Does Having a Hysterectomy Increase Your Risk of Future Prolapse?
As pelvic health awareness continues to grow, people continue to have more questions about how their current day decisions impact their future pelvic health. One such question that came up in the clinic recently revolves around hysterectomies and the subsequent risk of prolapse post-operatively. Does having a hysterectomy increase your risk of future prolapse?
In today’s blog post, we’re going to dive into the prevalence of hysterectomies, common indications and procedures used and what the literature says about your post-operative risk of prolapse. In order to understand the risk of prolapse following a hysterectomy, we have to understand all the key players.
How common is having a hysterectomy?
A hysterectomy is a surgery performed to remove all or part of the uterus. According to Yale Medicine:
About 500,000 hysterectomies are performed annually in the US.
It’s the second most common surgery for women after c-sections.
The average age of hysterectomy varies based on the study. Some cite 40-44 as the average age vs others that say 40-50. In Finland, it’s estimated that ⅓ will have a hysterectomy for benign causes by the age of 60.
What are the common reasons for a hysterectomy?
There are a number of reasons people may have a hysterectomy, including:
Adenomyosis: A condition where the tissue that typically lines the uterus grows into the uterine wall.
Dysmenorrhea: Pain associated with menstruation that can occur from the very first period or begin later in life.
Endometriosis: A condition where the tissue that typically lines the uterus grows outside the uterine wall. It’s important to note that endometrial tissue can grow back even after a hysterectomy.
Gynecologic cancers: This may include cancer of the uterus, ovary, cervix or endometrium.
Heavy or prolonged menstrual bleeding
Fibroids: These are non-cancerous growths that occur in the uterus. These growths range significantly in size and can appear on their own or in groups.
Uterine prolapse: A condition where the uterus descends down into the vagina.
Gender affirmation surgery: Surgeries performed in order to ensure an individual’s outward appearance matches the gender they are.
The reason for the hysterectomy will dictate the type of hysterectomy performed - more on that below.
What are the types of hysterectomy?
There are different types of hysterectomies, depending on the reason behind the hysterectomy and tissue being removed. Here’s a breakdown of the different types:
Supracervical or partial hysterectomy: The removal of the body of the uterus, leaving the cervix intact.
This can be used when more conservative methods of treatment fail to treat underlying medical conditions such as endometriosis, fibroids, prolapse, pelvic pain and abnormal bleeding.
Total hysterectomy: The removal of the full uterus, including the cervix.
This is done to reduce the risk of cervical cancer and is the most common type of hysterectomy.
Radical hysterectomy: The removal of the uterus, cervix, tissue around the cervix and upper part of the vagina.
A radical hysterectomy is typically done in the presence of cancer.
Hysterectomy with oophorectomy: The removal of the uterus, cervix and ovaries
This may be chosen due to a risk of ovarian cancer.
What kinds of procedures do people have and what are the risks?
Not all hysterectomies are performed via the same procedure. Kinds of procedures for hysterectomies include vaginal, abdominal, laparoscopic and robotic laparoscopic hysterectomy. We’ll outline the basic differences below.
Vaginal hysterectomy: In this procedure, the uterus is removed through a small incision in the vagina.
Abdominal hysterectomy: In this procedure, the uterus is removed through an incision in the low abdomen.
Laparoscopic hysterectomy: This procedure is performed through small incisions in the abdomen, typically including the umbilicus.
Robotic laparoscopic: A laparoscopic hysterectomy performed by your surgeon with computer and robotic assistance.
What’s the literature say about hysterectomy and your risk of future prolapse?
We’ll do a dive into the existing literature in a moment, but here’s the TL;DR:
If pelvic organ prolapse is the reason for a hysterectomy, the risk of experiencing a subsequent pelvic organ prolapse or future pelvic organ prolapse surgery increases as compared to if the hysterectomy was performed in absence of a prolapse. There may be a higher risk of prolapse with vaginal or laparoscopically assisted vaginal hysterectomies. Overall, the absolute risk of developing prolapse after a hysterectomy if the indication was something other than prolapse appears relatively low.
Important note: Data is constantly changing and research is often flawed. It appears that the method of the procedure and the indication for the procedure can impact the likelihood of future prolapse. Be sure to talk to your healthcare provider to better understand your personal risk factors!
Let’s break down some of the larger studies available on the topic of hysterectomy and future risk of prolapse:
Pelvic organ prolapse after hysterectomy: A 10‐year national follow‐up study, Kuittinen et. al., 2023
This study evaluated the rates and risk of future prolapse over 10 years following hysterectomy for benign (non-cancerous) indications. They excluded those who had a preexisting prolapse in their study. They included 3,582 people who underwent a hysterectomy in 2006 and followed them until 2016. They tracked future prolapse outcomes and compared different hysterectomy approaches.
Here’s what they found:
Over the 10 years the participants were followed, 1.6% underwent a prolapse related operation, and 2.6% of participants had prolapse related outpatient care visits.
Laparoscopic assisted vaginal hysterectomy (LAVH) and vaginal vault operation appeared to carry increased risk as compared to an abdominal hysterectomy.
Additional risk factors for prolapse development after hysterectomy included stress urinary incontinence and vaginal deliveries prior to the operation.
The study concluded that there is a relatively small risk for future pelvic organ prolapse in those who have a hysterectomy for benign indications without a preexisting prolapse.
The indication for hysterectomy as a risk factor for subsequent pelvic organ prolapse repair, Lykke et. al., 2015
This study looked at whether the reason for a hysterectomy is a risk factor for the future development of prolapse. They used data from 154,882 Danish women who had a hysterectomy, again for benign indications, between 1977 and 2009. They followed patients from their hysterectomy until either a prolapse surgery, death, emigration or the end of the study. The risk of subsequent prolapse was calculated based on various hysterectomy indications.
Here’s what they found:
The study found that the risk of subsequent prolapse was higher in folks who had a hysterectomy as as result of abnormal uterine bleeding (AUB), pain, endometriosis rather than fibroids or polyps.
Prolapse as the indication for the hysterectomy had the highest rate of subsequent prolapse.
Pelvic organ prolapse following hysterectomy on benign indication: a nationwide, nulliparous cohort study, Husby et. al. 2022
This study acknowledged that previous evidence had shown that parity (prior pregnancy) is a strong risk factor for prolapse and may “confuse the true correlation between hysterectomy and pelvic organ prolapse.” They aimed to assess whether there is an increased risk of prolapse following hysterectomy in those who have never been pregnant.
They included 9,535 women born between 1947 and 2000 who lived in Denmark between 1977 and 2018. They were each assigned 5 controls who were folks who had not had a hysterectomy for a total of 47,370 controls. Here’s what they found:
The risk of pelvic organ prolapse increased by 60% in those who underwent a hysterectomy.
After excluding those who underwent a vaginal hysterectomy, the results were largely the same between
They found higher rates of pelvic organ prolapse surgery in women who had a subtotal hysterectomy, total hysterectomy, or vaginal and laparoscopic-assisted vaginal hysterectomies.
Absolute risk was very low - only 29 of those in the hysterectomy group had a prolapse repair surgery. However they detereminted “as this cohort study of nulliparous women found an increased risk of pelvic organ prolapse surgery after hysterectomy, it is implied that the uterus per se protects against pelvic organ prolapse.”
As you can see, there are a number of factors that play into your personal risk factors of developing a prolapse following a hysterectomy. It’s important to take the time to review your circumstances with your medical provider in order to better understand your own risk.
What can you do prior to surgery to prepare for a hysterectomy?
Depending on the reason for your hysterectomy, the recommendations for prehab may vary. Prehab is the idea of preventatively rehabbing your body prior to a procedure. Generally, the stronger you go into surgery, the stronger you come out of it. The more time between the decision to have a hysterectomy and the time of the procedure, the more opportunity you have to prepare.
Here are two things you can do to prepare for your hysterectomy:
Work on core and pelvic floor strength and mobility: A hysterectomy impacts your abdominal and pelvic floor musculature. Going into surgery with strong and mobile abdominal and pelvic floor muscles will improve your body’s ability to recover and regain strength and mobility after surgery. Mobility exercises can include things like diaphragmatic breathing in various positions and a dilator program. Mobility can also include stretches like a figure 4 stretch, cobra pose and hip windmills. Strength exercises will vary based on your strengthening needs but can include anything from squats and lunges to exercises on a mat like bird dog and donkey kicks.
See a pelvic floor physical therapist prior to your procedure: Mentally and physically preparing for any procedure is a big task. Searching the internet can give you plenty of suggestions for what may serve you as you get closer to the date of your operation, but it can also be overwhelming to read the buffet of options and suggestions. Working with a pelvic floor PT can help you identify what matters for you. This depends on your body, underlying medical conditions and your goals heading into and out of surgery. A pelvic floor PT can physically evaluate you to identify your greatest areas for improvement.
What can you do following surgery to recovery from a hysterectomy?
Surgical recovery will vary based on the indication for your hysterectomy as well as the procedure used. Typically there are lifting and activity limitations in place for around 6 weeks after the procedure. In order to optimize outcomes following your hysterectomy, schedule an evaluation with a pelvic floor physical therapist. Regaining strength and flexibility in your muscles as well as modifying lifestyle factors can reduce your risk of developing pelvic organ prolapse in the future. Working with a PT can help you understand your individualized risks and what you can do to minimize them in the future.
Have questions about your pelvic health? Contact us here to schedule your free phone consultation today!
This post was written by Dr. Rebecca Maidansky, PT, DPT, owner and founder of Lady Bird Physical Therapy. Rebecca is a pelvic floor physical therapist in Austin, TX and founded Lady Bird Physical Therapy in 2019. She is the creator of Birth Preparation and Postpartum Planning, Baby Steps Fitness and the head writer and editor of The Pelvic Press.
Rebecca is a passionate writer and vocal advocate for pelvic health and the importance of improving access to perinatal care. She believes strongly that many common pregnancy pains and postpartum symptoms can be eased or even prevented with basic education and care.
She created this blog to help all birthing people manage common pregnancy pains, prepare for birth and recover postpartum.