Topic Overview

What is a hysterectomy?

A hysterectomy is surgery to take out a woman’s uterus, the organ in a woman's belly where a baby grows during pregnancy. After a hysterectomy, you will not be able to get pregnant.

Other organs might also be removed if you have severe problems such as endometriosis or cancer. These organs include the cervix (the lower part of the uterus that opens into the vagina), the ovaries (glands on both sides of the uterus that release eggs for pregnancy), and the fallopian tubes (the passageway between the uterus and the ovaries).

Whether or not the ovaries are removed will depend on your age and risk for certain types of cancer. For example, removing the ovaries lowers the risk of ovarian cancer and some types of breast cancer. But, if you have your ovaries removed before the age of menopause, you will go into early menopause, and you may be more likely to get heart disease or osteoporosis. Be sure to discuss all the benefits and risks of removing your ovaries with your doctor.

See an illustration of the female reproductive system.

What problems does this surgery treat?

Most often, hysterectomy is done to treat problems with the uterus, such as pain and heavy bleeding caused by endometriosis or fibroid tumors. The surgery may also be needed if there is cancer in the uterus, cervix, or ovaries. Some women may have the surgery during childbirth to save their lives if there is heavy bleeding that cannot be stopped.

Before you choose to have a hysterectomy, consider all of your treatment options. In many cases, this surgery is a last resort after trying other treatments for the problem.

How is the surgery done?

There are many different ways to do hysterectomy surgery. The type of surgery you have depends on three main things: the reason for the surgery, the size of the uterus and its position in the belly, and your overall health. The most common types are:

• Abdominal hysterectomy. In this type, the doctor makes a cut in the belly, either across the bikini line or straight up and down. The doctor takes out the uterus and the cervix. This type is most often done when cancer might be present or when severe endometriosis, a lot of scar tissue (adhesions), or a very large uterus makes the uterus hard to remove.
• Vaginal hysterectomy. With this type, the doctor takes out the uterus through the vagina. He or she makes a small cut in the vagina instead of the belly. Your doctor will not use this method when there is a chance that cancer may be in the uterus, cervix, or ovaries. Doctors use this type of surgery only in cases where the uterus is small and easy to remove.
• Laparoscopically assisted vaginal hysterectomy (LAVH). To do this surgery, the doctor puts a lighted tube (laparoscope) through small cuts in your belly. The doctor can see your organs with the scope and can insert surgical tools to cut the tissue that holds your uterus in place. Then he or she can remove the uterus through your vagina.
• Laparoscopic supracervical hysterectomy (LSH). With LSH, the doctor inserts the scope and tools through small cuts in your belly. He or she takes out the uterus in small pieces and leaves the cervix in place. This surgery is done only if you don't have cervical cancer.^1,
• Total laparoscopic hysterectomy (TLH). In this type, the doctor inserts a scope and tools through several small cuts in the belly. The doctor takes out the uterus and the cervix in small pieces through one of the cuts.

How long will it take to recover from surgery?

Feeling better after surgery takes time. Most women are in the hospital 1 or 2 days after the surgery. Some women stay in the hospital up to 4 days.

When you get home, make sure you move around, but also be sure you don't do too much. You can walk around the house and up and down stairs, but take it slow. During the first 2 weeks, it’s important to get plenty of rest. Even after you start to feel stronger, you should not lift heavy things (anything over 20 pounds). Also, you should not have sex until your doctor says it’s okay. It usually takes 4 to 8 weeks to get back to a normal routine.

Frequently Asked Questions

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Why It Is Done

In most cases, hysterectomy is an elective surgery used to treat noncancerous female reproductive system (gynecologic) conditions that haven't improved with medical treatment. For women who have no plans for pregnancy and have considered and tried other treatment options without success, a hysterectomy may be a reasonable treatment choice.

Hysterectomy is also a potentially lifesaving measure when used to stop heavy placental bleeding during childbirth or to remove cervical cancer or endometrial (uterine) cancer.

Reasons for hysterectomy include:

• Heavy menstrual bleeding and pregnancy-related bleeding.
• Uterine fibroids.
• Uterine prolapse.
• Endometriosis and adenomyosis.
• Chronic pelvic pain (only when caused by a diagnosed condition that can be corrected with hysterectomy).
• Cancer of the cervix, uterus, or ovaries.

Fortunately, as more effective treatment options have become available for fibroids, heavy menstrual bleeding, and endometriosis, fewer women are having to resort to hysterectomy, a major surgery. However, for those women who continue to suffer severe symptoms after other treatments, hysterectomy often brings significant relief.³ For example, a study of women with heavy bleeding reports relief both 6 months and 2 years after hysterectomy. Along with getting relief from the bleeding, women tended to feel better emotionally and have improved sleep, sexual desire, sexual satisfaction, and overall health.⁴

Hysterectomy Types

Hysterectomy is the surgical removal of a woman's uterus. In some cases, the ovaries and fallopian tubes are also removed during a hysterectomy procedure. This is called a salpingo-oophorectomy.

There are three major types of hysterectomy:

• Total hysterectomy is the surgical removal of the uterus and the cervix, which is the lower "neck" of the uterus that opens into the vagina.
• Subtotal hysterectomy is the removal of the uterus, leaving the cervix in place. It is also known as "supracervical" or "partial" hysterectomy.
• Radical hysterectomy is the removal of the uterus, cervix, ovaries, structures that support the uterus, and sometimes the lymph nodes. A radical hysterectomy may be done to treat endometriosis or cancer of the uterus, ovaries, or cervix.

Deciding whether to have a total or subtotal hysterectomy can be difficult. This is because research that compares the two is limited and shows only small differences. Factors that are commonly considered include:

• Recovery time. Subtotal hysterectomy typically has a quicker recovery time. This is because of lower risks of infection and damage to the urinary tract, and less blood loss than after a total hysterectomy.²
• Cervical cancer risk. In the past, doctors recommended a total hysterectomy to eliminate the risk of cervical cancer. But cervical precancer is easily detected with a regular Pap test. (If you have your cervix removed as part of a hysterectomy, you no longer need Pap tests.) Cervical cancer is found in less than 0.1% of women after subtotal hysterectomy.²
• Sexual well-being. A recent study reports that sexual well-being isn't affected differently by a subtotal versus a total hysterectomy.⁵
• Bladder and bowel function. One study reports that one year after hysterectomy, more women have urinary incontinence problems after a subtotal than after a total hysterectomy.⁵ Bowel function is not affected differently by a subtotal versus a total hysterectomy.²
• Menstrual-like vaginal bleeding. After subtotal hysterectomy, up to 20% of women have bothersome cyclic bleeding if they have not reached menopause, or when taking hormone replacement therapy after menopause.⁵ This happens when cells that bleed with every menstrual cycle remain with the cervix after the uterus is removed.

When considering a hysterectomy, ask your health professional about other treatments for your condition, what hysterectomy options are available to you, and how well hysterectomy is likely to work for you. If you have a hysterectomy, the type of procedure you have will depend on the medical reason for the hysterectomy, the size and position of your uterus, and your general state of health.

Different hysterectomy procedures (how the uterus is removed) include:

• Abdominal hysterectomy.
• Vaginal hysterectomy.
• Laparoscopically assisted vaginal hysterectomy (LAVH).
• Laparoscopic supracervical hysterectomy (LSH).
• Total laparoscopic hysterectomy (TLH).

For more information about procedures, see the section Comparison of Different Hysterectomy Procedures in this topic.

Comparison of Hysterectomy Procedures

There are several different hysterectomy procedures, each with advantages and disadvantages. Depending on your reason for considering a hysterectomy, you may have a choice between two or more procedures. For complicated or cancer-related conditions that require maximum access and careful examination, your doctor will likely recommend only an abdominal hysterectomy.

Vaginal hysterectomy

This type of hysterectomy is performed through a small incision in the vagina, rather than through an abdominal incision. The ovaries and other organs may also be removed. Vaginal hysterectomy tends to cause less pain, and takes less healing time than abdominal hysterectomy. A vaginal hysterectomy can be done:

• To remove small uterine fibroids.
• When the uterus is of normal size or slightly enlarged. However, some experienced surgeons are able to safely remove a very enlarged uterus without higher risk of complications.⁶
• When endometriosis growths (implants) are not present.

Vaginal hysterectomy requires more specialized surgical skill than an abdominal hysterectomy. It can pose a higher risk of injury to other organs. Vaginal hysterectomy is not used when there is a question about possible cancer in the uterus, cervix, or ovaries.

Abdominal hysterectomy

This type of hysterectomy is done through a larger abdominal incision, giving the surgeon the best possible access to the pelvic organs. The cervix may be removed with the uterus (total hysterectomy) or left in place (subtotal hysterectomy). The ovaries and other organs may also be removed. An abdominal hysterectomy is typically done when:

• The uterus is very large.
• Uterine fibroids are larger than 8 in. (20 cm) across or located around blood vessels.
• Cancer of the uterus, ovaries, or cervix is possible.
• An ovarian growth (mass) is suspected but can't be diagnosed on ultrasound.
• There is significant scarring or severe endometriosis in the pelvic area.

If a hysterectomy is chosen to treat endometriosis, an abdominal hysterectomy is usually required; for example, when endometriosis growths (implants) or scar tissue (adhesions) must be removed to restore the function of other organs.

Laparoscopically assisted vaginal hysterectomy (LAVH)

Laparoscopic hysterectomy is done with a viewing instrument (laparoscope) and surgical instruments inserted through a vaginal incision and one or more small abdominal incisions. The ovaries and other organs may also be removed. The uterus is detached from scar tissue, then removed through the vagina. It is done:

• When uterine fibroids are small to moderate in size.
• When the uterus is slightly larger than normal.
• To remove endometriosis and scar tissue (adhesions) confined to the uterus, fallopian tubes, and ovaries.
• To assess or remove ovaries at the same time as a vaginal hysterectomy.

LAVH is a newer surgery and requires the surgeon to have specialized training.

Laparoscopic supracervical hysterectomy (LSH)

Laparoscopic supracervical hysterectomy is done by inserting a laparoscope and surgical instruments through several small abdominal incisions. The uterus is removed in small pieces through a surgical instrument; the cervix is left intact (this is also known as subtotal or partial hysterectomy). This type of procedure usually causes minimal blood loss and pain. The hospital stay is shorter than for total abdominal surgery. Most women can return to normal activity a week or two afterward. LSH can be done:

• To remove uterine fibroids of any size.
• To remove a uterus of any size.

LSH is a newer surgery and requires special training. It usually takes longer to perform than abdominal or vaginal hysterectomy. LSH is not available in some geographic areas.

Total laparoscopic hysterectomy (TLH)

The total laparoscopic hysterectomy is done by inserting a laparoscope and surgical instruments through several small incisions in the abdomen. The uterus and the cervix are removed in small pieces through one of the incisions. TLH can be done:

• To remove uterine fibroids that are small to moderate in size.
• When there is not a lot of scar tissue in the pelvic area.
• When there is not a worry about cancer in the ovaries.

TLH is a newer surgery and requires the surgeon to have special training. It usually takes longer to do than abdominal or vaginal hysterectomy. But recovery and hospital stay are shorter than for total abdominal hysterectomy. TLH is not available in many parts of the country.

Risks of Hysterectomy

Hysterectomy poses some risks of major and minor complications. However, most women do not have complications after a hysterectomy.

Some studies have shown complication rates that are about the same for total laparoscopic hysterectomy (TLH), laparoscopically-assisted vaginal hysterectomy (LAVH), and total abdominal hysterectomy (TAH).^{9, 10} Your risk of problems after surgery may be higher or lower than average. This may depend in part on how experienced the surgeon is.

Major medical complications after hysterectomy

Rates of major complications after vaginal hysterectomy and abdominal hysterectomy (rounded to nearest 0.5%):⁸

In the study described above, the major complication rate was nearly twice as high after laparoscopic abdominal hysterectomies than after open abdominal hysterectomies. Complication rates were about the same for vaginal and laparoscopic vaginal surgeries. (These rates do not apply to radical hysterectomy done to treat cancer.)

• About 11% of women had at least one major complication after the laparoscopic abdominal surgery, compared with about 6% of those who had an open abdominal surgery.
• Although most major complications were equally rare after both types of surgery, more women had heavy blood loss requiring a transfusion after abdominal laparoscopic hysterectomy (4.6%) than after open abdominal hysterectomy (2.4%).

Minor medical complications after hysterectomy

Rates of minor complications after vaginal hysterectomy and abdominal hysterectomy (rounded to nearest 0.5%):⁸

In the study described above, there was no significant difference in minor complication rates, whether the hysterectomy was laparoscopic, vaginal, or abdominal. (These rates do not apply to radical hysterectomy done to treat cancer.)

Infection risk is lowest when your doctor gives you antibiotic medicine at the time of surgery.¹¹

Other ongoing complications of hysterectomy include:

• Difficulty urinating. This is more common after removal of lymph nodes, ovaries, and structures that support the uterus (radical hysterectomy).
• Weakness of the pelvic muscles and ligaments that support the vagina, bladder, and rectum. The weakness can cause bladder or bowel problems, such as cystocele, rectocele, or urinary incontinence (which is most common in women over age 60).¹²Kegel exercises may help strengthen the pelvic muscles and ligaments. However, some women need other treatments, including additional surgery.
• Continued heavy bleeding. Some vaginal bleeding within 4 to 6 weeks following a hysterectomy is expected. However, call your health professional if bleeding continues to be heavy.
• Early menopause caused by a slow, yet early decline of the ovaries (premature ovarian failure).³
• The formation of scar tissue (adhesions) in the pelvic area.

Preparing for a Hysterectomy

Before a hysterectomy, you may have:

• A physical examination, during which your health professional will ask you questions about your medical history.
• A pelvic examination.
• Blood tests.
• An electrocardiogram (ECG or EKG), which measures the electrical signals that control the rhythm of your heartbeat, if you are over the age of 40 or have diabetes or high blood pressure.
• A meeting with the doctor who will perform the hysterectomy. During this meeting, the doctor will explain how the surgery will be done, where the surgical incisions will be made, and the risks and expected outcomes of the surgery. You will probably receive written instructions about how to prepare for surgery at this time.
• A meeting with an anesthesiologist or nurse anesthetist. During this meeting, you will discuss the types of anesthetic recommended for use during the surgery. You may not meet with this person until the day of your surgery.

Your health professional may order additional tests based on your physical examination and medical history. These tests may include:

• A pregnancy test if you have not reached menopause.
• Urine tests, such as urinalysis, to check for any signs of urinary tract infection.
• A chest X-ray, for a general evaluation before using general anesthesia.
• Blood typing, in case you should need a blood transfusion (which is rare).
• Blood clotting studies, if you tend to have excessive bleeding or a history of deep vein thrombosis.

See a list of questions to ask your health professional when you are considering hysterectomy.

When to Call a Doctor

After a hysterectomy, call your health professional or go to the emergency department if you have:

• Chest pain, a cough, or difficulty breathing.
• Bright red vaginal bleeding that soaks two or more pads in an hour or forms large or painful clots. Some light bleeding or spotting is expected for up to 6 weeks following a hysterectomy. If your vaginal bleeding is heavier or different than what you were told to expect, call your health professional to discuss the problem.
• Pain or tenderness, swelling, or redness in your legs.
• A fever of 100 °F (37.8 °C) or higher.
• Pain that is not relieved by your pain medicine.
• Difficulty passing a stool, especially if you have not had a normal bowel movement for 3 to 5 days, or if you have mild pain or swelling in your lower abdomen.
• Difficulty passing urine, pain or burning when you urinate, blood in your urine, or cloudy urine.
• Pain, discomfort, or bleeding during intercourse.
• Hot flashes, sweating, flushing, or a fast or pounding heartbeat.
• Pain or swelling in the legs, especially the back of the calf.

Your health professional will give you specific instructions after your hysterectomy. Be sure to follow them. Usually, getting some rest and following those instructions will help postoperative problems diminish over time.

Recovery

Recovering from a hysterectomy takes time. You will stay in the hospital for 1 to 2 days for postsurgery care. Some women stay in the hospital up to 4 days.

Abdominal hysterectomy. As soon as you feel strong enough, get up and around as much as you can. This helps prevent problems after surgery like blood clots, pneumonia, and gas pains. During the first 2 to 3 weeks it is important to also get plenty of rest. You will gradually be able to increase your activities. To help you heal well, avoid lifting more than 20 pounds during the first 4 to 6 weeks after surgery. For the same reason, this is also an important time to avoid vaginal intercourse.

As soon as you can move easily without pain or without using narcotic pain medicine, you can drive. Complete recovery usually takes 4 to 8 weeks. Your return to a work routine will depend on how quickly you get back your energy and strength, and how demanding your work is.

Vaginal or laparoscopic hysterectomy. As soon as you feel strong enough, get up and around as much as you can. This helps prevent problems after surgery like blood clots, pneumonia, and gas pains. When you can move easily without pain, you can drive. To help you heal well, avoid lifting more than 20 pounds during the first 4 to 6 weeks after surgery. For the same reason, this is also an important time to avoid vaginal intercourse.

Recovery from a vaginal or laparoscopic hysterectomy takes much less time than from an abdominal surgery. After a routine laparoscopic surgery removing the uterus but not the cervix (laparoscopic supracervical hysterectomy, or LSH), most women are able to return to normal activity in 1 to 2 weeks. About 4 to 6 weeks after the hysterectomy, see your health professional for a follow-up examination.

How effective is hysterectomy for improving my symptoms?

For many women who still have severe symptoms after trying medicines or other treatment, hysterectomy often brings significant relief.³ For example, a study of women with heavy menstrual bleeding reports relief at 6 months and 2 years after hysterectomy. This was compared to women who used medicine or other treatment. Along with getting relief from the bleeding, women tended to feel better emotionally and have improved sleep, sexual desire, sexual satisfaction, and overall health.⁴ Most women report improvement in physical symptoms (including pelvic pain, abdominal bloating, and physical and social functioning) after a hysterectomy.¹³ For more information about how hysterectomy may or may not help different problems, see:

• Hysterectomy and chronic pelvic pain.
• Hysterectomy and heavy, irregular menstrual bleeding.
• Hysterectomy and endometriosis.
• Hysterectomy and uterine fibroids.
• Hysterectomy and uterine prolapse.

What are possible long-term problems after hysterectomy?

For some women, pelvic pain, low back pain, or pain with intercourse that they had before surgery persists or returns after surgery.¹⁴ The success rate is lower for women who have had prior pelvic surgery or radiation therapy to the pelvis.

Pelvic weakness. After a hysterectomy, some women develop other physical problems that are related to weakness of the pelvic muscles and ligaments that support the vagina, bladder, and rectum. The weakness can cause bladder or bowel problems, such as cystocele, urinary incontinence, or rectocele.¹²Kegel exercises may help strengthen the pelvic muscles and ligaments. However, some women need other treatments, including additional surgery.

Vaginal dryness from low estrogen levels may develop if your ovaries were removed (oophorectomy). This can also develop gradually after a hysterectomy. If sexual intercourse is painful because of vaginal dryness:

• Use a vaginal lubricant such as K-Y jelly, Astroglide, or Replens, or a polyunsaturated vegetable oil that does not contain preservatives. If you are using condoms, use a water-based lubricant, rather than an oil-based lubricant. Oil can weaken the condom so that it breaks. Avoid petroleum jelly (for example, Vaseline) as a lubricant because it increases the risk of vaginal irritation and infection.
• Use a low-dose vaginal estrogen cream, ring, or tablet, which will reverse vaginal dryness and irritation by affecting only the vaginal area. If you are having other menopausal symptoms, talk to your health professional about systemic estrogen replacement therapy (ERT) and other treatment options. For more treatment information, see the topic Menopause and Perimenopause.

Should I use estrogen replacement therapy (ERT) after a hysterectomy or oophorectomy?

Pain during intercourse may occur if your vagina was shortened during your hysterectomy. Changing positions may help make intercourse less painful. Talk with your health professional if you have any difficulty during intercourse after a hysterectomy.

How will I feel emotionally after my hysterectomy?

It is normal to have various concerns when faced with the possibility of having a hysterectomy. A woman's emotions are often based on her beliefs about the importance of her uterus, her fears about her health or personal relationships after a hysterectomy, and concerns about her enjoyment of sexual activities after surgery. If you are considering a hysterectomy, talk with your health professional about your specific fears and anxieties concerning the surgery.

Shortly after a hysterectomy, you may notice changes in your emotions. Studies have shown that most women reported better mood, quality of life, and sexual, psychological, and social functioning following hysterectomy. In one study, nearly three-fourths of the women who had problems with anxiety or depression before a hysterectomy were no longer depressed 12 months after the hysterectomy. Women who had been in therapy for psychological or emotional problems before having a hysterectomy had poorer outcomes than women who were not in therapy.^{4, 13, 3}

What to Think About

Hysterectomy is performed more often in the United States than in any other country.¹⁵ Your health professional may suggest other treatments before recommending a hysterectomy. If you are considering a hysterectomy and would like more information about other treatments or surgeries, talk with your health professional. Ask about the risks and benefits of each option. Consider both the immediate and long-term risks and benefits of all treatments.

Hysterectomy is a necessary and effective treatment for cancer of the pelvic organs, a severe infection of the uterus, or uncontrollable bleeding.

Following hysterectomy, you will not be able to become pregnant. If you have plans for a future pregnancy, hysterectomy is not an appropriate treatment option for conditions such as uterine fibroids, endometriosis, or pelvic organ prolapse. Talk with your health professional about other treatments.

Hysterectomy is not used to prevent pregnancy. There are many methods of birth control that are safe and effective. If you are not sure which method is best for you, talk with your health professional about your options.¹³ For more information, see the topic Birth Control.

Estrogen replacement therapy (ERT)

Women who have early, sudden menopause after hysterectomy are usually advised to use estrogen replacement therapy (ERT) to protect against bone loss. The low estrogen levels of menopause cause bone thinning. Compared with women who are not taking hormone therapy, women taking ERT have fewer hip fractures (a sign of estrogen's bone-protecting effect).¹⁶

ERT also helps with menopausal symptoms. Known ERT risks come from studies of women older than 50. It may be that the benefits outweigh the risks for younger women who take ERT until the age of natural menopause.¹⁷ This question needs further research.

The Women's Health Initiative (WHI) studied estrogen-only therapy in older women and found that it increases the risks of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism) and the risk of stroke during the first year of use.¹⁶ ERT offered no protection against heart disease. It was linked to ovarian cancer in a small number of women.^{18, 19}

Some studies have found a possible link between ERT and breast cancer.²⁰ In the WHI trial, women using ERT had no increase in breast cancer risk during the study's nearly 7 years of ERT treatment.¹⁶ However, the Million Women Study of British women ages 50 to 64 suggests that after 10 years of taking ERT, a small number of women develop breast cancer that is related to ERT.^{21, 22} (Many women in this age group also develop breast cancer without taking hormone therapy.)

If you have had breast cancer or ovarian cancer, do not take ERT or HRT.²⁰

For more information, see:

Should I use estrogen replacement therapy (ERT) after a hysterectomy or oophorectomy?

Other Places To Get Help

Organizations

Related Information

• Chronic Female Pelvic Pain
• Dysfunctional Uterine Bleeding
• Endometriosis
• Functional Ovarian Cysts
• Menopause and Perimenopause
• Oophorectomy
• Pelvic Organ Prolapse
• Uterine Fibroids

References

Citations

1. Gimbel H, et al. (2005). Lower urinary tract symptoms after total and subtotal hysterectomy: Results of a randomized controlled trial. International Urogynecology Journal, 16: 257–262.

2. Thakar RT, et al. (2002). Outcomes after total versus subtotal abdominal hysterectomy. New England Journal of Medicine, 347(17): 1318–1325.

3. Khastgir G, Studd J (2000). Patients' outlook, experience, and satisfaction with hysterectomy, bilateral oophorectomy, and subsequent continuation of hormone replacement therapy. American Journal of Obstetrics and Gynecology, 183(6): 1427–1433.

4. Kuppermann M, et al. (2004). Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: The medicine or surgery (Ms) randomized trial. JAMA, 291(12): 1447–1455.

5. Gimbel H, et al. (2003). Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow-up results. International Journal of Obstetrics and Gynecology, 110: 1088–1098.

6. Benassi L, et al. (2002). Abdominal or vaginal hysterectomy for enlarged uteri: A randomized clinical trial. American Journal of Obstetrics and Gynecology, 187: 1561–1565.

7. Campbell ES, et al. (2003). Types of hysterectomy: Comparison of characteristics, hospital costs, utilization and outcomes. Journal of Reproductive Medicine, 48: 943–949.

8. Garry R, et al. (2004). The eVALuate study: Two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ, 328(7432): 129.

9. Hoffman CP, et al. (2005). Laparoscopic hysterectomy: The Kaiser Permanente San Diego experience. Journal of Minimally Invasive Gynecology, 12(1): 16–24.

10. Ghezzi F, et al. (2006). Laparoscopic-assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: A randomized clinical trial. Journal of Minimally Invasive Gynecology, 13(2): 114–120.

11. Abramowicz M (2004). Antimicrobial prophylaxis for surgery. Treatment Guidelines from the Medical Letter, 2(20): 27–32.

12. Brown JS, et al. (2000). Hysterectomy and urinary incontinence: A systematic review. Lancet, 356(9229): 535–538.

13. Kjerulff KH, et al. (2000). Effectiveness of hysterectomy. Obstetrics and Gynecology, 95(3): 319–326.

14. Rhodes JC, et al. (1999). Hysterectomy and sexual functioning. JAMA, 282(20): 1934–1941.

15. Farquhar CM, Steiner CA (2002). Hysterectomy rates in the United States 1900–1997. Obstetrics and Gynecology, 99(2): 229–234.

16. Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701–1712.

17. North American Menopause Society (2004). Abridged recommendations for estrogen and progestogen use in peri- and postmenopausal women: October 2004 position statement of the North American Menopause Society. Menopause Management, 13(6): 12–19. Also available online: http://www.menopausemgmt.com/issues/13-06/issue.html.

18. Rossouw JE, et al. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA, 297(13): 1465–1477.

19. Beral V, et al. (2007). Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet, 369(9574): 1703–1710.

20. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Breast cancer. Obstetrics and Gynecology, 104(4, Suppl): 11S–16S.

21. Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419–427.

22. American College of Obstetricians and Gynecologists Women's Health Care Physicians (2004). Stroke. Obstetrics and Gynecology, 104(4, Suppl): 97S–105S.

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