Friday, May 01, 2009

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.