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Post-op: Getting back into shape

One of the things women in the later stages of postop recovery often ask on our message list is when and how they can resume or begin an exercise program to really get back into shape. That's a very good question because we definitely lose conditioning when we're inactive during early recovery and yet we need to return to physical activity in a manner that does not damage our healing.

Sadly, many surgeons, unless they have a personal interest in fitness, are not the best individuals to advise us. They will tell us to gradually increase our activity and avoid putting too much stress on our abdominals, but beyond that, unless they practice a sport themselves, they may not know what does or does not particularly require midbody strength.

For the guys and the women who live with them: hysterectomies, sexuality and old wives' tales

A hysterectomy is a daunting prospect for many men, and there are several concerns that men whose partners are facing a hyst typically have.

For some men, it's the helplessness in the face of a partner having such a severe health problem that she requires major surgery.  In American and much of other Western society, men are taught to be problem solvers, such that problems they cannot provide a solution to, situations where their encouragement and support are all they can bring to us, are very highly frustrating, and that frustration may be expressed as either unfocused anger or withdrawal of contact.

As women, we need to be aware that this response is normal and does not necessarily mean rejection of us as a partner. It means that where we can redirect the men in our lives as to how, specifically, they can help us with preparation and recovery, we may find they are more gracefully able to deal with their worries than if we silently wait for them to make a gesture of that help. And for men, it means that they need to reach for comfort with the idea that this isn't a problem they can solve, but a situation in which their support can ease that problem and truly provide what their women are needing.

 For other men, there is a concern over what a marriage may most mean to them: a ready, continuous supply of sex. Whether the relationship is a partnership or a religious one founded on the man owning the rights to the woman's body, many men are ill-equipped to deal with the notion that their spouses will be unavailable sexually to them for a period that the spouse, not they, will determine. For those whose religion only permits of procreative sex, there's that whole issue of what becomes of it when procreation is surgically eliminated. And when they tap into that delightful pool of Old Wives Tales that surround hysts and menopause, they can easily convince themselves that a hyst means the end of their (marital) sex life.

So there are some valid concerns here. Let's look at what is really involved.

How do they do that?

The Survivor's Guide to Surgical Menopause has tipped us to two interesting pages that give operative procedure details on:

• Salpingo-Oopherectomy (Fallopian Tube and Ovary Removal)
• Total Abdominal Hysterectomy (Uterus Removal)

DO NOT GO TO THERE IF YOU ARE SQUEAMISH. While there are no illustrations or photos, the terminology is medical and describes, layer by layer, each step involved.

It's also important that you understand that these are for "open" procedures. That means that they are the conventional, make-an-incision surgeries and that laparoscopic or vaginal procedures involve other steps. Other procedure variations don't seem to be posted to the site yet. And, of course, if you're having extra work done, like a recto/cystocele repair or endo removal, that will also change the exact method used.

Still, if you're wondering "how do they do that?" or why it takes some time to heal, this might help fill in those blanks.

The Survivor's Guide bookmark account has other useful and interesting stuff about surgeries, too--go check out tags like "surgery" and "hysterectomy."

Transfusions as a potential blood clotting risk for women

We give a lot of attention to some forms of blood supply risk when we consent to a transfusion, but a newly-released study contains an additional factor we may want to discuss with our surgeons when we are talking about having a transfusion either before or after we have a hysterectomy.

In this study, researchers found that

Transfusion was associated with an increase in the odds of developing VTE in women (odds ratio, 1.8; 95% confidence interval, 1.2-2.6) but not in men (odds ratio, 0.9; 95% confidence interval, 0.5-1.9). In the absence of transfusion, female compared with male sex was not associated with an increased risk of VTE (odds ratio, 1.2; 95% confidence interval, 0.8-1.7).

What does this mean for us? We already know that a hyst (or any abdominal surgery) raises our risk of developing a postop blood clot, and that's why our doctors usually prescribe elastic stockings and/or pneumatic hose as well as anticoagulant therapy as a regular part of our immediate postop care.

But it could be that women who have a transfusion before surgery, perhaps to correct anemia from excessive bleeding, as well as those who require transfusion to compensate for blood lost during the operation, may be incurring an extra risk factor. And since blood clots are a very serious health threat as well as a reason why future HRT use may be forbidden, this is something to take into account when making the decision to permit a transfusion.

It's not necessarily a reason to turn one down, of course: sometimes blood loss can be life-threatening and there may be few other options for dealing with the situation. If a doctor knows that this elevated risk exists, there may well be specific measures to do with both detection and prevention that can be put in place that help reduce this added risk exposure. It's not a simple or straightforward decision, so it needs to result from a discussion with your own surgeon or doctor. But this new information is definitely something to be sure they've heard of and are taking into account in how they manage your overall treatment.

If you want to share the content of this study, it is:

Association Between Venous Thromboembolism and Perioperative Allogeneic Transfusion

Kent R. Nilsson, MD, MA; Sean M. Berenholtz, MD, MHS; Elizabeth Garrett-Mayer, PhD; Todd Dorman, MD; Michael J. Klag, MD, MPH; Peter J. Pronovost, MD, PhD

Arch Surg. 2007;142:126-132.

Post-op: bowel activity

When bowels are handled and disturbed, as happens during a hysterectomy or any other abdominal surgery, they shut down activity for a period of time. This is why women are often surprised to find that they are limited to only liquids for the first day or so after their hyst: this gives the bowels a rest and doesn't overwhelm them before they are ready to resume activity. Eating too soon will only cause the undigestible food to back up, producing vomiting that is not a real appealing prospect for anyone who has just had abdominal surgery--not a pleasant thing to contemplate.

How do we know that our bowels are returning to function? Our caregivers can hear the sounds of sloshing when they listen with a stethescope, and before long, we can feel or hear the passage of gas. This is such an important recovery milestone that it is one of the criteria for discharge: we have to actually pass gas to demonstrate that our bowels are capable of taking up their digestive functions again.

For many women, this signals the most frustrating and uncomfortable part of recovery, however: dealing with gas and constipation. Narcotic drugs, low physical activity levels, a low-fiber diet, not drinking enough, and, for those who are users, lack of caffeine all contribute to impaired bowel motility and enhance these gas and constipation effects.

But those causes also provide us with a good set of things we can do to limit these unpleasant symptoms of our bowels recovering. 

Psychological Aspects of Pelvic Surgery

One of the things that is the most daunting about a hysterectomy is that for many of us, it represents the first major surgical experience of our lives. We don't know what to expect, and when we are facing a surgery that can have so many profound effects on our lives, our health and even our own self-image, that can all add up to a terrifying prospect.

While we used to be able to turn to our doctors for assurances of what we would be facing and how it would affect us, the truth is that the current model of medical practice often speaks more to the needs of insurance companies and malpractice lawyers than patients. We may see test results and permit forms, scheduling clerks and bland, lowest-common-denominator generic informational pamphlets, but we may hardly have a chance to meet the person who will hold our life and wellbeing in their hands for a matter of hours.

But how do we manage to gain the information we need if not from our surgeons? Most of us don't even begin to know the kinds of questions we should ask because the whole situation is so distant from our normal lives. I hope that as you've read this website you've gained a clearer impression of what to expect, so that you can begin to "try on" how surgery might fit in your life and speculate on what to expect, determine what specific things you need to ask about.

I'd like to add to this by pointing to a continuing education module for doctors that has recently been posted on medscape (free registration will be required to access it): Psychological Aspects of Pelvic Surgery. As the article notes:

This article briefly considers the gynecologic surgeon's preoperative responsibilities, special needs of various patient populations, and care during and after hospitalization. The aim is to encourage gynecologists to recognize that although a gynecologic operation may be an ordinary procedure for the surgeon, it is a unique experience for the patient. Her sense of well-being and health may be threatened; she may lose control of her body for some period of time; and she may perceive the planned procedure as temporarily or permanently affecting her sexual identity. As once complicated procedures become routine, the gynecologic surgeon risks losing perspective about the impact of surgery on the life of the individual woman.

Why would you want to read an article that tells your surgeon how to meet your preop needs? Because this helps you know what your doctor could tell you, and with that information on what constitutes good care, you are better prepared to directly ask for what you need. Now you don't need to wonder if you are "being a bother" by "wasting" his precious time with questions: it's his job to be available and answering questions is exactly the opposite of bother. Now you don't need to feel that you are especially clueless for not knowing all these things, since according to this article, all women in this position need this kind of care from their surgeons. If we know what he should be doing for us, we're better prepared to make sure we get it. It's as simple as that.