The Duchess of Cornwall’s hysterectomy has done a service to women by reassuring them that though the procedure is performed much less often than formerly, it is still sometimes a necessary treatment, even if there is no malignancy.

The most common indication for a hysterectomy in women without cancer is dysfunctional uterine bleeding. This is the heavy menstrual bleeding that causes anaemia and undermines a woman’s quality of life.

Before dysfunctional uterine bleeding is diagnosed, other causes of excessive bleeding are excluded. Tests will include trans-vaginal ultrasound to examine the uterine wall to detect any fibroids and to view ovaries to exclude polycystic ovarian syndrome. A biopsy will be performed on the the uterine lining to exclude malignancy.

If the bleeding does not respond to hormonal treatment the standard treatment for dysfunctional bleeding is now endometrial ablation, the removal of most of the lining of the uterus, so that periods are dramatically reduced or stopped. Small parts of the endometrium may remain, even without detectable bleeding, so that it is not suitable for women after ablation to take oestrogen-only HRT.

There still is a remote chance of malignant change. Both the NHS and private insurers have encouraged uterine ablation rather than hysterectomy as a cheaper, easier, less invasive and therefore safer method of dealing with dysfunctional uterine bleeding.

The other frequent reason for hysterectomies, other than uterine malignancies, is the treatment of heavy bleeding from multiple, large fibroids. Single, or a few, fibroids are now usually removed by a myomectomy, the shelling-out of the fibroid from the uterine muscle, or the deliberate interruption of the blood supply to the fibroid, known as embolisation.

Hysterectomies may be total or subtotal. The former is the most commonly used procedure. A subtotal hysterectomy leaves the cervix intact, but is rarely recommended because its advantages are debatable but its disadvantages obvious as the cervix is a possible site for a future cancer.

During a hysterectomy the ovaries may also be removed. The surgery involved in the hysterectomy often interferes with ovarian blood supply, so that even if they are left, an early menopause is likely. Removing the ovaries also removes the chance of developing a cancer of the ovary.

Hysterectomy is a safe operation that shouldn’t cause anxiety to either the patient, their family, the surgeon or anaesthetist. In uncomplicated cases, the 30-day mortality rate 15 years ago, when the last extensive survey was carried out, showed that in otherwise uncomplicated cases, and excluding those women having a hysterectomy for cancer, it was 16 per 10,000 cases. It is now probably less.

The two most common serious operative risks of a hysterectomy are haemorrhage and deep-vein thrombosis (DVT) with pulmonary emboli. In a good hospital, staffed by experienced surgeons and with cautious medical guidance, the threat of DVTs is minimalised, and either event is unlikely.

A technical problem that can complicate total hysterectomies is damage to the ureter, the tube that carries the urine from the kidney to the bladder.

A patient will probably be up within 24 hours, home within a week and back to normal within six weeks. After the operation she should avoid heavy work, especially anything that might raise intrathoracic pressure. This is the type of exercise that makes a patient grunt with effort, as when they are lifting heavy weights, or pulling or pushing with vigour. The operation should not take more than an hour from beginning to end. After six weeks of convalescence, a patient should have recovered.

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