Gynecologic Surgical Miscommunications: 

In my last post I described how there is a large difference in terminology between ordinary consumers and Gynecologists. One of the most common operations done in developed countries is to remove the uterus. The most common cause for this operation, called a hysterectomy, is Fibroids. Other causes might be bleeding, endometriosis, pain, adenomyosis, cysts, precancerous conditions, adhesions, prolapse related conditions, obstetrical problems, and cancer. In the past it was done for contraception.

There are really three essentially different parts of the pelvic structures associated with a hysterectomy. The uterus itself is divided into the upper part, called the body (or fundus in latin), and the lower part called the cervix. There is a slightly narrowed neck in between the fundus and the cervix. As far as I know the English and Latin name for the cervix is the same. These two different parts of the uterus do different things for a woman, and therefore the reasons for removing one part may not apply to the reasons for the other part. In many cases, the fibroids affect only the body of the uterus, and not the cervix. Therefore, a women might choose to keep her cervix, and only remove the fundus. This is a legitimate choice. There are good reasons for removing the cervix, and good reasons for keeping it. My patients have made either decision based on really good analysis of their wants and needs.

The third pelvic structure associated with a hysterectomy is the ovaries. Again, the reasons for removal of them are completely distinct from the hysterectomy decision. I will explain later what those reasons might be. The problem comes from the differences in terminology used by various people.

What a Gynecologist calls a Complete Hysterectomy is removal of the uterus. This includes the fundus and the cervix. This does not include the ovaries. It may include a tiny bit of the top of the vagina where it surrounds the cervix. The common abbreviations for a different types of complete hysterectomies are TAH (total abdominal hysterectomy), TVH (total vaginal hysterectomy), LAVH (laparoscopic assisted total vaginal hysterectomy, TLH (total laparoscopic hysterectomy), and robotic hysterectomy (no usual acronym yet), radical hysterectomy (only done for moderate stage cancer).

When a Gynecologist schedules a removal of the ovaries as well, it will be called an Oophorectomy. There are two common pronunciations for this word. One pronunciation states the "oooh" sound once, another pronunciation says the "oh" sound twice. I have heard both about equally common.

When the fallopian tubes are removed as well we are left with a most common operation: a "Total abdominal hysterectomy and bilateral salpingo-oophorectomy". This is shorted to the acronym TAH/BSO. There are a nearly infinite number of combinations of the above hysterectomy procedures associated with a BSO. For instance one could have a LAVH/BSO. Something that I have done many times.

The problematic miscommunication arises when people will say "I have had a total hysterectomy. Everything was removed". To a Gynecologist, this seems to be an oxymoron. You cannot have everything removed and call it a total hysterectomy. Everything removed means that the ovaries are removed as well. This is usually what the people mean when the say it. But technically, everything removed is a total hysterectomy and bilateral salphingo-oophorectomy. The difference is huge. If a women still has her ovaries, she may have not have had her menopause yet. Her bones will be stronger. Any suspicious cysts in her pelvis will be presumed to be ovarian cancer. The potential for mayhem is huge. Even if the women is sure she had a total hysterectomy, and only a total hysterectomy, she may or may not have her ovaries still. I have seen it both ways.

Personally, I take no chances. I try to get as good a story as I can from the patient. But sometimes we just have to have the notes and reports. A (moderately) good doctor can tell a patient she had a total hysterectomy, and trust that the patient and her family understands the technical meaning of the words. But, in my experience, if a doctor states "total hysterectomy", the patient and her family implicitly understand that the ovaries came out too. And this implicit understanding is totally wrong.

If the Gynecologic surgeon leaves the cervix in, it is called a "subtotal hysterectomy". When a patient or her family hears that, they assume the ovaries were left in. Nothing could be further from the truth. A subtotal hysterectomy can be done with or without an oophorectomy. The words "subtotal hysterectomy" don't say anything about the ovaries. In my opinion, the words "subtotal hysterectomy" should not be used with patients or families because of the ovarian connotation which is a complete miscommunication.

Tomorrow I will describe the reasons for keeping or removing the ovaries and the cervix.

And then after that the Therapeutic Alliance with your doctor.

Thanks for reading. I'm having fun writing this. Please post comments below.

John W Marcus MD
Obstetrics and Gynecology
Ridgewood New Jersey.
201-447-0077