Indications for hysterectomy

1. Benign gynecological conditions

• Symptomatic uterine fibroids (leiomyomas) causing heavy menstrual bleeding, pressure symptoms, pain, anemia, or a large rapidly enlarging uterus when fertility preservation is not desired.
• Abnormal uterine bleeding that persists despite appropriate medical therapy or less invasive procedures, after excluding malignancy.
• Adenomyosis causing refractory heavy bleeding and pelvic pain.
• Endometriosis, especially severe disease with persistent pain or bleeding after conservative medical and surgical treatments.
• Chronic pelvic pain clearly attributable to uterine disease, after careful assessment for non-gynecological causes.
• Uterine prolapse or other pelvic organ prolapse, when definitive surgical repair is indicated.
• Persistent/recurrent pelvic infection, such as a tubo-ovarian abscess not responding to antibiotics and drainage, in selected situations.

2. Premalignant disease

• Atypical endometrial hyperplasia / endometrial intraepithelial neoplasia (EIN), particularly when childbearing is complete or reliable conservative follow-up is unsuitable.
• Persistent or recurrent high-grade cervical precancer when excisional/conservative management is unsuccessful or inappropriate.

3. Malignancy or strong suspicion of malignancy

• Endometrial carcinoma
• Cervical cancer - often requires radical hysterectomy in selected early-stage cases.
• Uterine sarcoma or suspected uterine malignancy.
• Selected cases of ovarian, fallopian tube, or other pelvic cancers as part of cytoreductive surgery.

4. Obstetric emergencies

• Uncontrollable postpartum hemorrhage unresponsive to uterotonics, tamponade, embolization, and conservative surgery.
• Placenta accreta spectrum, especially placenta percreta or severe accreta, often managed by planned cesarean hysterectomy.
• Uterine rupture with uncontrollable bleeding or irreparable uterine damage.
• Severe uterine sepsis or necrosis in exceptional circumstances.

Key principle