The cervix can be surgically removed, and roughly 600,000 hysterectomies are performed each year in the United States alone, making it one of the most common gynecological surgeries. Whether the cervix comes out during that procedure depends on the type of hysterectomy and the reason for surgery. Total hysterectomy removes the uterus and cervix together, while subtotal (also called supracervical) hysterectomy removes the uterus but leaves the cervix in place. A third option, called trachelectomy, removes only the cervix while preserving the uterus. The choice among these depends on what’s being treated, whether you want to preserve fertility, and how you and your surgeon weigh a set of tradeoffs that the research has mapped out in detail.
Why the Cervix Gets Removed
The most straightforward reason is cervical cancer. When cancer is found in the cervix itself, removing it is often non-negotiable. For early-stage cervical cancer in people who want to preserve fertility, a radical trachelectomy removes the cervix and surrounding tissue while leaving the uterus intact, an approach first described by the surgeon Dargent and now performed through both open and robotic techniques.1PubMed Central. Cervical Cancer and Fertility-Sparing Treatment For more advanced disease or when fertility isn’t a concern, total hysterectomy with cervix removal is standard.
Precancerous cervical changes, called cervical intraepithelial neoplasia (CIN), are usually treated more conservatively. Italian gynecological guidelines, for instance, classify hysterectomy as unacceptable for high-grade precancerous lesions except in limited cases where less aggressive approaches aren’t feasible.2PubMed Central. Hysterectomy for cervical intraepithelial neoplasia: A retrospective observational multi‐institutional study The preferred treatments for precancerous changes are excision procedures like loop electrosurgical excision (LEEP) or cold-knife conization, which remove only a portion of cervical tissue. These procedures have similar residual disease and recurrence rates, though LEEP tends to leave positive margins more often.3PubMed Central. Comparison of Cold-Knife Conization versus Loop Electrosurgical Excision for Cervical Adenocarcinoma In Situ (ACIS): A Systematic Review and Meta-Analysis
Beyond cancer, people have the cervix removed for several other reasons. Pelvic organ prolapse with cervical elongation sometimes calls for vaginal hysterectomy with cervix removal, particularly when the cervix has descended significantly.4PubMed Central. Vaginal Hysterectomy Management of Pelvic Organ Prolapse with Cervical Elongation: A Case Report Gender-affirming hysterectomy for transgender men and nonbinary people assigned female at birth is another growing indication, where total hysterectomy including cervix removal eliminates the need for future cervical screening.5PubMed. Surgical outcomes after gender-affirming hysterectomies: a consecutive case series of 72 patients Heavy or painful periods, endometriosis, and fibroids that haven’t responded to other treatments round out the common reasons.
Total Versus Subtotal Hysterectomy
The debate over whether to take the cervix during hysterectomy has swung back and forth for decades. Until the late 1930s, leaving the cervix behind was standard practice because removing it carried a high risk of deadly infection. Once antibiotics and better surgical technique arrived, total hysterectomy became the norm in the U.S. and U.K., partly because removing the cervix eliminated the risk of cervical cancer entirely.6Journal of Minimally Invasive Gynecology. Past, Present, and Future of Hysterectomy That reasoning has been somewhat eroded by modern Pap smear screening, colposcopy, and outpatient treatment for precancerous changes, which together can catch and treat cervical problems before they become cancer.7Obstetrics & Gynecology. Supracervical hysterectomy: … A time for reappraisal With the rise of laparoscopic surgery, many surgeons have returned to the subtotal approach because it’s technically simpler through a scope.
In terms of short-term surgical outcomes, keeping the cervix has modest advantages. A Cochrane review found that subtotal hysterectomy results in less post-operative fever and urinary retention compared to total hysterectomy, and takes about 11 fewer minutes in the operating room with roughly 57 mL less blood loss.8PubMed Central. Total versus subtotal hysterectomy for benign gynaecological conditions A separate meta-analysis found similar results, with hospital stays about half a day shorter for the subtotal group.9Clinical Therapeutics. Total Versus Subtotal Hysterectomy: Systematic Review and Meta-analysis of Intraoperative Outcomes and Postoperative Short-term Events These differences are real but small enough that they don’t strongly favor one approach over the other by themselves.
The tradeoff is cyclical vaginal bleeding. When the cervix stays, a thin layer of endometrial tissue sometimes remains attached to it, and hormonal cycles can cause light bleeding that mimics a period. A large randomized trial found this happened in about 7% of women after subtotal hysterectomy.10PubMed. Outcomes after total versus subtotal abdominal hysterectomy The meta-analysis data suggest it could be even higher, with one analysis reporting cyclical bleeding in roughly 14% of the subtotal group versus just over 1% after total hysterectomy.9Clinical Therapeutics. Total Versus Subtotal Hysterectomy: Systematic Review and Meta-analysis of Intraoperative Outcomes and Postoperative Short-term Events For many people, this ongoing spotting defeats one of the main purposes of the surgery.
What Happens to Sexual Function
Concerns about losing sexual sensation are one of the most common reasons people hesitate about cervix removal, and the worry isn’t baseless. An online survey found that over 16% of respondents reported experiencing pleasurable sexual sensations from the cervix, and people who had undergone cervical procedures reported lower rates of pleasure across multiple genital areas, along with decreased desire, arousal, and lubrication.11The Journal of Sexual Medicine. The contribution of the cervix to sexual response: an online survey study That finding understandably raises alarm.
But when you look at head-to-head comparisons of people who had their cervix removed versus those who kept it, the picture levels out. A systematic review and meta-analysis comparing total and subtotal hysterectomy found no meaningful difference in overall sexual function or sexual pain between the two groups. Subtotal hysterectomy was associated with some improvement in overall sexual function scores, but total hysterectomy showed improvement in sexual pain scores, and the differences between the two were not statistically significant.12The Journal of Sexual Medicine. Hysterectomy and sexual function: a systematic review and meta-analysis A study specifically asking women whether cervix removal or retention affected their sexual satisfaction found no difference at around 15 months of follow-up.13European Journal of Obstetrics & Gynecology and Reproductive Biology. Cervix removal at the time of hysterectomy: factors affecting patients’ choice and effect on subsequent sexual function
How do you square those findings? One explanation is that the cervix does contribute to sexual sensation for some people, but removing a condition that causes pain, heavy bleeding, or constant discomfort tends to improve the overall sexual experience enough to offset any lost cervical sensation. Many people undergoing hysterectomy were avoiding sex beforehand because of symptoms, so the post-surgical improvement in quality of life tends to overshadow anatomical changes.
Pelvic Floor and Prolapse Risk
The cervix sits at the junction where several ligaments anchor the pelvic organs. The nerve fibers running through and around the lower uterosacral ligaments connect to the cervix and uterus.14American Journal of Obstetrics and Gynecology. Paracervical uterine denervation by transection of the cervical plexus for the relief of dysmenorrhea Removing the cervix means disrupting these attachments, which raises a theoretical concern about pelvic organ prolapse down the road.
A nationwide cohort study found that hysterectomy overall was associated with a roughly 40% increased risk of prolapse requiring surgery or pessary use. Notably, total hysterectomy carried a statistically significant increase in prolapse risk, while subtotal hysterectomy did not, though the subtotal group was smaller, making the comparison less definitive.15Maturitas. Risk of pelvic organ prolapse after hysterectomy for benign conditions: A nationwide cohort study A 10-year Finnish follow-up found that women who had laparoscopic-assisted vaginal hysterectomy had about three times the risk of prolapse surgery compared to those who had abdominal hysterectomy, and about four times the risk specifically for vaginal vault prolapse.16PubMed Central. Pelvic organ prolapse after hysterectomy: A 10‐year national follow‐up study Still, the absolute numbers were low: about 1.6% of women in that cohort needed prolapse surgery over 10 years.
For people undergoing cervix removal as part of cervical cancer treatment, the risk factors for pelvic floor problems are somewhat different. A study of cervical cancer patients found that being 45 or older, having a urinary catheter in place for a week or more, experiencing constipation after surgery, and having delivered two or more babies were all independent risk factors for pelvic floor dysfunction.17PubMed Central. Risk factors for postoperative pelvic floor dysfunction in patients with cervical cancer: evidences for management strategies
What Happens When You Keep the Cervix
Leaving the cervix in place avoids some of the issues above, but it creates its own set of long-term considerations. The retained cervical stump is still cervical tissue, and cervical tissue can still develop problems. Fibroids are the most commonly diagnosed lesions in excised cervical stumps, and the stump can also develop dysplasia or, rarely, cancer.18PubMed Central. Cervical stump leiomyomata after supracervical hysterectomy; a case report with review of literature Among people who had a subtotal hysterectomy, roughly 1% to 3% develop cervical stump cancer, which accounts for about 3% to 9% of all cervical cancers.19Clinical and Experimental Obstetrics & Gynecology. Cervical Stump Cancer after Subtotal Hysterectomy: A Retrospective Research of 127 Cases from China and Literature Review
A retrospective analysis of secondary cervical stump removals found three main reasons patients came back for a second procedure: prolapse of the stump (about 31%), spotting (about 19%), and cervical dysplasia (about 18%). Some patients needed the stump removed because of unexpected findings on the original pathology report, while others developed new gynecological cancers more than five years after the initial subtotal hysterectomy.20PubMed Central. Retrospective analysis of secondary resection of the cervical stump after subtotal hysterectomy: why and when? Removing a retained cervical stump is technically more challenging than the original surgery because of scar tissue, so a second operation is not a trivial undertaking.
People who keep their cervix also need to continue regular cervical screening. This is a point that sometimes gets lost after surgery. If you had a subtotal hysterectomy for fibroids, you still have a cervix and still need Pap smears. If you had a total hysterectomy for a benign condition and the cervix was removed, there is insufficient evidence to recommend routine vaginal cuff screening afterward.21JAMA. Effectiveness of Vaginal Papanicolaou Smear Screening After Total Hysterectomy for Benign Disease That distinction matters because unnecessary screening generates false positives and anxiety, while missed screening in someone who still has a cervix risks letting problems develop undetected.
Fertility After Trachelectomy
For people with early-stage cervical cancer who want to have children, radical trachelectomy is the fertility-sparing option. The cervix is removed along with surrounding parametrial tissue, but the uterus stays. A cerclage (a stitch that acts like a purse string) is placed where the cervix used to be, creating a new barrier between the uterus and the vagina.
Pregnancy after trachelectomy is possible but carries elevated risk. One study following patients after radical trachelectomy found that among those who actively tried to conceive, about 54% achieved a pregnancy. Just over half of those pregnancies were spontaneous, while the rest required fertility treatment. The miscarriage rate was notable, with 5 first-trimester losses out of 20 pregnancies, but 70% of pregnancies resulted in live births.22PubMed Central. Reproductive counseling and pregnancy outcomes after radical trachelectomy for early stage cervical cancer Preterm delivery is the major concern, since the cervix normally acts as a mechanical barrier keeping the pregnancy in place. The cerclage substitutes for this, but it’s not a perfect replacement, and pregnancies after trachelectomy tend to deliver earlier than average.
Vaginal Cuff Complications
When the cervix is removed during total hysterectomy, the top of the vagina is stitched closed to create what surgeons call the vaginal cuff. This stitched closure usually heals without incident, but it can occasionally separate, a complication called vaginal cuff dehiscence. In one large institutional study, cuff dehiscence occurred in just under 1% of total hysterectomies. Both laparoscopic and robotic approaches were associated with substantially higher odds of dehiscence compared to open surgery, though continuous suturing of the cuff was protective.23PubMed Central. Vaginal cuff dehiscence: risk factors and associated morbidities
In rare cases, cuff dehiscence can happen years or even decades after the original surgery, sometimes with bowel herniation through the vaginal opening.24PubMed Central. Vaginal Cuff Dehiscence Following Remote Hysterectomy: An Unusual Case of Bowel Evisceration This is genuinely uncommon, but it’s the kind of surgical complication that doesn’t exist at all if the cervix was left in place, since the vaginal canal remains structurally intact. That said, successful repair of cuff dehiscence is well-documented, and many patients recover fully even from dramatic presentations.25PubMed Central. Vaginal cuff dehiscence and evisceration 11 years after a radical hysterectomy: A case report
Quality of Life and Psychological Effects
For most people, hysterectomy improves quality of life regardless of whether the cervix is removed. A randomized trial comparing total and subtotal hysterectomy found improvements in six out of eight quality-of-life domains after surgery, with no significant difference between the two approaches. Psychological symptoms, including anxiety and depression, improved after both types of operation.26PubMed. Hysterectomy improves quality of life and decreases psychiatric symptoms: a prospective and randomised comparison of total versus subtotal hysterectomy Patient satisfaction scores likewise show no meaningful difference between cervix-removing and cervix-sparing approaches, whether looking at pain, wellbeing, or painful intercourse.27PubMed. Is cervix removal associated with patient-centered outcomes of pain, dyspareunia, well-being and satisfaction after laparoscopic hysterectomy?
That said, the psychological dimension deserves honest attention. Research on body image after hysterectomy has found that women commonly report perceiving their body as different, feeling “hollow,” or feeling alienated from their own bodies after the surgery, and that greater changes in body perception correlate with higher rates of depression.28PubMed. Effect of psychological care given to the women who underwent hysterectomy before and after the surgery on depressive symptoms, anxiety and the body image levels These feelings don’t appear to depend strongly on whether the cervix was or wasn’t removed. They seem tied more to the loss of the uterus itself and what it represents, including fertility, femininity, and normalcy. Psychological support before and after surgery has been shown to help, and the fact that quality of life objectively improves for most people doesn’t mean the emotional adjustment is automatic or easy.
The Vaginal Microbiome After Surgery
An aspect of cervix removal that rarely makes it into pre-surgical conversations is its effect on the local microbial environment. The cervix produces mucus that helps maintain the vaginal pH and supports the growth of protective Lactobacillus bacteria. After total hysterectomy, the shortened vaginal canal and absence of cervical mucus production change the local ecology. Research has linked a vaginal microbiome low in Lactobacillus and high in bacteria like Prevotella and Gardnerella to post-surgical urinary tract infections.29Nature. Preoperative vaginal microbiome as a predictor of postoperative urinary tract infection This doesn’t mean cervix removal causes chronic infections, but it does mean the vaginal environment shifts, and that shift may make some people more susceptible to urinary or vaginal infections in the months following surgery. Whether these changes persist long-term is still being studied, and for most people the effect is manageable. But if you’ve historically been prone to vaginal or urinary infections, it’s worth discussing with your surgeon as part of the decision-making process.