Healing

While I haven't begun to exhaust pre-op topics, I'm going to flip over to the other side and talk about healing and postop stuff for a bit, since it's important even to those just at the planning stages to understand something about what is involved in the healing. Although it's easy, when you're looking at this surgery, to focus on the operation itself as an endpoint, in fact that is simply the beginning of the real work: healing. And it's how well you undertake the active work of healing that determines the ultimate results—and your satisfaction with them—of your hyst.

The main tasks of postop healing from a hysterectomy (of any type)

The earliest weeks of healing have three basic objectives:

1. Watching for/protecting from infection: nothing in the vagina for 6 weeks, minimum; get specific permission for bathing/swimming (doctors vary--I got permission for both once my staples were out; others wait at least 6 weeks); report any smelly or pus-like discharge, incisional heat/redness/swelling, or elevated temperature; and keep your incision clean and dry.
2. Protecting internal healing by not lifting anything heavier than a coffee mug (well, 5ish lbs) or doing anything that is so joggly that your abdominal contents whip around and stress all the gazillions of internal sutures. This includes doing laundry, running a vacuum, riding a bike, doing exercises other than walking until you have specific clearance (again, usually at 6 weeks or so). This also includes driving a car—don't do it until you are released, both for the protection of your healing and for the protection of the rest of the world who would be imperiled by your inability to react/brake/move as quickly as you should.
3. Enhancing good tissue healing by getting plenty of fluids, eating a diet with adequate protein, fiber, iron and other nutrients, gradually increasing your physical endurance by walking more each day, every day (my own rule of thumb was to exercise only as far as I could recover in a nap that day—no carrying over fatigue). Naps are good: nap at least daily up till 6 weeks and whenever you need to after that.

Sex

One of the big questions everyone has is sex. The "nothing inside" rule is firm, firm, firm. The risks of damage to dissolving sutures, not to mention infection, are too high. At that early stage of healing, the scar tissues are too stiff and inelastic to stretch without tearing—and if you open your cervical cuff (the place where they have closed off the top of your vagina, creating a pseudo-cervix that supports and closes the end) at all, you've opened the whole contents of your abdomen to communication with the outside world (Big Yuck). Also, some women have suture ends in the vagina whose sharp ends men have run into, causing catastrophic loss of...interest. This does not mean that you cannot satisfy your partner using other means, and does not mean that you cannot test out your response on your own or with your partner using non- penetrating/non-contaminating methods. Usually it's good to ask your doctor when it is safe to experience an orgasm (which stresses all those internal sutures and healing points) and wait a bare minimum of at least a couple weeks before trying this, just to allow internal healing to get a good start.

Healing sensations and time

You will experience a lot of twinges and zots as healing takes place. Nerves and other tissues heal at different rates, so these sensations spread out over a couple months.

Healing is not a smooth curve, but rather a series of steps in which one type of scar tissue forms, then is dissolved and replaced by another. Healing starts with a scab, and then gradually moves toward the end result of smooth, strong, elastic scar. In the interim stages, that new tissue is vulnerable to damage.

One of those periods comes at about 12 days, when the earliest scarring resolves into a stronger one and sutures are dissolving and letting go. It is very common to experience a little spotting or extra twinging as your body readjusts things in this first major healing stage.

Skin numbness and burning are also common in a nerve healing stage. I've heard that nerves regenerate around your incision at the rate of about an inch a month, but not all abdominal numbness or edgy sensations from cut nerves go away, even with time. This is typical of any surgical incision, and isn't special to a hyst.

You can expect to go through these tissue healing stages for at least two months, and it takes six months to a year to reach maximal healing. That's right: that long.

OMG, it takes how long?

My doctor said I'd be all healed and ready to go back to work in 6-8 weeks. Now you're saying a year. What's with this?

This is a classic "apples and oranges" situation. From your surgeon's perspective, by 6 weeks you've healed through the immediate postop period in which you are likely to have complications from the actual surgery itself. He can't do much more for you, now—it's up to your own body to finish the process up—so he considers you "done" as a patient.

But that only means that you've gotten the early, most fragile work finished. From this point, healing is slow but steady, without a lot of drama. But for the first six months postop, you're still doing heavy healing as all those scars turn to good strong tissue and your nerves grow back. The drain on your body will express itself as much more fatigue that you'll expect, and you'll continue to have some belly swelling late in the day or when you overstress the healing area. You will reach about 80% of your total healing by roughly six months and it takes the rest of your first postop year to reach 100% of the healing you will ultimately achieve.

If this amount of time seems astonishing to you, you have a lot of company. Overwhelmingly, women who have had a hyst say that the single thing they were least prepared for is the duration and extent of postop fatigue. That fatigue, I'll point out again, is due to the complexity of the surgery and the great extent of physical healing involved; it's nothing specific to the actual nature of the organs removed.

My postop body

What happens to the space where my organs were? Is there a big hole now?

The healthy uterus is really quite small—barely a small woman's fist in size. So it's not as though there's a huge space when it's gone. Now, those of us with the fruitbasket of fibroids (have you noticed? everyone's is "big as a grapefruit" or "a cantaloupe" or whatever) have gotten used to everything being shoved out of place and cramped in by our oversized uteruses. Frankly, when a big uterus full of fibroids goes away, the sensation is a big "aaahhhhhhhh." You regain your bladder capacity, your bowels don't snarl themselves up trying to empty, and everything just feels like a better fit again. Your guts may actually feel a bit "slithery" for the first few days, but that's okay--they are on panels of slippery tendon, and meant to do this. That sensation goes away once everything has moved back into its rightful place again. And because that newly-vacated space is so small and your innards are meant to move around, things just ease back into position and "fill" that space right up.

Do the abdominal muscles bridge the gap created by the incision in surgery? Do these muscles ever grow together again?

Yes, they are firmly sutured back together, bringing the cut edges back into alignment. They will heal (scar) back together and be essentially a strong as they ever were.

If they do not heal fully or the scar is weak and rips back open (in the muscle layer—not through the skin!), then you have a condition called a "hernia." This can be repaired later, either by a surgery with an incision or by a laparoscopic procedure. Women who fail to take adequate care of their healing belly tend to be more prone to later hernias along that incision line.

The scar

How can I minimize my scar? What will help it heal?

I've heard of women using Mederma, but does it really make a big difference? That Mederma is pretty pricey stuff.

What about vitamin E? My hairdresser says that really makes a scar disappear.

I've seen women report being very satisfied with Mederma, but also women express the same results in roughly the same time frame who were using vitamin E or nothing special, so it's hard to make a call on this. To some extent, your scarring will reflect every other scar you've ever had: if you tend to heal nicely over time, you most likely will have a minimal scar (assuming a tidy surgeon); if you are prone to large, lumpy scars, this one may follow suit. Women with a history of keloid scarring may need to make their surgeons aware of the problem and ask to have special measures taken to try to minimize the keloid tissue formation.

I personally used the oily contents of a regular vitamin E capsule massaged (gently) into mine a couple times a day, and I'm quite happy with how mine healed. To be honest, though, I have no idea whether the vitamin E had any particular effect or whether it was simply the massage...or just my personal healing style. Doctors are divided in their opinions on the efficacy of vitamin E for healing. For some months my scar was red and hard and lumpy, but now it's just a white to pink line. Just remember that you don't want to put anything on it till the staples are out and it's scabbed over well. And whatever you put on should be pretty simple stuff—I accidentally got some body moisturizer on mine when it was still fresh and that stuff really burned until I rinsed it back off, even though it's fine on the rest of my skin and I use it all the time.

Recovery period: household chores

One thought for your husband/family needing direction with household stuff: don't forget that just because you can't, physically, do the chores doesn't mean that you can't verbally direct someone else in their performance. The way I look at it is that the recovery period promotes you to management: you point; they jump.

On the other hand, several women I know have successfully convinced their husbands that having a hyst means that you can never vacuum again. I leave you with this thought in hopes that happy creative contemplation of it will help pass the time until your surgery.

Healing and exercise

But do you really know, medically, about the harmful aspects of stretching? If I just stretch to the point of not feeling a real pull, wouldn't that be all right?

What I know is the basic physiology of healing and the basic post-op care of wounds. There are multiple healing phases between the initial cut, scab, and eventual scar tissue, and even that scar can, years later, change due to things like nutritional status (as an aside/example, fr'instance, severe scurvy causes old scars to reopen). It's not a case of cut once/heal once. Every 12 days or so your body goes through a stage in which the past stage of healing is dissolved/absorbed and replaced with a new, stronger stage. At those points, when this is going on, the ultimate strength of the scar tissue is vulnerable to stresses put on the scar area as that dissolution/replacement is going on. And, since the cells along an incision/scar (remember: we're talking all the internal repairs as well as the surface incisions on your belly and in your vagina) aren't all on exactly the same schedule, there's a fairly good-sized window for damage to occur.

Now, don't let this feed too much paranoia, ladies. I'm talking about severe events, not just routine living. But stretches and exercising, especially impact loading with acceleration/deceleration, are the extreme sort of stress that can indeed damage the scar. And you might be fine even so. Or, in another 30 years, you could find yourself with a little hernia. It's about setting up the odds of getting the best possible results.

Who can know how far along I am in healing? How can I tell when it's safe? Would a physical therapist feel or take x-rays?

No. They can look at your stage of exterior healing and utilize their training and experience in predicting broad norms for when you are ready to do something (and that is valuable, don't get me wrong), but they cannot make firm and absolute determinations of exactly when it is or is not safe for you, nor can they quantify in any specific way exactly how much you can stress a given area. Even a PT, if they were working with you as a trainer, would be wanting feedback from you on how hard you are working that surgical area. They would tell you more or less what I have: you need to listen to your own body and you are the best judge of how much you are stressing it with any particular activity.

Am I being conservative here? Yes. I do this from the firm belief that we only get one chance to do this right, and the investment in patience pays off years later. When it's only a matter of a month, the line between cautious and go-for-it, I do firmly believe that staying on the gentle side of the line is correct. At the same time, I don't believe in being inert--you need to push yourself up to that line to hold your own while the healing is going on. Personally, I believe that line lies where you can feel a little stretch but not a pull. In the early healing months, gentle exercises limited in effort and building endurance seem to serve our needs best.

Are there websites or books that will tell me specifically what exercises "bind" the abdomen horizontally across the vertical incision?

No. There are no single broad bands of muscle that run laterally across your belly, and belly tone is provided by layers of muscles running in different directions from different attachment points. What you need to do is exercise and strengthen all the muscles together. Over-training one set and not the others will affect your posture and can lead to back pain. You need to work them all.

The good news is that those muscles will gradually begin to regain tone just from the normal activities of daily life. At first, this includes things like rolling over in bed and getting up to the bathroom. If we are careful to stand upright, fully straight, instead of hunching over, we are already exercising those muscles in the right way. As we can do more, like walking further and going up and down stairs, we gradually work the muscles harder in a very gentle way and they can resume more and more of their usual load. It's important to hold to the fine line between challenging them and over-stressing them, which is why early stomach-flattening exercises are a bad idea and can actually cause more damage than help.

After all that giant uterus I had taken out, I thought I'd for sure have a nice flat belly after surgery. Instead, I look six months pregnant. Help! How can I get this to go away?

There are two things going on in belly healing. One is the muscles re-attaching at the cut and forming a good scar, as well as regaining their former tone. The other has to do with swelling as the day goes on, which includes some fluid collection in the tissues due to circulation disruption during surgery. This is really the same mechanism as the swelling that recurs in a sprained ankle when you use it too heavily again, even months after it has seemingly healed.

You will get—especially—afternoon belly swelling long after you have regained enough muscle strength to sit up without pushing up using your hands, perhaps for 6 months or so. It's easy to blame that limp afternoon belly on muscles, when it really isn't entirely that and it will (yes, really) resolve with time. I know that even with my horizontal incision, I spent several months wearing loose dresses rather than pants that turned into tourniquets as the day went on. This is normal.

So, much as firm answers sound as attractive as a firm belly, neither one is exactly within reach. Sorry.

I've seen women ask about wearing a "belly binder" postop, or a girdle. Should I do this to help support my belly?

No, not unless your doctor specifically recommends it. This is a sort of old-fashioned thing that is now understood to be counterproductive. By supporting your belly and taking the workload away from your muscles, it actually delays the process of their regaining their own strength and can result in weakened abdominal muscles. There's also the risk that too tight a binder or girdle will cause circulatory trapping that can lead to blood clots.

It's healthier for your muscles to be gradually and gently challenged by everyday activities. It's also important to stand up very straight, even right after surgery, so the muscles don't shorten to your hunched-over posture. Your doctor has stitched you up very firmly: you are not going to have your belly break open, so stand tall.

Once you're more active, the discomfort of jouncing your belly around serves as a good reminder of when you're over-doing and stressing healing tissues. Once you are standing/walking more, you may find that wearing a light pair of control top pantyhose or elasticized panties will support your belly while shopping or other gradually lengthening activities, but don't use it as an excuse to over-extend yourself and do be wary of the tourniquet effect.

Remember: your goal is is to retrain your belly muscles to resume their normal work, not to substitute elastic garments for them.

A rough schedule of post-op recovery

It's all very well to talk about finding our own level of healing, but it's also scary not knowing what to expect or not knowing whether we're healing as we should be. Things like our pre-op state of health, our specific operative pathology, and the exact procedures we had done are really the driving influences. But for those who would like a general set of guidelines, this is roughly what a broad average looks like.

Week 1: comfort, exercise and rest

Focus is on balancing comfort with the need for exercise to get your system moving again (prolonged bed rest is especially hard on lungs, guts and the circulatory system [= clot risk]). Pain meds are good, but narcotics cause constipation and so should be used judiciously. Many of us feel only moderate "be careful" discomfort rather than "knock me out, please" pain, so don't plan on being in agony. Drinking a lot along with exercise (walking increasing distances at increased intervals, with rest in between) are your best strategies. Watch for signs of postop infection.

Week 2: pacing your recovery

Focus is on increasing your endurance and stamina. You'll feel substantial improvements daily, but will need to moderate growing impatience to be up and about with the need to continue devoting your energies to healing. Lift nothing heavier than a mug, continue heavy fluids and eat plenty of fiber to keep your guts going in this ongoing lowered activity. You'll have your staples/sutures out and be healing on the surface if you had an abdominal incision, but all surgeries still have a long way to go to heal internally. Don't rush. Oral anti-inflammatories or mild pain relievers, longer walks outdoors, and a daily nap characterize this week. Also, bathing may be permitted if it hasn't been by now. Your belly will still be poofy and flaccid, but you'll see improvement over week 1.

Week 3: not a setback

Your increasing stamina will cause you to do more than you should, thus leading to increased fatigue and a feeling that you are losing ground. This is a major turning point in internal healing, but to you it will feel like hitting a wall: more fatigue just when you are bored; more abdominal discomfort just when you thought you were really getting on top of things. It's not a disaster, but it's very frustrating. Plus, you're bored with walking and all the housebound stuff. You can't drive for at least another week (many insurance companies won't cover you yet), but you're ready for more car trips with someone else. Most of us go out and overachieve in a giant box store and come home discouraged this week. Will you ever be better? Yes. But you can't zip your levis yet.

Week 4-6: more visible progress

Progress picks up again. You're still aware, every day, of having had the surgery but you will be able to sleep on your stomach again and move around more freely, without always thinking of your belly. You continue to need a daily nap, and shouldn't stint on it as you need the energy to devote to healing. Clothing is a totally boring agony: returning nerve function along belly incisions can cause great (albeit short-lasting) irritation; best choices are sweats/tights/long loose dresses. You are doing more around the house again, but still need to limit what you lift; you can drive again. You may get the okay to resume sexual relations (with vaginal penetration). This is scary the first time. Talk with your partner about your concerns and try to arrange a position in which you can control the depth of penetration. This is not the occasion for circus sex.

Week 7-8: nearly there?

You feel nearly back to being able to do stuff, and you are getting ready to return to work. You should still nap any time you feel tired. Your clothes still may not fit. You may have a second checkup now, and get clearance for work. If you have a job that is physically demanding, ask your doctor for a written direction as to lifting and other performance limits to take to work. You may get your doc's okay to return to your fitness program so long as it doesn't stress your belly (fitness swimming is good; step aerobics is not).

Month 3: why am I not all better yet?

You return to work and are floored at how totally wiped out you are for the first week. Plan on nothing more than work and sleep. It will get better. Don't feel bad about napping, although it won't happen on a daily basis any more. You are still only about 75% healed. More of your clothes fit, but you are motivated to develop a fitness/weight reduction plan. If sexual relations are still uncomfortable, check with your doctor to see if a little vaginal estrogen might enhance healing and elasticity.

Month 4-6: reaching 80%

By the end of this period, you have whole days that go by in which you do not think about having had surgery. Your incision is fading. Your vaginal scarring (the cervical cuff or other incisions) is resolving and becoming more elastic, and sex is less nervous-making. You are 80% of the way to your ultimate extent of healing, and have resumed most of your preop activities (or perhaps more, if you were seriously impaired by your preop condition).

The rest of the first year: leaving your hyst behind you

By your hysterversary you are 100% as healed as you are going to get. Abdominal incisions may still be sensitive to pressure. The surgery begins to fade as part of your identity. Any hormonal changes wrought by surgery and subsequent HRT should be settled down. You are moving on.