decision to undergo subtotal hysterectomy [77]. The existing data suggest no difference in these outcomes and reveal no potential advantage in favor of cervical retention [71][78]. In a prospective study, Ajao et al. registered no apparent difference between those who underwent cervical removal or retention [77]. However, a higher percentage of patients who underwent subtotal hysterectomy were reported to have experienced an improvement in their postoperative QoL [34][79]. In a retrospective cohort study and follow-up survey comprising 249 patients, Ajao et al. noted that retention of the cervix did not appear to increase the risk of persistent symptoms [80]. Berner (2015) also registered no difference between the two allocated treatment groups with regard to pelvic pain reduction, patient satisfaction, or QoL at 12 months after hysterectomy in women with adenomyosis [32]. In a randomized clinical trial with a 14-year questionnaire follow-up, Andersen et al. confirmed that subtotal abdominal hysterectomy was not superior to total abdominal hysterectomy with regard to any outcome [70].

This entry is adapted from the peer-reviewed paper 10.3390/jcm12113697

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