Prevalence and Indications for hysterectomy

Indications should be discussed thoroughly : indeed too often the indication is based upon an incomplete or incorrect diagnosis while the surgery itself tends to vary with the technical skills of the surgeon.

For those looking for a pregnancy : what are the limits of surgery ?

For myomas, a solitary myoma can ‘always’ be operated conservatively. Multiple myoma’s depend upon the skill of the surgeon.

The real limits for conservative surgery varies with the skill of the surgeon, while it is important to know that technically it is much easier to do an hysterectomy than a large myomectomy.  Moreover following myomectomy adhesions tend to develop.

Pain and/or a big uterus (more than 1 kilo)

A Uterus with one or more myomas bigger than 14 weeks of pregnancy (>1 kgr) is een absolute indication since this volume almost invariably will give complaints, and since it is unwise to let the uterus further grow. Moreover from 1 kilo onwards a laparoscopic hysterecomy becomes difficult.
An enlarged uterus with a myoma, pain and /or irregular bleeding.
Severe hypogastric pain is often used as an indication for an hysterectomy.  Pain however is so multifactoreal that one should be prudent not to miss a diagnosis such as endometriosis, adhesions, pelvic congestion etc.   Adenomyosis is a difficult diagnosis which is rarely 100% certain,  while the relationship between pain and adenomyosis is diffcult to establish.Even focal adenomyosis is not an easy diagnosis.  Therefore when the only symptom is pain, decisions will often be taken during laparoscopy, where other causes of pain should be excluded.
Smaller myoma’s with bladder or bowel symptoms are relative indications. It should be discussed whether an hysterectomy, or a laparoscopic or hysteroscopic myomectomy should be performed

Bleeding disorders are rarely in indication for hysterectomy

Bleeding disorders first of all require a diagnosis by hysteroscopy and or ultrasound.
A polyp or submucous myoma ishould be treated hysteroscopically.
Menorrhagia with an otherwise normal uterus should be treated with an hysteroscopic endometrium ablation.

Menorragia with an enlarged uterus is an indication for an hysterectomy.
Irregular bleeding Besides medical hormonal treatment irregular bleeding can be caused by a polyp or a myoma.

Menorrhagie met baarmoedervergroting : best hysterectomie

Prolaps of the uterus and/or  urinary incontinence

This is discussed in detail in pelvic floor surgery.

What are the most frequent mistakes and why.

Not performing hysteroscopy for diagnosis and not performing hysteroscopic surgery.  Thus poliepectomies, submucous myoma and ideopatic menorragia are shifted to the more invasive hysterecomy.

Inadequate diagnosis of pelvic pain
Inadequate diagnosis of irregular bleeding.
An abdominal hysterectomy for an uterus of less than 1 kilo.