Elective Total Abdominal Hysterectomy for Symptomatic Uterine Fibroids: A Perspective on Its Impact on Women’s Reproductive Health

Abstract

The chapter defines total abdominal hysterectomy (TAH), its historical background and epidemiology in the management of uterine fibroids in women who are in their reproductive years. The clinical presentations of uterine fibroids and circumstances in women of this age group that may indicate total abdominal hysterectomy as the option of surgical intervention is explained. The advantages of vaginal and laparoscopic approaches to hysterectomy were discussed. A detailed description of the surgical procedure is given with emphasis on its safety. Ways of avoiding intraoperative bleeding, during hysterectomy for uterine fibroids, were explained. The dilemma of decision making on the choice of the procedure by the gynaecologist and the patient is highlighted. Its impact, postoperatively, on the reproductive health of the women is discussed in perspective. Methods of fertility preservation in reproductive age women who are to undergo abdominal hysterectomy were mentioned. The chapter is concluded with a summary of its contents and the learning points.

1. Introduction

1.1 Uterine fibroid

1.1.1 Aetiology and epidemiology

Uterine fibroids are benign tumours of the smooth muscle of the uterus. Each fibroid arise from a single monoclonal cell of the smooth muscle of the myometrium. Their growth is affected by the female hormones, oestrogen and progesterone.

The exact aetiology of uterine fibroid is unknown. About 30% of fibroids have various chromosomal abnormalities ranging from trisomy, translocation and deletion. They are found commonly in women of reproductive age group. Other risk factors are being a black American, nulliparity, obesity, early menarche and family history of fibroids.

Fibroids are found in up to 80–90% of females worldwide. They are present in 20–25% of reproductive age women [1]. About one fifth of gynaecological clinic visits are as a result of fibroids and the estimated cost of their management is up to two billion dollars in the United State [1, 2, 3].

1.1.2 Symptoms and signs of uterine fibroids

Uterine fibroids are commonly asymptomatic, only about 30% of patients present with severe symptoms which varies in individual patient and according to the size and location of the fibroid in the uterus or degenerative changes within the fibroid. The commonest symptom is heavy menstrual bleeding. There may be pelvic pain in the form of dyspareunia, dysmenorrhea, and noncyclic pain. Abdominal protrusion and pressure of the mass on adjacent pelvic organs like the bladder and the rectum can result in urinary incontinence, urinary retention, hydro-nephrosis, constipation, and tenesmus respectively. Uterine fibroid is also associated with infertility and obstetric complications such as miscarriage, preterm labour/delivery, foetal malpresentation, and post-partum haemorrhage [4, 5, 6].

1.2 Hysterectomy

1.2.1 Definitions

Hysterectomy is the removal of the uterus. Total hysterectomy is the removal of both the body and the cervix of the uterus. Subtotal hysterectomy is the removal of the uterine corpus leaving the cervix in situ. Total abdominal hysterectomy is the removal of the uterus and the cervix through an abdominal incision. When the ovaries and fallopian tubes are removed in addition, it is referred to as total abdominal hysterectomy with salpingo-oophorectomy (TAH + BSO) or panhysterectomy [7].

1.2.2 Historical background

The first hysterectomy was a subtotal abdominal hysterectomy in which the uterus was removed and the cervix was left situ. It was performed by Charles Clay in 1843. It was Richardson who performed the first total abdominal hysterectomy in 1929. Over the years there had been modifications and improvements in the technique of the procedure. Total abdominal hysterectomy is preferred except in circumstances where it is difficult to perform with attendant increased risk of morbidity and mortality to the patient [8].

1.2.3 Surgical approach to hysterectomy

Hysterectomy can be performed through three different surgical approaches including; the abdominal, vaginal and laparoscopic route.

Laparoscopic approach has the advantages of shorter hospital stay, lower incidences of blood loss, postoperative pain, febrile morbidity and wound infections when compared with abdominal approach. The operating time is shorter in abdominal approach and the ability to navigate a distorted pelvic anatomy and perform extensive adhesiolysis safely is better than with laparoscopic hysterectomy. Vaginal approach has similar advantages as laparoscopic technique in terms of safety profiles with shorter operative time to its advantage. Several studies have shown that all outcomes are more favourable with vaginal hysterectomy compared with both laparoscopic and abdominal hysterectomy. Abdominal hysterectomy had been more common than the other routes until in recent times when laparoscopic methods are increasingly being preferred [9, 10, 11].

1.2.4 Indications for hysterectomy

Hysterectomy is a procedure that is indicated in both benign and malignant gynaecological conditions and some obstetric complications. Majority of the procedure are performed for benign conditions. The leading indications are, uterine fibroids, abnormal uterine bleeding, uterine prolapse, endometriosis and adenomyosis. Others are chronic pelvic pain, pelvic inflammatory disease, malignances of the uterus, cervix and ovary and postpartum haemorhage [12, 13].

1.2.5 Indications for total abdominal hysterectomy for the treatment of fibroids in women of reproductive age group

Removal of the uterus in women of reproductive age group comes with objectionable consequences. There is loss of fertility and menstrual flow. If the ovaries are removed in addition, premature menopause sets in. The indications for hysterectomy and the method in this age group should be well guided. In addition to vaginal hysterectomy as an alternative method of hysterectomy, the introduction of laparoscopic hysterectomy procedures had gained worldwide acceptance in recent times. In order to differentiate the areas of indication for each method, the German Society of Obstetrics and Gynecology (DGGG, Deutshe Gesellschaft fur Gynakologie and Geburtshiife) prepared a guideline; “Indications and methods of Hysterectomy for Benign Gynecology Disease”. The following recommendations were made on the management of symptomatic uterine fibroids:

• It should first be verified that the symptoms are actually caused by the fibroids.

• Decision about treatment approach to be taken should be made together with the patient in consideration of her circumstances.

• Hysterectomy can be offered to those who do not wish for further childbirth, do not respond to alternative treatments or wish to undergo hysterectomy.

• The patients should be counselled about the success and failure rates of each method of fibroid treatment [14].

The surgical methods of approach to hysterectomy have been compared in several publications, including recommendation from the National Institute for health and Clinical Excellence (NICE) and the recommendation by the American College of Obstetricians and Gynecologists (ACOG). Vaginal hysterectomy was found to have the lowest complication rate and cost followed by laparoscopic hysterectomy procedures. It was recommended that abdominal hysterectomy should only be performed when there is a special indication for it (Table 1) [2, 14, 15].

Large diffuse fibroids with uterine size greater than 18 weeks Anatomic distortion due to pelvic organ disease or adhesions Patient’s choice after adequate counseling Lack of facilities and experience to offer patients alternative surgical methods

Table 1.

Indications for TAH as treatment for uterine fibroids in reproductive age women.

1.2.6 Abdominal hysterectomy rate in the management of uterine fibroids

Hysterectomy is the common gynaecological surgery performed in women worldwide. About 67% of hysterectomies in the UK were performed abdominally. Up to 39% of all hysterectomies performed annually in the United States were due to symptomatic uterine fibroids. In Germany, approximately 60% of hysterectomies, were done to treat uterine fibroids. In 2012, abdominal hysterectomy rates in the United States, Germany, Australia and Switzerland were reported to be 56%, 15%, 28.0% and 23.9% respectively [10, 13].

2. Hysterectomy in the reproductive age women; the dilemma of decision making

Hysterectomy is the definite treatment for uterine fibroids. However, it may not be an appropriate treatment option in reproductive age women due to loss of fertility and menstrual function; the hallmark of femininity. In addition to the loss of fecundity, it is also associated with low self-esteem, depression and anxiety [16, 17]. It may be a difficult decision for the women who wants to preserve their child bearing and or menstrual function.

On the other hand, hysterectomy is the only form of treatment that is associated with no recurrence. This benefit clearly outweighs the risk of recurrence, further investigations and treatments that are associated with uterine-preserving modalities. The cumulative rate of recurrence following myomectomy is 63–76% and majority of them will require further intervention [18]. Similarly, secondary hysterectomy was required for persistence of symptoms in 35% of patients after successful uterine artery embolization (UAE) for uterine fibroids [19]. Also, the re-intervention rate following fibroids treatment with MRI-guided high intensity ultrasound wave is 20.7%, this is largely due to symptomatic recurrence in 63.3% of cases [20]. Therefore, hysterectomy is an excellent option for reproductive age women who are not desirous of fertility and has completed their family size.

In addition, hysterectomy may be a life-saving procedure in the setting of uncontrollable haemorrhage during myomectomy. Besides, at 3-month after successful UAE, the risk of unintended hysterectomy is 1.5% [21]. In view of this, it is pertinent to counsel the women on the possibility of hysterectomy prior to these procedure and informed consent taken.

The choice of hysterectomy in women of reproductive age group depends on the severity of symptoms and the desire of the patient to mountain fertility. But, because there are uterine preserving alternative methods of treatment, decision making on the option of hysterectomy often puts both the patient and the gynaecologist in a state of dilemma. Often times, the patients have already decided on the treatment they want before coming for consultation. The gynaecologist is expected to provide them with information on the available options, their benefits and risks. They can then decide on the option that best suits them [2, 14].

3. Procedure of total abdominal hysterectomy

It is pertinent for the surgeon undertaking this procedure to bear in mind the risk of mortality and debilitating morbidity that are associated with it. However, there had been a rapid decline in morbidity and mortality over the years due to improvement in patient evaluation, refinement in surgical techniques and surgical duration. The surgeon needs to pay attention to these refinements to ensure a safe procedure. The technique of total abdominal hysterectomy in contemporary use is a modification of the classic Richardson method [8].

3.1 Preoperative preparations

Before the procedure it is necessary to take a brief history, a detailed physical and abdominal examination and to request biochemical and radiological tests as may be appropriate for the patient [22]. Table 2 shows a list of such tests. The purpose of the evaluation is to;

• Delineate the size and extent of the uterine fibroid.

• Detect medical and other pelvic organs disease.

• Ascertain if the uterus is mobile or fixed.

• Choose the appropriate abdominal incision.

• Ascertain if the patient is fit for the procedure.

Investigation	Indication
Full blood count (FBC)	To detect anaemia and evidence of infection
Fasting blood sugar (FBS)	To screen for diabetes mellitus
Electrolytes, urea & creatinine	To access renal function
Pregnancy test (PT)	To rule out pregnancy
Pap smear	To rule out cervical cancer
Ultrasound scan of abdomen & pelvis	To access size of the uterus & detect other pelvic pathology
Chest X-ray	To detect cardio-respiratory disease
Intravenous pyelography (IVP)	To detect involvement of ureters and kidneys
CT scan/MRI	To complement findings on USS if necessary

Table 2.

List of essential preoperative investigations.

The outcomes of evaluation are to be discussed with the patient. Medical co-morbidities detected especially anaemia, hypertension and diabetes mellitus should be treated appropriately prior to surgery. The patients should be counselled on the procedure plan and informed consent should be obtained. Bowel preparation may be necessary before the day of surgery to enhance exposure, reduce trauma to the bowel and prevent contamination of field during surgery. The pubic hair should be reduced with scissor or shaved with razor in the morning of surgery. A broad spectrum antibiotics like ceftaxidime or cefotaxime 2 g intravenously as prophylaxis against infection. Between 1 and 4 doses are given at 12 hourly intervals beginning 30 minutes before commencement of surgery.

Preventive measure against deep vein thrombosis and pulmonary embolism should be instituted in patients at risk. The use of sequential compression devices and low molecular weight heparin have been recommended [7, 8, 22, 23, 24].

3.1.1 Preoperative counselling

Abdominal hysterectomy may be accompanied by surgical morbidity and possibly mortality. Additionally, some patients do suffer from post-hysterectomy regret, especially among premenopausal women. Therefore, preoperative planning and decision-making should be comprehensive. The gynaecologist needs to build trust with the patient, the indications for the surgery and alternative treatment options have to be explained thoroughly to the patient. Potential for operative and postoperative complications should be discussed. Patient’s desire for childbearing in the future and the possibilities should also be included in the counselling. Extensive pre-operative planning and execution of preventive measures have been associated with improved outcomes of surgery [25].

3.2 Operative technique

Patient is placed in supine position anaesthetized and an examination under anaesthesia is performed to unravel features that were not evident during initial physical examination and if there is need for specific preparation that have not been made. A Foley catheter is inserted into the bladder and the balloon is inflated with normal saline to retain it. The abdomen and vagina are cleaned with antiseptic solution and covered with sterile drapes with a window exposing the surgical site. For benign conditions like uterine fibroids, the abdomen is opened through a pfannenstiel incision on the skin. A midline subumbilical incision may be necessary when the uterine size is bigger than 12 weeks size or when there is a need for an increase in exposure. The peritoneal cavity is opened and explored for pathologies. The bowel is packed away from the pelvis by adjusting the surgical table to the Trendelenburg position and applying a large pack secured outside the abdomen with a clip on a long tape attached to it. The pack should be wet with normal saline before application to avoid damage to the bowel. A Balfour retractor is paced for exposure of the surgical fields. With the surgeon’s hand in the pouch of Douglas, the uterus is lifted and elevated out of the pelvis (Figure 1). A large clamp is placed on each uterine cornu, such as to include the origins of the tubes and the round ligament to allow manipulation of the uterus. The right round ligament is stretched by manually deviating the uterus to the left side of the patient. It is clamped, cut and ligated around the midpoint. The same step is repeated on the left side of the patient. The anterior leaf of the broad ligament is then incised from this point to open the vesico-uterine folds of peritoneum. The bladder is dissected and reflected downward from the lower uterine segment, cervix and upper vaginal to lateralize the ureters and keep them out of harm’s way. The incision is extended postero-laterally on the posterior leaf of the broad ligament, then directed superiorly, parallel and lateral to the infundibulopelvic ligament on the pelvic sidewall. The retroperitoneal space is thus opened by this manoeuvre. The soft areolar connective tissue is carefully separated with the index finger to expose the retroperitoneal structure.

Figure 1.

Uterus riddled with fibroids lifted out of the pelvis through a midline sub-umbilical incision.

The ureter is identified around the bifurcation of the common iliac artery and should be kept under direct vision. If the ovaries and the tubes are to be removed, they are moved together towards the uterus medially. A finger is used to create a window in the posterior leaf of the broad ligament and the infundibulopelvic ligament is double clamped cut and ligated. If the ovaries are to be retained, the tube is mobilise towards the uterus medially and the utero-ovarian ligament on each side is clamped, cut and ligated between the ovary and the free tube. Then the uterine artery is identified, the connective tissue overlying it is dissected. It is double clamped perpendicularly at the level of the internal os, cut and ligated. The same procedure is repeated on the other side. The rectum is mobilised from the posterior cervix by incising the posterior leaf of the broad ligament to the level of the utero-sacral ligament. The cardinal ligament and the utero-sacral ligaments are clamped, cut and ligated (Figure 2). The next step is to clamp the vaginal angles, open the anterior fornix with a scalpel and then expand the incision round the cervix. The edges of the vaginal are clamped at intervals, the vault is then closed antero-posteriorly. The cardinal and utero-sacral ligament stumps are sutured to the vaginal angle on both side to prevent postoperative vaginal vault prolapse and enterocoele. The vault is covered by suturing the peritoneum of the anterior leaf of broad ligament to its posterior leaf with the stumps of the tubo-ovarian, cardinal and utero-sacral ligaments buried retroperitoneally. The bladder peritoneum is suture, to the pouch of Douglas. The pelvis is inspected to ensure that the stumps are not bleeding (Figure 3). The peritoneum is lavaged with normal saline. The anterior abdominal wall incision is then closed in layers with subcuticular suture to the skin [7, 8, 23, 24, 26, 27].

Figure 2.

Clamps on the upper stumps of the ligated and tied round ligaments, infundibulopelvic ligaments, uterine arteries and the cardinal ligaments.

Figure 3.

Reperitonization of the pelvis with all the stumps buried retroperitonially.

The hysterectomy specimen is sent to histopathology laboratory for report (Figure 4).

Figure 4.

Hysterectomy specimen sent for histopathology report.

3.2.1 Modification of technique due to uterine fibroid

Modifications to the operative technique may be necessary if the pelvic anatomy is distorted due to; large uterus, broad ligament fibroid and cervical fibroid. In these circumstances, there may be limited space in the pelvis and access may be difficult. The ureters are displaced laterally and the blood vessels are usually dilated and tortuous. There is a high risk of injury to ureters, uterus and bladder. The risks associated with these situations are preventable. The uterus needs to be correctly oriented by locating landmark anatomical structures like the round ligaments, fallopian tubes and the ovaries. The procedure should start from the pelvic side wall that is most easily accessible. Adequate exposure and access to pelvic sidewall can be achieved with a debulking myomectomy. The largest most accessible fibroid should be removed first in a rapid manner to control haemorrhage [8, 26, 27].

3.3 Histopathology of uterine fibroids

Uterine fibroids are also called leiomyoma derived from leio, meaning smooth, myo – muscle and –oma is a suffix indicating a benign neoplasm. They are also referred to as fibromyomas. They are benign mesenchymal neoplasm arising from smooth muscle tissue of the myometrium of the uterus. However, there could arise from the cervix and broad ligament [2].

Grossly, they appear firm, greyish white to tan nodules of varying sizes ranging from grain size in millimetres to over 25 cm in widest diameter. Sizes as large as 50–60 cm had been reported [28, 29]. It could be single but most commonly, they are multiple. They have greyish white whorled appearance on cut surfaces.

Following hysterectomy specimen, there could be complete or partial distortion of the uterine architecture. They could be pedunculated and extend from the serosal surface of the uterus. On cut section, they appear as well circumscribed nodular masses below the endometrial lining (submucous), within the myometrium (intramural) or below the serosa (subserosal). In some cases, the submucous fibroids could be pedunculated, bulge and dilate the endometrial cavity. The pedunculated masses could protrude down to the cervix. Most that protrude through the cervix might have an ulcerated surface with areas of necrosis and haemorrhage (Figures 5 and 6).

Figure 5.

A enlarged hysterectomy specimen with distorted architecture with multiple intramural fibroid nodules.

Figure 6.

A hysterectomy specimen with a large degenerate submucous fibroid compressing the endometrial cavity. Another small intramural fibroid is noted.

Various degenerative changes impact on the appearance. There could be cysts within the mass containing clear myxoid to clear fluid in cystic degeneration. In red degeneration, they appear red to brown on cut surfaces. In calcific degeneration, the tissue could be hard with chalky white appearance on cut surfaces with gritty sensation. A nodule could be transformed into a ‘stone’ due to extensive calcification. In hyaline degeneration, they could be yellowish in areas [30].

Microscopically, they are composed of proliferating smooth muscle cells which are spindle shaped disposed in interlacing and anastomosing fascicles and bundles. The nuclei are elongated with blunt ends and inconspicuous nucleoli. The cytoplasm is moderate, eosinophilic and indistinct. Mitotic figures are infrequent, less than 5 per 10 high power field.

The neoplasm is fairly circumscribed and exerts pressure on the surrounding normal myometrium with formation of a pseudocapsule [29]. The intervening stroma can be extensively hyalinised in hyaline change. Myxoid stroma change could also be seen. There may be areas of dystrophic calcification. In cystic degeneration, the cyst is devoid of epithelial lining. In large leiomyoma, there can be areas of necrosis. Areas of haemorrhage and congested vascular channels can be seen.

Special names are being given to particular features. A cellular leiomyoma is given when there is hyper-cellularity than normal [31]. This is usually more cellular than the surrounding normal myometrium. The component cells could resemble epithelial cells and are thus called epithelioid leiomyoma. A mitotically active leiomyoma is seen when the mitotic count is above 5. The count is about 6–20/10 high power field. However, these mitotic figures are normal. A bizzare or symplastic or atypical leiomyoma is when the cells show cytonuclear pleomorphism with large atypical nuclei. Giant cells could be seen. However, there is no increase mitotic count or necrosis. This is important to differentiate from leiomyosarcoma which is the malignant counterpart where there is increased cellularity, pleomorphism, increased mitosis and necrosis (Figures 7 and 8).

Figure 7.

H&Ex400—histologic section showing proliferating spindle cells disposed in interlacing fascicles.

Figure 8.

H&Ex400—histologic section showing focal stromal hyalinization.

Leiomyoma express oestrogen and progesterone receptors. They are positive for desmin, smooth muscle actin, muscle specific actin and caldesmon. They are positive for vimentin. Epithelial membrane antigen is usually negative. However, occasional positivity for cytokeratin does occur [31, 32].

3.4 Postoperative care

The care given to patients post abdominal hysterectomy is about the same for any other major abdominal surgery. A Summary is presented in Table 3 [7, 8, 24].

Administration of intravenous fluids for the first 24 h especially if patient is feeling nauseated or vomiting. Indwelling Foley catheter should be discontinued the morning after surgery if there is no bladder or ureteric injury. Pain relief with appropriate analgesia Encourage ambulation as early as the afternoon or evening on the day of surgery. Commencement of oral intake within 24 h after surgery Removal of skin sutures on the seventh post operative day. Discharge patient after removal of skin sutures if there are no complications. Patient to avoid vaginal intercourse for up to 6 weeks. Patient to report any symptoms and signs of complications such as fever, pain, vomiting, purulent discharge per vagina or from the wound and severe bleeding per vagina.

Table 3.

Postoperative care and instructions on discharge.

3.5 Complications of abdominal hysterectomy

Abdominal hysterectomy is associated with the risks of morbidity and mortality. Complication can occur intraoperatively, postoperatively, or both. They can be immediate or long term. The major complications are listed in Table 4.

Complications
Immediate; Post operative pyrexia Severe haemorrhage Bladder, ureteral and bowel injury Surgical site infection Anaesthetic complications Deep vein thrombosis Neuropathy Long term; Vagina vault prolapse Pelvic adhesion Urinary incontinence Premature menopause Regret

Table 4.

Complications of abdominal hysterectomy.

Obesity, diabetes mellitus, large uterus, cervical fibroids, adhesion and improper surgical technique have been identified as risk factors to complications.

Serious complications are comparatively rare. Various complication rates have been reported ranging between 1.4% and 4.4%. Infection complications after abdominal hysterectomy are most common with the rate ranging from 2.5% to 10.5%. Genito-urinary tract injury is estimated to occur at a rate of 1.2%, with 75% of it occurring intraoperatively. Haemorrhage requiring blood transfusion is reported from different studies at a rate of 1–6%. The rate of blood transfusion is 4–6%. Deep vein thrombosis, bowel injury, vaginal vault, prolapse, neuropathy and death are all relatively less common with a rate less than 1% [8, 24, 33, 34, 35].

3.5.1 Avoidance of intraoperative bleeding during abdominal hysterectomy for uterine fibroid

Therefore, minimising the amount of intraoperative bleeding is essential to reducing associated preoperative morbidity and mortality. Under normal circumstances, adequate attention to proper surgical technique is enough to secure haemostosis during abdominal hysterectomy. However, additional preventive and therapeutic measures may be necessary in the presence of risk factors for bleeding. Techniques that have been used to prevent or control heavy bleeding during abdominal hysterectomy include; prophylactic vasopressin, preoperative misoprostol, ligaSure, ligation of uterine and iliac arteries, and trans arterial embolization of uterine or internal iliac arteries using interventional radiologic procedures. These procedures can be performed both prior to hysterectomy and for persistent bleeding after hysterectomy. Dilute vasopressin solution injected about 1 cm media to the uterine arteries has been found to reduce blood loss by 40%. Studies have shown ligaSure vessel-sealing device to be more effective in securing haemostasis than misoprostol and tranexamic acid.

Blood loss is effectively reduced through bilateral uterine artery ligation. The ascending branches of the uterine arteries are ligated with a suture at the level of the vesicouterine peritoneal reflection. The suture is passed lateral to the vessels through an avascular area of the blood ligament close to the cervix. Ligation or stapling off the internal iliac artery significantly reduces blood loss. After insulating the artery, ligation is done about 2 cm distal to the origin of the posterior branch to limit collateral flow to the uterus and prevent gluteal ischemia [36, 37, 38].

3.5.2 Therapeutic mappings of uterine fibroids during labour

Uterine fibroids have been found in about 3–12% of pregnant women and are also associated with adverse pregnancy outcomes. There is increased risk of peripartum haemorrhage and caesarean section due to fetal malpresentation. Postpartum haemorhage is one of the leading courses of maternal mortality [35, 39, 40].

For a pregnant woman in labour with coexisting uterine fibroids, adequate preparations should be made for the treatment of potential complications due to the fibroids. In case of obstructed labour, the therapeutic options are; caesarean section with myomectomy and or caesarean hysterectomy as may be indicated [41].

Interventions that may be necessary for persistent severe postpartum haemorrhage include, selective uterine artery embolization or ligation, ligation of the internal iliac artery and postpartum hysterectomy. There should be no delay in carrying out any of these interventions as may be necessary [37, 38].

4. Impact of TAH on reproductive health of women of reproductive age group

Total abdominal hysterectomy for uterine fibroids has huge impacts on women’s sexual and reproductive health. These impacts could be positive or negative.

Positive impacts of TAH include symptomatic relief from symptoms of fibroids, improved sexual functions and improved quality of life [42]. Being a definitive treatment for uterine fibroids, TAH provides permanent relief from symptoms such as menorrhagia, dysmenorrhoea and pressure symptoms. Getting relief from these distressing symptoms improves their quality of life by reduced hospital visits due to anaemia and dysmenorrhea.

Also, majority of patients are reported to have improved sexual function after TAH [43, 44, 45]. This improvement in sexual function is probably due to improved overall health due to higher haemoglobin levels, and relief from pelvic pressure and pain. The permanent amenorrhoea also results in less impediment to regular sexual intercourse.

Since TAH involves total removal of the cervix and uterine corpus, a remote positive impact is the elimination of both cervical and endometrial cancer risk, and upper genital tract infections. This eliminates the need for regular pap smears and treatment for both premalignant cervical lesions and pelvic inflammatory disease. Reduced incidence of depressive illness has been reported among patients who had hysterectomy for uterine fibroids and this improvement in mental health is likely due to relief from the debilitating effect of menorrhagia, dysmenorrhea and abdominal distension from huge fibroids [46]. The complete sense of cure from TAH is also likely to contribute to the improvements in the mood of these patients.

Negative impacts of TAH include psychological problems and sexual difficulties. One major psychological challenge some women face after hysterectomy is the loss of sense of femininity which could result in low self-esteem and impaired sexual function [47, 48]. Also, TAH in younger and nulliparous women result in loss of reproductive capacity with a consequent adverse psychologic effect on the woman and her partner [44]. These patients may also experience worsening of anxiety disorders.

In addition, when bilateral salpingo-oophorectomy (BSO) is performed together with TAH in reproductive age women, there is significant decline in sexual function and increased psychosocial health risk [49]. Some studies have suggested reduced sexual satisfaction due to removal of the cervix in TAH; however, the evidence is inconclusive. Other studies have found no significant difference in sexual function in women who underwent TAH compared to those who had sub-total hysterectomy.

While many patients will have positive experiences following TAH for symptomatic uterine fibroids, others will have less desirable experiences. Adequate preoperative counselling will enable patients with uterine fibroids to measure their expectations and adjust appropriately.

4.1 Methods of fertility preservation in premenopausal women undergoing abdominal hysterectomy

For reproductive-age women with uterine fibroids desiring future childbearing, the best option is to avoid hysterectomy. Alternative treatment methods that preserve the uterus and fertility such as myomectomy, and uterine artery embolization (UAE), high intensity focused ultrasound (HIFU) and medical therapy should be adopted where possible [50, 51].

However, hope is not lost for those women in whom hysterectomy is inevitable. Assisted Reproductive Technologies (ART) have provided an array of options for fertility preservation to help them have their own genetic children. These include; controlled ovarian stimulation and cryopreservation of oocytes or embryos and cryopreservation of ovarian tissue. There is also the option of third-party reproduction which includes donated oocytes or embryos and surrogacy [52].

4.1.1 Embryos and oocytes cryopreservation, ovarian tissue cryopreservation and surrogacy

A woman who has been scheduled to undergo hysterectomy is given ovulation induction drugs to stimulate production of excess oocytes. These are either cryopreserved or used to produce embryos, through in vitro fertilisation techniques, for cryopreservation. If the time to surgery does not permit this process, her ovarian tissue can be cryopreserved or donor oocytes and embryos can be used. For the process of fertility to complete, the woman will need the help of a surrogate mother to serve as gestational carrier after hysterectomy. It is to be noted that embryo cryopreservation, donor embryo, and surrogacy have generated a lot of ethical, moral, and legal issues. The patient should be referred to specialised fertility center for proper counselling and treatment [53, 54, 55].

5. Conclusion

In conclusion, uterine fibroids are benign tumours of the smooth muscle of the uterus. They are present in 20–25% of reproductive age women. Hysterectomy is the definitive treatment and there are 3 different methods of approach to it, abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy procedures. Between 30 and 60% of hysterectomies are performed to treat uterine fibroids and about 15–59% are reported to be abdominal hysterectomy.

Total abdominal hysterectomy is the removal of the uterus and the cervix through an abdominal incision. If the ovaries and the tubes are removed in addition, it is referred to as total abdominal hysterectomy with bilateral salpingo-oophorectomy. The procedure is relatively safe with low morbidity and mortality rates. It has both positive and negative impacts on the reproductive health of women. The major consequences in reproductive age women are loss of fertility and premature menopause. The choice of hysterectomy in this age group depends on the severity of the symptoms and the desire of the patients to maintain fertility. There are alternatives modes of treating uterine fibroids which are uterus-preserving. There are also methods of fertility preservation for those in whom hysterectomy is unavoidable. Therefore, the gynaecologist is expected to counsel the patients adequately on these so that they can decide on the option that best suits them and their decision should be respected.

Acknowledgments

The authors thank Mr. Olagunju Femi D for Typing and arrangement.

Conflict of interest

The authors declare no conflict of interest.

Acronyms and abbreviations

ACOG	American College of Obstetricians and Gynecologists
ART	Assisted Reproductive Technology
BSO	bilateral salpingo-oophorectomy
DGGG	Deutshe Gesellschaft fur Gynakologie and Geburtshiife
GSOG	German Society of Obstetrics and Gynecology
FBC	full blood count
FBS	fasting blood sugar
HIFU	high intensity focused ultrasound
IVP	intravenous pyelography
NICE	National Institute for Health and Clinical Excellence
PT	pregnancy test
TAH	total abdominal hysterectomy
UAE	uterine artery embolization