Is it essential to remove the neck of the womb at hysterectomy?

It had become routine practice to remove the cervix when performing abdominal hysterectomy in the United Kingdom and in the majority of other countries. The arguments in favour of removing the cervix are:-

  • cancer of the cervix cannot develop later.
  • the cervix may be the cause of pain or discharge if it is not removed.
  • there is a greater chance of a blood collection (haematoma) in the pelvis soon after surgery with the subtotal hysterectomy complicating recovery a concept that does not seem to have strong foundation.
  • if the cervix is not removed, there is a greater chance of prolapse in years to come but there are no comparative trials to demonstrate this.

There are, however, times when it may be safer to conserve the cervix. Occasionally, it may be densely adherent to the bowel (usually the rectum) particularly if there is severe endometriosis in the area. If the gynaecologist believes the risks to the bowel or urinary tract may outweigh the advantages, it may be decided during the operation that leaving the cervix in place (sub-total hysterectomy) is in the patient's best interest.

Many French women prefer to have the cervix conserved at the time of hysterectomy as there is a suggestion that this prevents reduction of sexual satisfaction. The argument in favour of removing the cervix pre-dates cervical smears. If smears have been abnormal removing the cervix would seem appropriate but if there have been regular smears showing no abnormality sub-total hysterectomy should cause less anxiety in this regard. Some believe that conserving the cervix (sub-total hysterectomy) reduces the likelihood of bladder symptoms in the long-term.  

A woman of forty presented with heavy periods and premenstrual syndrome. She had always been keen on a conservative approach. Endometrial ablation had provided temporary improvement but within a couple of years she felt that further surgical intervention was required. She had read extensively and elected to have a sub-total hysterectomy with removal of the ovaries and tubes. Her cervical smears had been normal. The operation was uneventful and she was home on the fourth day. She elected to take HRT tablets (oestradiol 2mg daily). She returned to her work with children by the third week and when we saw her six weeks after surgery she felt like a new woman absolutely wonderful. She will continue to have her routine cervical smears as her cervix has not been removed.

From the late 1990's, gynaecologists in the UK have become increasingly inclined to discuss the question of the subtotal procedure with their patients when counselling them with regard to hysterectomy.

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This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

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