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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.

Physical Therapy

In the physical therapy department of the hospital, however, are folks who are trained in exactly this: safely ramping up physical activity. Not every woman will need their help, but women with particularly extensive surgeries, multiple repairs, those who were in especially bad shape pre-op, or those who suffered surgical complications may well benefit from their expertise in getting started back on the track to better healthy activity.

Your surgeon may not offer, but if you ask he is likely to be perfectly willing to write a prescription for at least a short period of physical therapy to get you started. With a prescription, most insurance programs will cover these costs (but, obviously, check your own program's limitations beforehand).

So if you feel you are particularly challenged in terms of getting started and knowing how to move forward in regaining strength and endurance, this may well be the sort of expert help to seek out.

Early recovery activity

We may not think of it as exercise, but many of the things we do early on are in fact just that.

Our first exercise begins the day of surgery itself when we sit and then stand up for the first time. We should take the time to center ourselves, get steady on our feet, and then stand tall. Yes, it will feel as though our guts are going to fall out on the floor, but no, they really won't. We may need to support our bellies with a folded towel or pillow for security until we learn to trust our sutures, and that's fine. But it's important to stand up fully straight so those muscles don't shorten and our scars contract.

Each time we get up, those early days, we should take a few moments before walking to stand tall and start to make a conscious effect to support our abdominal contents with our belly muscles. Go ahead: suck them in. I don't mean try to flatten the swelling or pull so hard you have to hold your breath, but we can gently begin to tension them and remind them do their normal work. This is good, and it's not going to tear anything.

Walking is our first and most important exercise, and we begin that the very day we have surgery. Every day we should walk a little bit more. Every day, we should walk a little longer, a little further, a little more often.

As we do it, that walking should be gentle on our bellies--we don't need to gallop along with our bellies flopping about; that only causes damage. And for every walk we take, we need enough rest afterward so that we don't feel the effects of it. Many small walks are the way to build up to longer walks.

When we can't easily get our walking done in a gentle and protected fashion indoors, we're ready to go outside or to extend our walks using a treadmill. Working on a flat treadmill is best at the beginning, just because elevating it puts greater stress on the abdominals from the stepping-up motion.

Note, please, that I'm not giving you firm guidelines on walking so many blocks by such and such a week of recovery. In fact, we'll all vary on what the right amount of exercise is for our own bodies. Some of us were in great physical shape pre-op and have those muscles ready to go; some of us could barely stagger from bed to bathroom even before surgery and may not have walked a block for years. Some of us have simple surgeries and our bodies heal well and quickly; some of us had complicated surgeries, multiple repairs, and may have suffered poor health for years. Because of these many personal factors, we'll each progress at a different rate.

What matters is not the numbers but that we each progress in some fashion that challenges us but does not tire us beyond our ability to rest back to a good energy level. This metric will guide us throughout our recovery: we should do however much we can bounce back from with our next rest period. If we don't feel fatigue at the end of our exercise, we're ready to increase. If after a nap or a night's sleep we're still tired, we've done too much and should hold there (or maybe back off a tad) until we are more fully rested.

Other early exercise

In the first postop two or three weeks, we're discouraged from doing stretching exercises that put tension on our operative area. At the same time, in this period it's critical that we not walk around hunched over grasping our bellies and suffer poor posture and shortening of our scars. The gentle exercise of lying flat on the back on a firm surface and fully stretching out in a relaxed way, not actually pulling the tissues, is a very good one for this period.

While it's possible to lie on furniture on your back, this is rarely firm enough to let us really flatten our backs out well. For those who can manage it, the floor provides a better surface for this exercise.

And yes, it's difficult getting up and down from the floor. The best tip I've seen for this is to use the top of stairs: climb up (carefully at first!) until you are a few steps from the top and then sit on the top. From there, you should be able to slide and lie back onto the floor, using your arms to ease down onto your side. To get up again, reverse the process, sliding towards the stairs, feet first, until you can "walk" your feet down the stairs and stand up, using the rail to help with balance and steadiness. In the first week or at least the first few times you do this, be sure to have someone standing by to help steady you if you feel wobbly.

Getting that belly flat

Post-op swelling happens to all of us. There's a good reason why: just as swelling occurs with a twisted ankle to provide immobility and protection, so fluid collects in our bellies to help immobilize the contents and protect from injury while healing. And indeed, just as our twisted ankle may swell with use for months later, long after it looks to us to be healed, so belly swelling will continue to celebrate excessive activity.

What's important to remember about this is that this is fluid doing this, not muscular weakness. We cannot exercise this away. Only time and healing will reduce this.

How long? Constant swelling will diminish after the first few months but we'll swell with activity for six months or more, depending upon just how much surgery we've had. For example, returning to work often marks a notable resumption of belly swelling that takes a week or more to regain the level it had towards the end of our recuperation period. We need to remember this and dress with this expansion room in mind so we don't end up throttled halfway through our day. By six to eight months post-op, though, this becomes much less common and we gradually see it disappear.

At the same time, women who have had abdominal incisions are aware of lost muscle tone. "When can I start doing situps?" they ask on message lists. In fact, that's not something to do for a few months. But that doesn't mean that your belly isn't working at all.

From the day of surgery, we're resuming belly toning. We use those muscles to sit up and to stand up straight. That walking I've been talking about? Totally uses belly muscles. Walking up stairs or on an inclined treatmill? Once we're cleared to put stress on those belly muscles by our surgeons (ask at your two-week checkup), those things that look like they're using our legs actually also involve our abdominals and are the next step in toning back up.

We will also, as we resume our normal household activities, be regaining belly tone. Some of the things we're forbidden early on, like loading a dishwasher or doing the laundry, involve bending and twisting and are forbidden then exactly because they do work our bellies. Once we're cleared to do them, then, they are providing an early workout for those muscles. We tend to think of chores as neutral things that don't count as exercise, but as we recover, they most certainly are just that and should be treated as such.

Other exercises

The point where we transition from just chores and normal tasks, like walking up the stairs, to a more structured workout program happens when our bodies are ready for further challenge. We are ready to to build not only muscle tone, but regain cardiovascular and muscle endurance. Walking, even at a more brisk pace, doesn't demand enough effort any more.

At the same time, we still need to limit the jouncing and shear motions to our abdominal contents. For this reason, running and bicycling are not considered good early reconditioning activities. Running is the queen of belly bouncing and pedaling a bike, whether indoors or out, requires a great deal of abdominal muscular effort. They are best left for a few months further along in our recovery, when we are less likely to disrupt internal healing. What we need now is to use our legs and arms and cardiovascular system, not jounce our midsection.

For that reason, swimming is an excellent exercise once our incisions are closed: it supports us from that jouncing and yet allows us to work the rest of the body very hard.

My doctor gave me permission to swim after my two-weeks check, and said only to take it easy on my midbody. I was in the habit of swimming laps for an hour three times a week before surgery, and when I first got back in the pool at about 2 1/2 weeks (when I was able to walk an easy mile without strain), I swam very gently for about 10 minutes and found that my knees were so wobbly that it took me another 5 minutes to climb out of the pool. I found that kicking was much more difficult than I expected (again, it uses the abdominals) so the kickboard was out, but that a gentle crawl or backstroke worked fine for me. I gradually increased my swims by no more than 5 minutes a week, just to keep from pushing faster than my body could keep up with and still heal, and found that by holding to that time limit, I could swim a little harder each time. Long before I was able to achieve aerobic level activity any other way, I could swim to get my heartrate up and work all of my limbs without undue stress on my healing belly. This sort of approach is good for postop recovery just because it does permit hard work without overstressing healing areas.

On our message list we often get questions about using weights or doing yoga. Since both of those rely upon strong, activated mid-body muscles for support, even when working other areas, we need to be very very careful how we move forward.

When working with weights, we need to start very slowly with very light weight and focusing strongly on feeling how we're using our abdominals. This is where working with a physical therapist or very experienced trainer who understands rehab is more likely to be effective at both moving us forward and avoiding injury than just taking the word of some jock at the gym.

For those looking to resume yoga practice, standing in tadasana or moving to sit in balasana would be very good for early focus on gently starting the abdominals to work; moving to table and cat/cow in a gentle way might be a good advance after a few weeks postop.The more demanding warrior or twisting poses should probably be deferred for some time and full sun salutations are going to be much too stressful for some months. Someone experienced in their practice is probably centered in their body enough to work to a gentle extent, but I would not recommend early recovery period as a time to begin yoga, just because it can be too easy, without a very experienced and attentive instructor, to try to be more gymnastic than is compatible with safe and sensible recovery.

Nonetheless, yoga is a good way to gradually work up the demands on our abdominals (in the hands of a good instructor who knows that we're working on rehab) and can be especially useful because it balances flexibility and twisting with pure abdominal muscle contraction—something that just doing situps fails to provide. Further, yoga, with its focus on doing and holding one pose very very well can put us more in tune with our bodies than the more competitive atmosphere at the gym with its "push it further" philosophy, while still providing a workout that can leave us utterly limp at the end of an hour.

No firm rules other than good sense

So the main idea in this time is to first regain and control good posture gently supported by our abdominals and stretching our spine out tall, then to extend our stamina by walking further and further. It's better—by which I mean ultimately more effective—to walk a mile with our belly muscles supporting good posture than to force ourselves to begin doing a situp. We should at all times only do what does not provide strain and only do as much of it as we can rest from in our next rest period. How and what we extend our conditioning with depends upon what appeals to us and what resources we have available to practice it, but this is a time to take advantage of expert guidance if we're unclear on how to work out without stressing our abdominal healing.

While it may take many months to fully put our healing behind us, recovery of physical conditioning begins as soon as we leave the OR. Even for women who have no desire for athletics, working on good posture and body control while healing well will pay off in better comfort and stamina in all of their daily activities.

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.

Procreation and fertility

We can deal with this issue very simply: a woman who has a hyst, irrespective of whether or not she retains her ovaries, will not ever have another baby. If her marriage or sexual eligibility requires her fertility, the idea that every act of sexual intercourse will be procreative in order for her to permissibly satisfy her husband's sexual desires, she will no longer be able to function in that capacity.

Some women elect not to treat their medical conditions rather than end their marriages or cause religious conflict. I cannot offer guidance, here, other than to sympathize deeply with those whose belief systems give control of their bodies to someone else, and hope that the rewards their religion promises them are adequate to sustain them through this difficult choice.

Before surgery

Now let's consider the surgical effects. The top of the vagina, where the cervix is located, is the barrier between the "dirty" outside world and the "clean" abdominal contents; breaching that barrier raises the risk of infection, up to and including fatal peritonitis. This is something to take very seriously indeed, because things that are a part of the normal flora and fauna we deal with on the outside of our bodies (and the vagina, even though it feels interior, is in fact considered an extension of "external") can become direly threatening when they gain access to internal organs.

In order to introduce the least threatening mix of organisms when the vagina is cut for surgery, a woman may be asked to abstain from penetration for some time before surgery, or to use an antibacterial douche, or her surgeon may give her no specific directions at all in this regard. Preps vary widely according to the exact surgery a woman will be having and the preference/experience of the surgeon. If your surgeon doesn't volunteer this information beforehand, it's appropriate to ask when one can last have sex before surgery.

Unless a man feels it is critical to his ownership or dominance of the woman to meet his needs rather than hers, this timing issue represents a matter of infection risk and should be honored. If his self control is not adequate to permit abstinence, then the couple might wish to explore non-penetrative options for satisfying his needs since those would not pose the same risk of increasing the bacterial population and raising risk during surgery.

After surgery

Following surgery, there is a two-fold recuperation period that should be observed.

First, there is a time during which the muscular activities that accompany arousal and orgasm could pose a risk to internal incisions and newly-forming scar tissue. As we note elsewhere on this site, there are specific stages of tissue healing, and when these are interrupted, the final product is less strong and durable. When we do early damage, we don't get a second chance to do it right. This can be a difficult time for both partners because there is often a hormone surge in the first few postop weeks that increases a woman's libido. But part of what we ask our surgeons before surgery should be how long we should abstain from orgasm by any means.

The other issue is one, again, of infection. The question here—and it's a question for your surgeon—--is how soon after surgery we can have intercourse with penetration. And by penetration, I mean anything that goes into the vagina.

This is typically a much longer period, one of weeks; often it's not even decided how long this will be until the 2-week postop check. That's because the doctor needs to directly examine healing vaginal tissues to be sure that all incisions are fully closed and able to preserve that critical barrier against infection. Until that time, it's literally life-threatening to risk introducing any new organisms in there. If healing is going slowly, he may prescribe some supplemental estrogen in a cream or vaginal tablet to enhance tissue health and healing response; if excessive scarring is present, he may use a chemical treatment to cause it to slough off and heal more cleanly rather than remain fragile and susceptible to infection. So until that exam (and perhaps after that, if more healing is needed), we just can't be sure that we're adequately protected from infection by a fully-closed incision.

Does that mean that we cannot engage in other sexual activities? No. At any stage a woman can pleasure her partner in any manner that is acceptable to them that does not put her at risk. That means that she cannot have an orgasm during the time that this is too risky and that means that she cannot enjoy penetration of any kind for a—typically—somewhat longer period. That also means that she can be pleasured by any means other than penetration between the time when she is cleared for orgasm and when she is cleared for penetration.

So it's not sex per se that is ruled out; it is only some forms of sex and that for the woman. So long as a couple is willing to be flexible, this period does not necessarily need to be one of deprivation for a man. Now, a healing woman suffers from fatigue and the effects of drugs and stress and may far prefer cuddling and sympathy and comfort to circus sex, but that's something a couple will have to work out based upon their various roles in the relationship.

Resuming sexual relations

Once a woman has been determined to be healed enough for penetration to be safe, a doctor usually gives permission for full sexual relations. Often the period of at least semi-abstinence means that the couple has a fair amount of built-up tension facing this event. On the man's side, it may be eagerness and some resentment at having had his desires thwarted for a time. On the woman's side, there may be eagerness but also concern for what her newly-healed body will feel like.

And there's justification for that. As I noted in the "elsewhere" linked above, healing tissue does not have the elasticity and sensation that fully healed tissue will. To put it more bluntly, the top of the vagina and vaginal cuff feel a lot more like cardboard than normal vaginal tissue. An over-enthusiastic thrust will feel like it's hitting a wall and while that may or may not be uncomfortable, can be extremely startling.

If a woman has had vaginal repairs, her vaginal walls may also feel tight and inflexible. And her partner could encounter "stickers" or ends of protruding sutures that haven't absorbed and disappeared yet. If the couple is expecting a joyous and vigorous reunion, the disappointment could be crushing. While I don't mean to suggest that this is going to be a disaster, I am pointing out some of the possibilities we might not be anticipating. And I can share that women who have reported the best experiences are those who were prepared to take things slowly and gently and, especially, using positions that allow women to control the depth of penetration.

Those are the absolute things that result from the physical needs due to surgery and the protections needed to prevent serious infection or tissue damage.

Menopause means drying up down there, right?

The other concern that both men and women have, however, is the mystique built up around menopause as the end of a woman's sex life. Even a woman who retains her ovaries when she has a hyst stands a good chance of entering menopause earlier than she might otherwise have done. And the myth of menopause includes the notion that she will "dry up down there" and lose all interest in sex. So for many men whose wives are facing a hyst, they may feel that they are facing the end of their married sex life.

Let me stop right here and say: not true. Sex goes on and female desire goes on.

Okay, heart beating again? Good. Now we can look at why these myths persist and what can be done to prevent them from being realized.

There are two aspects to this situation, both hormonal. Now, we don't do so much about hormones here because they're a whole complex topic worthy of their own attention. For women facing surgical menopause, I always recommend the very complete and as easy to understand as possible Survivor's Guide to Surgical Menopause. Their webmaster, Framboise, has some excellent posts she's made about libido to their yahoo group (linked to on their site sidebar) and I'm drawing heavily on her expertise in what I'm going to give in a very abbreviated fashion here.

Local hormones: vaginal health

First, let's look at the local issue of hormones. That is, vaginal levels of estrogen. Remember how a few paragraphs ago I mentioned that doctors sometimes might prescribe an estrogen product for vaginal use if we are healing slowly? The deal is that our vaginal tissues (which includes the supporting ligaments as well as those involved in our bladders, both functional and supporting) are very very sensitive to estrogen levels and require a certain amount of this hormone to function best. Those functions include elasticity, moisture, tissue strength, nerve function, good blood flow, and immune function. When estrogen levels are too low to maintain vaginal tissue health, we experience dryness, lack of lubrication, lack of sensation, burning, itching, increased infections, vaginal tissue tears, and even incontinence or prolapse.

In with those effects, note the parts about lack of sensation, elasticity, lubrication: all of those are critical to sexual arousal just as much as to sexual response. That's right: the functionality we lose with low estrogen levels undermines our entire ability to feel desire or arousal. It doesn't matter what our brains want to do; if the local tissues can't respond, we don't get to do it.

Current research suggests that about 50-60% of menopausal women, whether in natural or surgical menopause, experience some degree of this condition, known medically as "vaginal atrophy" or "urogenital atrophy." Why? Because women are taught by the myths to expect to "dry up" and because they are taught to be ashamed of that part of their bodies so they don't report these problems to their doctors. And because doctors themselves are too embarrassed to ask their female patients about their vaginal and sexual health, they never broach the topic and give women the opportunity to discuss it.

Here's the good news and why it's so tragic that women and their doctors don't deal more openly with it: it's fully treatable. That's right: easily treated in most cases. Please take time for a sigh of relief and then we'll move along to talking about that in more detail.

The treatment for vaginal tissue estrogen deficiency is local estrogen supplementation. Regardless of whether a woman needs or decides to use systemic hrt, she can use special preparations for vaginal dosing that affect only these tissues. Now some women can't do that, the women who are using hormone deprivation to treat specific diseases like hormone-sensitive cancer or endometriosis. But other women can use these products at very low risk of affecting their systemic hormone levels because these agents contain very low levels of hormones, just enough to be used up by the tissues to which they're applied and without enough to spill over into systemic circulation. Women have a choice between creams, gels, rings (like a diaphragm without the center) and vaginally-inserted tablets, and after a time of more frequent dosing to repair existing damage, these products are typically used once or twice a week for maintenance.

Yes, maintenance: this isn't something that is "cured" by treatment. Like our vitamins, these are supplements that we require an ongoing supply of. You can read more about vaginal atrophy and its treatment at the Survivor's Guide to Surgical Menopause and there are more details there about using the specific vaginal hrts, including which brands contain human-identical or synthetic estrogens and whether those estrogens come from plant or animal sources.

What if you don't want to use hormones at all? Sadly, that means that you cannot treat this problem effectively. While lubricants and over the counter moisturizers can provide some limited comfort on a temporary basis, they can't provide the healing and support for fully-functional tissues that estrogen can. So it's a choice that a woman may have to make if she develops this problem. Certainly it's fine to try out these approaches if the condition seems mild, but the critical thing is to remember that this help exists if it is needed. And that if sexual desire is limited or gone, that this is the first step in troubleshooting it.

Let me restate that: women who "dry up down there" can obtain treatment that most women, aside from those choosing hormonal deprivation to treat a specific disease condition, can use and that is very very successful in reversing the situation. And these treatments are covered by the typical medical insurance plan and some of them are very inexpensive, although all of them do require a prescription.

Okay, so what about if that doesn't do it? Then what?

That turns out to be a systemic hormonal issue, more often than not. Uh, not? There's a "not"? Yeah, let's go ahead and get that out of the way first.

Structural damage

The "not" has to do with surgical damage. It's possible that some of the structures that physically create the sensations and responses we define as arousal or orgasm might be damaged during surgery to the extent that we are no longer capable of feeling them or feel them to a reduced extent.

How could that happen? Several ways, in fact.

For one, we might have such severe disease that to surgically remove it, we have to accept collateral damage to adjacent structures. Women who have a radical hysterectomy for cancer or women who have extensive scarring from endometriosis typically have more extensive surgery done and a higher risk of adjacent damages.

Women who have lots of internal scarring for other reasons might have their organs so snarled up that identifying key landmarks and separating things out clearly to preserve nerves might be impossible.

While our anatomy is pretty consistent in general, when it comes down to where this tiny nerve is, whether it's exactly here or just over there, we actually show a lot of variability. And sometimes, no matter how clear the field of view and careful the surgeon, things just aren't where they're expected to be and damage happens.

Damage can be temporary, too. Swelling can compress nerves and blood vessels nearby can take time to heal before they can support nerve healing. Nerve healing, when it happens, is very very slow: months instead of weeks. So what seems to be gone or impaired early on after surgery may still recover by a year later.

Surgeons come into this situation as well. Some are more competent and practiced than others. Some care more to do a careful and tidy job. Some have a schedule that allows them to take the time to do a careful job while others are held to a deadline that requires a faster, less attentive pace. Some surgeons feel, based on their personal values, that women who are no longer fertile don't require or deserve sexuality and they may make no attempt to preserve structures needed for sexual sensation. These surgeons may genuinely believe they are performing a kindness for these women by removing a source of these unseemly urges.

All of this is why our pre-op interview is critical: if preserving sexual structures is important to us, we need to suck up any embarrassment and let our surgeons know this. How they respond will tell us whether we can trust them to do their best or whether we might be well-advised to shop around for someone who might better share our priorities.

And if a surgeon isn't deeply experienced in doing the particular surgery we're planning, if he or she doesn't do this regularly, maybe we might do better with someone who does. "Can do" a surgery doesn't carry the same expertise as "does it every week," and who wants to be a learner project on something this important? (Please don't take this to mean that I am slamming teaching hospitals, by the way--that's not at all the case. There, new surgeons are closely supervised and in fact are being taught the latest and best techniques from masters in the field, so individual surgeon experience takes on a different meaning in that particular setting.)

While there are many outcomes we have no control over, choosing our surgeon is one way we can help make sure things will go as successfully as possible. But we need to communicate with him: surgeons have many great capabilities, but telepathy is not, alas, one of them. Speak up about what's important to you and your spouse, because you can't put things back afterward if it turns out you didn't share priorities with your doctor.

But won't they shorten my vagina?

One common fear of both women and their spouses is that the shortening of the vagina due to formation of the cuff that replaces a cervix will impair penetration. This is typically not the case. The vagina is highly elastic (at least, when its estrogen levels are adequate) and will easily stretch to the extent that this is absolutely not an issue. While women may have this sensation early in their recovery because the healing tissue has not yet regained full elasticity and mature scar tissue, that is a temporary situation. Only women who have vaginal repairs and some bladder procedures will have permanent remodeling of their actual, functional vaginal dimensions, and discussion of the effects of those repairs on vaginal dimension and response should absolutely be a part of preop planning.

Back to the hormone question

Okay, now that we've taken that detour, let's return to the topic of systemic hormone effects on sexuality. While this primarily speaks to menopause, I think that's an overly simplistic reading of the hormone changes we can expect with this surgery. For example, women who have a hyst and retain their ovaries experience a 50% risk of entering natural menopause within the following five years.

But there are other hormonal issues that we can encounter as well. Some of us have our surgeries for disorders that affect our ovarian hormonal system. Women with endometriosis, for example, may produce and be accustomed to especially high levels of estrogen. Women with PCOS may produce and be acclimated to high levels of testosterone. Women with other ovarian disorders or disorders that might have silently be affecting their ovaries—even just a situation where fibroids are distorting the uterus and compressing one or both ovaries—all of these women may have been experiencing preoperative hormone situations that will change to some extent when their primary disorder is remedied with a hyst, even if they keep their ovaries and those organs continue to function normally. While we typically expect hot flashes and mood instability as hallmarks of hormonal changes, they aren't necessarily the only ones we may encounter.

Again, this issue of hormonal balance and adequacy is a very large and complex topic and you really belong over at the Survivor's Guide for it. But let me run through a quick overview.

Estrogen provides the foundation for our libido and sexuality. Yes, there's lots of publicity about testosterone and how it's the miracle hormone for libido. That's an oversimplification and in fact a dangerous one, since testosterone carries some fairly significant negative effects when we're exposed to an excess of it. The key point is that a lot of the supposedly libido-beneficial effects of testosterone supplementation can in fact be a result of the body's ability to convert testosterone to estrogen, so that what we're really seeing in these situations is improved estrogen coverage, albeit by this indirect (and riskier) method. In fact, the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause states this specifically and suggests that women for this reason establish good estrogen balance before adding any other hormones. That seems to be a much sounder (and, based on the posters at the Survivor's message list, more effective) approach than just throwing a little testosterone at the problem and hoping it'll go away.

At the Survivor's yahoo group (which is linked from their website sidebar), they've characterised the difference between the two hormones' effects thusly:

• Estrogen provides for feeling sexy, for desiring sex, for becoming aroused and experiencing orgasm;
• Testosterone provides an itch for genital stimulation.

What about non-hormonal drugs to do this? While yes, there is Viagra for women and it may work in some circumstances, it won't necessarily get around a lack of the proper hormonal foundation for sexuality. In other words, if your spouse wants an eager recipient, that might help; if you want full and rewarding sexuality, you might more effectively look to hormone balance than stimulants.

What about all of the over-the-counter supplements that claim to "naturally" and "safely" restore or enhance sexual desire? Probably not going to happen. Every few years another agent is identified and heavily marketed ("not available in stores" and often identified as a "miracle cure") and shortly after women or their spouses spend a small fortune on these supplements, they lose interest in them because, really, they don't do much. There are no non-hormonal agents capable of carrying out the same functions as hormones. Just because it grew in an unrefined plant, it doesn't mean it's safe. In fact, most pseudo-hormonal agents are actually plant defenses developed to disrupt the hormonal balance and fertility of animals eating them. So while soy or black cohosh may help stabilize hot flashes for women in natural perimenopause, they are not agents that are capable of providing vaginal estrogen needs and they are not typically capable of supporting libido in the absence of good hormone coverage.

So, in summary, there's good news and there's bad news

The good news about hormonal balance is that it can be addressed and if we do a good job of restoring estrogen coverage, we generally restore libido as well.

The bad news is that there is no recipe for doing this: we need to find a doctor to work with who understands that hormone needs are personal and unpredictable and need to be identified by experimentation and patience. The process works, but it's not as straightforwards as taking an antibiotic at the usual dose and having an infection clear up. But, once again, that's a major topic of discussion over at the Survivor's Guide yahoo group and too detailed to undertake here. That help exists there if you need it.

What are the odds?

All of this has been a long lot of writing, but I'm trying to give you as full a picture as I can of the situation and the factors that enter into it. All of the major disruptors of sexuality can be dealt with short of destruction of sexual anatomy. Many women, here on our yahoo list and elsewhere, can tell you that their sex lives are as good or even, where they were being constrained by the health issues for which they had a hyst, improved by their surgeries. Many women need no treatment whatsoever to maintain sexuality. The odds are that this will be your experience as well. The women who experience surgical damage are very, very few. The women for whom hormonal stability and adequacy are out of reach are few and often have other conflicting health needs. Despite those old wives' tales, then, a hyst does not doom one's sexuality although there is undeniably a postponement period during surgical recovery.

Sex afterward may be a bit different, though

One thing women often agree on, however, is that arousal and orgasm may feel somewhat different post-hyst. Not worse or better; just different.

That makes sense from an anatomical standpoint: uterine contractions are a notable part of the sensation of orgasm, and although surrounding remaining muscles still respond in the same way, some women notice that change.

Other women for whom cervical stimulation was an important element of arousal may miss that aspect of sensation when they've had this portion of the bottom of their uterus/top of the vagina removed. On the other hand, those women who found cervical stimulation unpleasant often report greater relaxation when they're not braced for that discomfort.

And some women find that changes in abdominal nerves and their routes or of the supporting ligaments make for odd sensations, cramps, or other feelings, although these are rarely of an extent that interferes with sexual enjoyment (and if they do, this can often by corrected by further surgery once the problem is identified). This is more typical of the postop year, when things are still getting sorted out, but some new or odd sensations may be permanent.

So much for the old wives' tales, then

And that's about it. Not a sentence of doom to anyone's sex life, although things may change a bit just as our bodies do change as our lives go on. Much of the distress that surrounds this topic could be alleviated if women and their partners simply knew going in that much of what they see in the early postop period is not permanent, and that much of what menopause is charged with is amenable to modification.

Old wives' tales are just that: old. There's no need for women today to suffer in isolation and fear that there is no help for what they are experiencing just because no one in their immediate vicinity knows what they are going through. We, here, know and can share with you the knowledge that things are likely to be just fine and that if not, there are lots of things to be done about that.

Does that help with your concerns? Please feel free to come join our message list to ask more questions on any of this if you need more information.

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. First of all, getting off of narcotics and making the transition to, usually, anti-inflammatories, removes that direct bowel-slowing effect. Obviously, this needs to be balanced against pain control needs, but it's a good reason to be sure that we really need the level of relief narcotics provide.

Activity is a big but simple thing we can do to help out. Regaining bowel activity is one of the reasons we're up and about so rapidly after surgery. And it's the reason why, when we complain about gas, the answer we're likely to receive is "walk" and then "walk some more." While anti-gas medications can help somewhat by breaking the gas up into smaller collections, nothing will get it moving out of our system but the bowel function that is stimulated by walking. Walk and toot, and those gas pains will be, literally, left behind.

Diet, once we've passed that all-important first gas, is the key to getting things back on a proper functional basis. While liquids and undemanding foods are the thing while we're waiting to regain function, once things are working, our bowels need the stimulus of something to work on. Fiber provides that: bulk to keep our stools soft and moving. That means that early postop meals should include fruits and vegetables in good measure, even when our appetites are still weak (a normal symptom of bowels that are still feeling puny). It's common to do more nibbling than meal-eating in the first week or two postop, and that's fine, so long as those nibbles are chosen with bowel recovery in mind. Dried fruit is a great snack that doesn't require preparation and can be kept handy; precut vegies and dip are another snack that can be easily stored and comes to hand readily even when family and friends aren't around to help us to meals. Making good dietary choices like this will go a lot further to remedy our discomforts than just indulging in junk food.

With all of that fiber, though, we have to drink plenty of liquids. Fiber alone is a fine way to create rocks, but that tends not to be a very pleasant experience when the time comes for *cough* disposal. Drinking lots of fluids means that the fiber will be moist and flexible as it transits our guts, and that makes for the best stimulatory effects. What kinds of fluids? Coffee and caffeinated beverages are okay as a morning kick-off (and if you've been a serious coffee drinker, your bowels may be addicted to this signal), but when continued all day, have an overall dehydrating effect due to the stimulation caffeine gives the kidneys (and contributes to bladder cramping, by the way--another frequent postop complaint). Instead, fruit juices, fizzy waters, diet drinks and just plain water are better choices. Some women feel that the carbonation in these drinks causes more gas problems. While most gas is actually removed from the drinks in the stomah (that's why we're belching), if it seems a problem for you, then by all means avoid fizzy drinks. But women in general don't need to automatically do this unless they know they are prone to this problem--fizzy is fine, especially if you do belch up that gas (yeah, recovery isn't pretty).

How much drinking is enough? Watch the color of your urine: palest yellow is good; anything significantly colored (unless you've just taken your B vitamins) suggestes that you could benefit from another glass of something. Sipping away at a glass every hour or so is a good plan that doesn't take a lot of effort.

New research has also given us another tool: chewing gum. Research has shown interesting results on how chewing gum may return bowels to greater activity a whole day or more before they would do so using more conventional management techniques. While we're lying around being less active it's probably a good idea to make that sugarless gum for our teeth's sake, but I think that a little gum sounds like something easily done and not likely to be harmful even if it doesn't help spectacularly. But please, while you are still in the hospital and on dietary restrictions, do check with your surgeon before reaching for your gum--there may be other reasons why this might be inadvisable in your particular case.

And what can we do once we're home and dreading that first scary bowel movement or struggling with constipation? First of all, use all of the techniques above to make sure things are as easy on your bowels as possible. These considerations aren't just for while you're in the hospital--carry them over for the first several weeks of recovery, at a minimum. If you haven't been eating fiber, for example, adding some dried fruit (and plenty of fluid, remember, to make it work) to your diet can have amazing results within a day. If you've been sitting on the pot without success, get up and walk laps around the house, around the yard--whatever you're up to at your level of activity recovery.

It's tempting to just reach for a medication for help with this. It's true that if you've allowed yourself to become significantly constipated that something may be necessary to help out your normal bowel capability. But laxatives are not a good substitute for fiber and activity--they just are things that can help you make good use of those tools.

And not all laxatives are created equal. Please don't use the old-style mineral oil laxatives--they have been demonstrated to cost you critical vitamins that you need for healing right now. Instead, call your surgeon's office and ask what their recommendations are for post-op laxatives. In fact, if you're reading this preop and know you have a tendency to constipation and want to shop for something to have on hand postop in case it's needed, ask beforehand what your surgeon thinks provides the best kind of stimulation for your own surgery and body. Let me be more specific: too harsh a laxative or too much laxative may cause such strong bowel contractions that you can be in significant pain or even may risk damage to your surgical site, depending on the exact surgery you had. Ditto the use of enemas or laxative suppositories: for some women, rectal penetration is as risky as vaginal in early recovery, so don't just assume that because you can buy these products without prescriptions, they hold no risks for you.

And remember that laxatives are not a maintenance strategy. They provide a short term major boost to activity, but that doesn't get around your need to redevelop good bowel habits for your recovery. Use a laxative once or twice if nothing else has proven productive, but at the same time, start putting those simpler, less glamorous steps in place to give your bowels what they really need to be healthy: fiber, fluid, and plenty of exercise.

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.