Benefits of Cervical Preservation During Hysterectomy
Preserving the cervix during hysterectomy (supracervical hysterectomy) offers no significant benefits for most patients compared to total hysterectomy and is not recommended as standard practice for benign uterine disease.
Limited Benefits of Cervical Preservation
- Supracervical hysterectomy may be associated with less blood loss and shorter surgical time compared to total hysterectomy, but these differences are not clinically significant 1, 2
- Historically, some have argued that the cervix plays a role in sexual arousal and orgasm through stimulation of nerve plexuses, but this theory has not been supported by high-quality evidence 3
- There is no evidence that preserving the cervix prevents postoperative urinary dysfunction or improves sexual function compared to total hysterectomy 2, 4
Disadvantages of Cervical Preservation
- Women with preserved cervix require ongoing cervical cancer screening, unlike those who undergo total hysterectomy for benign disease 5, 6
- Cervical preservation is associated with an increased risk of cervical cancer (0.05-0.27%) compared to total hysterectomy 1
- Women with preserved cervix may continue to experience cyclic vaginal bleeding after surgery 2
- There is an increased risk of requiring reoperation for cervical bleeding in women who undergo supracervical hysterectomy 1
Indications for Total Hysterectomy (Cervical Removal)
- Total hysterectomy is strongly recommended for women with benign uterine disease based on risk-benefit assessment 1
- Total hysterectomy is particularly important for women with current or significant history of abnormal cervical cytology 2
- For endometrial cancer with cervical involvement, simple hysterectomy with postoperative radiation therapy is recommended to decrease the risk of locoregional recurrence 6
- Radical hysterectomy should be considered for patients with bulky cervical involvement 6
Special Considerations
- Cervical preservation may be appropriate in specific fertility-sparing scenarios:
- Radical trachelectomy with pelvic lymph node dissection is recommended for stage IA1 and IA2 cervical cancer in patients who wish to preserve fertility 6
- After childbearing is complete, hysterectomy can be considered for patients who had radical trachelectomy if they have chronic persistent HPV infection, persistent abnormal Pap tests, or desire this surgery 6
Post-Hysterectomy Screening Recommendations
- Women who have had a total hysterectomy with removal of the cervix for benign disease do not require routine Pap tests 5, 6
- Women who have had a hysterectomy for cervical intraepithelial lesions should continue screening until three documented, consecutive, technically satisfactory normal/negative vaginal cytology tests and no abnormal/positive cytology tests within a 10-year period are achieved 5
- Women with a history of in utero DES exposure and/or with a history of cervical carcinoma should continue screening after hysterectomy for as long as they are in reasonably good health 5
- Women with a supracervical hysterectomy must continue routine cervical cancer screening 6
Common Pitfalls
- Assuming cervical preservation improves sexual function: Recent evidence shows hysterectomy is usually associated with improved quality of life and sexual function regardless of whether the cervix is removed 2
- Performing supracervical hysterectomy without informing patients about continued need for cervical screening and possible continued bleeding 2
- Failing to consider individual risk factors for cervical disease when deciding on surgical approach 1, 2