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* [http://www.medicanalife.com/watch_video.php?v=55f056d67e0ca77 Laparoscopic Hysterectomy] Video
* [http://www.medicanalife.com/watch_video.php?v=55f056d67e0ca77 Laparoscopic Hysterectomy] Video
* [http://www.hersfoundation.org/anatomy Female Anatomy: Functions of the Female Organs]
* [http://www.hersfoundation.org/anatomy Female Anatomy: Functions of the Female Organs]
* [http://www.serfinaz.com/play/Korku_Gerilim/Vaginal_Hysterectomy Video: Vaginal Hysterectomy] (in German)
* [http://www.medicanalife.com/watch_video.php?v=0dad1bb7c94191a Video: Vaginal Hysterectomy] (in German)
* {{dmoz|Health/Medicine/Medical_Specialties/Obstetrics_and_Gynecology/Gynecology/Hysterectomy/}}
* {{dmoz|Health/Medicine/Medical_Specialties/Obstetrics_and_Gynecology/Gynecology/Hysterectomy/}}
* {{dmoz|Health/Women%27s_Health/Support_Groups/Hysterectomy/}} (Hysterectomy Support Groups)
* {{dmoz|Health/Women%27s_Health/Support_Groups/Hysterectomy/}} (Hysterectomy Support Groups)

Revision as of 07:01, 18 October 2009

Hysterectomy
Specialtygynaecology
ICD-9-CM68.9
MeSHD007044

A hysterectomy (from Greek ὑστέρα hystera "womb" and εκτομία ektomia "a cutting out of") is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus, and cervix of the uterus; often called "complete") or partial (removal of the uterine body but leaving the cervical stump, also called "supracervical"). It is the most commonly performed gynecological surgical procedure. In 2003, over 600,000 hysterectomies were performed in the United States alone, of which over 90% were performed for benign conditions.[1] Such rates being highest in the industrialized world has led to the major controversy that hysterectomies are being largely performed for unwarranted and unnecessary reasons. [2]

Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes), and changes her hormonal levels considerably, so the surgery is normally recommended for only a few specific circumstances:

  • Certain types of reproductive system cancers (uterine, cervical, ovarian) or tumors
  • As a prophylactic treatment for those with either a strong family history of reproductive system cancers (especially breast cancer in conjunction with BRCA1 or BRCA2 mutation) or as part of their recovery from such cancers
  • Severe and intractable endometriosis (overgrowth of the uterine lining) and/or adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall) after pharmaceutical and other non-surgical options have been exhausted
  • Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed over or inside the birth canal) or placenta accreta (a placenta that has grown into and through the wall of the uterus to attach itself to other organs), as well as a last resort in case of excessive postpartum bleeding
  • For transmen, as part of their gender transition
  • For severe developmental disabilities

Although hysterectomy is frequently performed for fibroids (benign tumor-like growths inside the uterus itself made up of muscle and connective tissue), conservative options in treatment are available by doctors who are trained and skilled at alternatives. It is well documented in medical literature that myomectomy, surgical removal of fibroids with reconstruction of the uterus, has been performed for over a century.[specify]

The uterus is a hormone-responsive reproductive sex organ, and the ovaries produce the majority of estrogen and progesterone that is available in genetic females of reproductive age.

Some women's health education groups such as the Hysterectomy Educational Resources and Services (HERS) Foundation seek to inform the public about the many consequences and alternatives to hysterectomy, and the important functions that the female organs have all throughout a woman's life. [3][4][5]

Incidence

According to the National Center for Health Statistics, of the 617,000 hysterectomies performed in 2004, 73% also involved the surgical removal of the ovaries. In the United States, 1/3 of women can be expected to have a hysterectomy by age 60.[6] There are currently an estimated 22 million people in the United States who have undergone this procedure. An average of 622,000 hysterectomies a year have been performed for the past decade.[6]

In the UK, one in 5 women is likely to have a hysterectomy by age 60, and ovaries are removed in about 20% of hysterectomies.[7]

Indications

Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.[8]

Uterine fibroids, although a benign disease, may cause heavy menstrual flow and discomfort to some of those with the condition. Many alternative treatments are available: pharmaceutical options (the use of NSAIDs or opiates for the pain and hormones to suppress the menstrual cycle); myomectomy (removal of uterine fibroids while leaving the uterus intact); uterine artery embolization, high intensity focused ultrasound or watchful waiting. In mild cases, no treatment is necessary. If the fibroids are inside the lining of the uterus (submucosal), and are smaller than 4 cm, hysteroscopic removal is an option. A submucosal fibroid larger than 4 cm, and fibroids located in other parts of the uterus, can be removed with a laparotomic myomectomy, where a horizontal incision is made above the pubic bone for better access to the uterus.

Technique

Hysterectomy can be performed in different ways. Traditionally, it has been performed via either abdominal incision (total abdominal hysterectomy, or TAH, via laparotomy) or vaginal canal (vaginal hysterectomy). However, the vaginal route cannot be used if the "supracervical" procedure is desired. With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because the procedure is much less invasive and the post-operative recovery is much faster with fewer complications. LAVH is performed such that the final removal of the uterus (with or without removal of the ovaries) was via the vaginal canal. Thus, LAVH is also a total hysterectomy, namely, the cervix must be removed with the uterus. The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports. Total laparoscopic hysterectomy (TLH) involves disconnecting the uterus, and other structures as needed, by operating only through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports." Then all tissue to be removed is passed through the vagina or through the tiny half-inch abdominal incisions. For large multifibroid uteri total laparoscopic hysterectomy can still be performed with the use of in situ morcellation by gynecologists who are experienced in laparoscopic techniques.[9] Total abdominal hysterectomy can be safely replaced by total laparoscopic hysterectomy if the surgeon has the required laparoscopic skills and the intention to do it.[10]

Most hysterectomies in the United States and in most parts of the world are done via laparotomy. A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. The open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. However, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity.

The fastest-growing technique is robotic hysterectomy, which as the name implies is a form of robotic surgery. It uses the da Vinci Surgical System which is manufactured by Intuitive Surgical corporation. It has the same advantages as laparoscopic hysterectomy, such as smaller incisions, less scarring, less pain, less blood loss, shorter hospital stay, and less chance of infection, but is much easier to perform because the surgeon uses a comfortable ergonomic computer console to control the articulating robotic arms of the device. Surgeons who find laparoscopic hysterectomy to be too challenging are very likely to grasp robotic surgery.

Many women want to retain the cervix believing that it may affect sexual satisfaction after hysterectomy. It has been postulated, without data, that removing the cervix causes excessive neurologic and anatomic disruption, thus leading to vaginal shortening, vaginal vault prolapse, and vaginal cuff granulations. These issues were addressed in a systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which reported the following findings[11]:

1. There was no difference in the rates of incontinence, constipation or measures of sexual function.

2. Length of surgery and amount of blood lost during surgery were significantly reduced during supracervical hysterectomy compared to total hysterectomy, but there was no difference in post-operative transfusion rates.

3. Febrile morbidity was less likely and ongoing cyclic vaginal bleeding one year after surgery was more likely after supracervical hysterectomy.

4. There was no difference in the rates of other complications, recovery from surgery, or readmission rates.

In the short-term, randomized trials have shown that cervical preservation or removal does not affect the rate of subsequent pelvic organ prolapse[12]. However, no trials to date have addressed the risk of pelvic organ prolapse many years after surgery, which may differ after total versus supracervical hysterectomy. It is obvious that supracervical hysterectomy does not eliminate the possibility of having cervical cancer since the cervix itself is left intact. Those who have undergone this procedure must still have regular Pap smears to check for cervical dysplasia or cancer.

Types of Hysterectomy:

  • Radical hysterectomy : complete removal of the uterus, upper vagina, and parametrium
  • Subtotal hysterectomy : removal of the fundus of the uterus, leaving the cervix in situ
  • Total hysterectomy : Complete removal of the uterus including the corpus and cervix

Benefits

Women with a risk of breast cancer, especially those with BRCA1 or BRCA2 gene mutations, have been shown to have a significantly reduced risk of developing breast cancer after prophylactic oophorectomy.[13] In addition, removal of the uterus in conjunction with prophylactic oophorectomy allows estrogen-only hormone replacement therapy (HRT) to be prescribed to aid the individual through their transition into surgical menopause, instead of estrogen-progestin HRT, which has a slightly increased risk of breast cancer as compared with post-menopausal non-hysterectomized women taking HRT.[14]

The Maine Women's Health Study of 1994 followed for 12 months time approximately 800 women with similar gynecological problems (pelvic pain, urinary incontinence due to uterine prolapse, severe endometriosis, excessive menstrual bleeding, large fibroids, painful intercourse), around half of whom had a hysterectomy and half of whom did not. The study found that a substantial number of those who had a hysterectomy had marked improvement in their symptoms following hysterectomy, as well as significant improvement in their overall physical and mental health one year out from their surgery. The study concluded that for those who have intractable gynecological problems that had not responded to non-surgical intervention, hysterectomy may be beneficial to their overall health and wellness.[15]

One of the conditions most cited by women who have complex pelvic and reproductive issues is pain[16]. This is particularly true for women who have other conditions that amplify pain, such as fibromyalgia and chronic fatigue syndrome.[citation needed] Removal of a condition that is causing pain has a dramatic effect on reducing the overall pain levels of a person with such disorders; for many women with such pain conditions, a hysterectomy is preferable to the continual pain which adds to the burden of their already painful lives, even though the loss of hormones post-surgery may initially contribute to an increase in the symptoms of their disorder[17].

Risks and side effects

The average onset age of menopause in those who underwent hysterectomy is 3.7 years earlier than average.[18] This has been suggested to be due to the disruption of blood supply to the ovaries after a hysterectomy. When the ovaries are also removed, blood estrogen levels fall, removing the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from a naturally-occurring menopausal state; the former is a sudden hormonal shock to the body that causes rapid onset of menopausal symptoms such as hot flashes, while the latter is a gradually occurring decrease of hormonal levels over a period of years with uterus intact and ovaries able to produce natural female hormones even after the cessation of menstrual periods.

When only the uterus is removed there is a three times greater risk of cardiovascular disease. If the ovaries are removed the risk is seven times greater. Several studies have found that osteoporosis (decrease in bone density) and increased risk of bone fractures are associated with hysterectomies.[19][20][21][22][23][24] This has been attributed to the modulatory effect of estrogen on calcium metabolism and the drop in serum estrogen levels after menopause can cause excessive loss of calcium leading to bone wasting.

Some women find their natural lubrication during sexual arousal is also reduced or eliminated. Those who experience uterine orgasm will not experience it if the uterus is removed. The vagina is shortened and made into a closed pocket and there is a loss of support to the bladder and bowel.[specify]

Those who have undergone a hysterectomy with both ovaries removed typically have reduced testosterone levels as compared to those left intact.[25] Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced bone density,[26] while increased testosterone levels in women are associated with a greater sense of sexual desire.[27] Hysterectomy has also been found to be associated with increased bladder function problems, such as urinary incontinence.[28] Hysterectomies have also been linked with higher rates of heart disease and weakened bones.[29]

Removal of the uterus without removing the ovaries can produce a situation that on rare occasions can result in ectopic pregnancy due to an undetected fertilization that had yet to descend into the uterus before surgery. Two cases have been identified and profiled in an issue of the Blackwell Journal of Obstetrics and Gynecology; over 20 other cases have been discussed in additional medical literature.[30]

Alternatives

Many alternatives to hysterectomy exist. Those with dysfunctional uterine bleeding (DUB) may be treated with endometrial ablation, which is an outpatient procedure in which the lining of the uterus is destroyed with heat. Endometrial ablation will greatly reduce or entirely eliminate monthly bleeding in ninety percent of patients with DUB. In addition, uterine fibroids may be removed and the uterus reconstructed. This procedure is called a "myomectomy." A myomectomy may be performed through an open incision or, in appropriate cases, laparoscopically.[31] Various other techniques (such as uterine artery embolization, Myolysis, radio frequency ablation, and Focused Ultrasound Surgery) kill the fibroid, and then leave it in place to be (usually only partially) reabsorbed by the body. Prolapse may also be corrected surgically without removal of the uterus.[32]

Menorrhagia (heavy or abnormal menstrual bleeding) may also be treated with the less invasive endometrial ablation.[33]

Uterine artery embolization is described as a minimally-invasive procedure to control bleeding in conditions like postpartum hemorrhage[34] and for treatment of uterine fibroids. It is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally-invasive procedures under radiological guidance. The radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter-like a piece of spaghetti) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (fluoroscopy). A mass of microspheres or polyvinyl alcohol (PVA) material (an embolus) is injected into the uterine arteries in order to block the flow of blood through those vessels. The embolic material then becomes permanently lodged in the uterine arteries making this an irreversible procedure. Significant adverse effects resulting from uterine artery embolization have been reported in the medical literature[1] [2]. Death from embolism, or septicemia (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure.[35] Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for administration of intravenous antibiotics. [36] Misembolization from microspheres or polyvinyl alcohol (PVA) particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body. [37] Ovarian damage resulting from embolic material migrating to the ovaries. Loss of ovarian function, infertility[38], and loss of orgasm. Failure of embolization surgery- continued fibroid growth, regrowth within four months. Menopause - iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels. [39] Post-Embolization Syndrome (PES) - characterized by acute and/or chronic pain, temperatures of up to 102 degrees, malaise, nausea, vomiting and severe night sweats. Foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus. Hysterectomy due to infection, pain or failure of embolization. [40] Severe, persistent pain, resulting in the need for morphine or synthetic narcotics. [41] Hematoma, blood clot at the incision site. Vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion (fibroids pushing out through the vagina), unsuccessful fibroid expulsion (fibroids trapped in the cervix causing infection and requiring surgical removal), life threatening allergic reaction to the contrast material, and uterine adhesions.

As part of transitioning from female-to-male

Main article: Sex reassignment surgery female-to-male

Hysterectomies with bilateral salpingo-oophorectomy are often performed either prior to or as a part of sex reassignment surgery for transmen. Some in the FTM community prefer to have this operation along with hormone replacement therapy in the early stages of their gender transition to avoid complications from heavy testosterone use while still having female-hormone-producing organs in place (e.g. uterine cancer and hormonally-induced coronary artery disease) or to remove as many sources of female sex hormones as possible in order to better "pass" during the real life experience portion of their transition.[42] Just as many, however, prefer to wait until they have full "bottom surgery" (removal of female sexual organs and construction of male-appearing external anatomy)[43] to avoid undergoing multiple separate operations.[44]

See also

References

  1. ^ Wu, JM, Wechter, ME, Geller, EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol 2007; 110:1091
  2. ^ "Are Hysterectomies Too Common?". TIME Magazine. 2006-07-01. Retrieved 2007-07-17.
  3. ^ "Facts about hysterectomy". Hysterectomy Alternatives and Aftereffects. Retrieved 2007-06-07.
  4. ^ "Female Anatomy: the Functions of Female Organs". Hysterectomy Alternatives and Aftereffects. Retrieved 2007-06-07.
  5. ^ "Hysterectomy Educational Resources & Services". Hysterectomy Alternatives and Consequences. Retrieved 2009-02-13.
  6. ^ a b "Hysterectomy". National Women’s Health Information Center. 2006-07-01. Retrieved 2007-06-07.
  7. ^ Gautam Khastgir, John Studd. Hysterectomy and HRT. p. 3.
  8. ^ Roopnarinesingh R, Fay L, McKenna P (2003). "A 27-year review of obstetric hysterectomy". Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 23 (3): 252–4. PMID 12850853.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Walid MS, Heaton RL. (2008). "Laparoscopic extirpation of a 3-kg uterus". Arch Gynecol Obstet. 279: 607. doi:10.1007/s00404-008-0827-9. ISSN 1432-0711. PMID 19011884.
  10. ^ Walid MS, Heaton RL. (2009). "Can laparoscopic hysterectomy replace abdominal hysterectomy in benign gynecological surgery?". ACOG 57th Annual Clinical Meeting, Chicago. doi:10.3252/pso.eu.57acog.2009.
  11. ^ Lethaby, A, Ivanova, V, Johnson, NP. Total versus subtotal hysterectomy for benign gynecological conditions. Cochrane Database Syst Rev 2006; CD004993
  12. ^ Thakar, R, Ayers, S, Clarkson, P, Stanton, S, et aI. Outcomes after Total versus Subtotal abdominal hysterectomy. N Engl J Med 2002; 347;1318
  13. ^ Rebbeck TR, Lynch HT, Neuhausen SL; et al. (2002). "Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations". New England Journal of Medicine. 346 (21): 1616–22. doi:10.1056/NEJMoa012158. PMID 12023993. {{cite journal}}: |access-date= requires |url= (help); Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  14. ^ DeNoon DJ (2006-04-11). "Estrogen HRT: No Breast Cancer Risk". Retrieved 2007-06-07.
  15. ^ Parker WH. "Hysterectomy--A Gynecologist's Second Opinion". Retrieved 2007-06-07.
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  20. ^ van der Voort DJ, Geusens PP, Dinant GJ (2001). "Risk factors for osteoporosis related to their outcome: fractures". Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 12 (8): 630–8. PMID 11580076. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
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  23. ^ Hreshchyshyn MM, Hopkins A, Zylstra S, Anbar M (1988). "Effects of natural menopause, hysterectomy, and oophorectomy on lumbar spine and femoral neck bone densities". Obstetrics and gynecology. 72 (4): 631–8. PMID 3419740. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
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  25. ^ Laughlin GA, Barrett-Connor E, Kritz-Silverstein D, von Mühlen D (2000). "Hysterectomy, oophorectomy, and endogenous sex hormone levels in older women: the Rancho Bernardo Study". J. Clin. Endocrinol. Metab. 85 (2): 645–51. doi:10.1210/jc.85.2.645. PMID 10690870. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
  26. ^ Jassal SK, Barrett-Connor E, Edelstein SL (1995). "Low bioavailable testosterone levels predict future height loss in postmenopausal women". J. Bone Miner. Res. 10 (4): 650–4. PMID 7610937. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
  27. ^ Segraves R, Woodard T (2006). "Female hypoactive sexual desire disorder: History and current status". The journal of sexual medicine. 3 (3): 408–18. doi:10.1111/j.1743-6109.2006.00246.x. PMID 16681466. {{cite journal}}: |access-date= requires |url= (help)
  28. ^ Minassian; et al. (2003). "Urinary incontinence as a worldwide problem". Int J Gynaecol Obstet. 82 (3): 327-38. doi:10.1016/S0020-7292(03)00220-0. PMID 14499979. {{cite journal}}: Explicit use of et al. in: |author= (help)
  29. ^ McPherson K, Herbert A, Judge A; et al. (2005). "Self-reported bladder function five years post-hysterectomy". Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 25 (5): 469–75. doi:10.1080/01443610500235170. PMID 16183583. {{cite journal}}: |access-date= requires |url= (help); Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  30. ^ "Early Ectopic Pregnancy after Vaginal Hysterectomy", P.S. Cocks, published August 23, 2005; retrieved September 7, 2007.
  31. ^ William H. Parker, Rachel L. Parker, "A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health," 2002, Plume; Rev ed., 89-92, 105-150.
  32. ^ Frederick R. Jelovsek, "Having Prolapse, Cystocele and Rectocele Fixed Without Hysterectomy"
  33. ^ Health.com: 5 operations you don't want to get - and what to do instead
  34. ^ Management of severe postpartum haemorrhage by uterine artery embolization
  35. ^ Vashisht A, Studd JW, Carey AH (2000). "Fibroid Embolisation: A Technique Not Without Significant Complications". British Jounral of Obstetrics & Gynecology. 107: 1166–1170.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  36. ^ de Block S, de Bries C, Prinssen HM (2003). "Fatal Sepss after Uterine Artery Embolization with Microspheres". Journal of Vascular and Interventional Radiology. 14 (6): 779–783.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  37. ^ Dietz DM, Stahfeld KR, Bansal SK (2004). "Buttock Necrosis After Uterine Artery Embolization". Obstetrics & Gynecology. 104: 1159–1161.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  38. ^ Robson S, Wilson K, David M (1999). "Pelvic Sepsis Complicating Embolization of a Uterine Fibroid". The Australian and New Zealand Journal of Obstetrics and Gynaecology. 39: 516–517. doi:10.1111/j.1479-828X.1999.tb03150.x.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  39. ^ Walker WJ, Pelage JP, Sutton C (2002). "Fibroid Embolization". Clinical Radiology. 57: 325–331. doi:10.1053/crad.2002.0945.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  40. ^ Common AA, Mocarski E, Kolin A (2001). "Leiomyosarcoma". Journal of Vascular & Interventional Radiology. 12: 1449–1452.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  41. ^ Soulen MC, Fairman RM, Baum R (2000). "Embolization of the Internal Iliac Artery: Still More to Learn". Journal of Vascular & Interventional Radiology. 11: 543–545. doi:10.1016/S1051-0443(07)61604-2.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  42. ^ Hudson's FTM Resource Guide, "Why Have A Hysterectomy?", retrieved May 8, 2007.
  43. ^ Hudson's FTM Resource Guide, "FTM Gender Reassignment Surgery, retrieved May 9, 2007.
  44. ^ Hudson's FTM Resource Guide, "Types of Hysterectomy", retrieved May 8, 2007.
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