tag:blogger.com,1999:blog-84184092024-02-20T10:06:08.438-08:00Hysterectomy ToolboxThinking about a hysterectomy? Preparing for one? Recovering? Your best tool throughout the process is knowledge.Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comBlogger37125tag:blogger.com,1999:blog-8418409.post-53311841390794040252018-05-30T13:18:00.002-07:002018-05-30T13:19:42.780-07:00Privacy PolicyWith the new GDPR rules in the EU, we're taking this opportunity to make our privacy policy explicit, no matter where you're reading from.<br />
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Your privacy is pretty safe with us. <b>We collect no information ourselves</b>; we set no cookies; we do not interact with your computer in any way other than to provide these page files on this web service for your browser to call up and read. We simply don't have any information about any of our readers that we could do anything with, even if we were so inclined—which we aren't.<br />
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<b>Blogspot</b>, the publishing service we use to construct and host this site, does provide cookies in your browser. This is not under our control and we have no access to them or to the information they contain. You should have received a privacy notice automatically when you opened the page if you are in the EU—which we are unable to even review because we're not in the EU. We can, however, share with you <a href="https://policies.google.com/privacy" style="color: #909090; text-decoration-line: none;">this page on Google's privacy policies and data management</a> in general. If all else fails, here are instructions on how to disable cookies in <a href="https://support.google.com/chrome/answer/95647" style="color: #909090; text-decoration-line: none;">Chrome</a> or <a href="https://support.mozilla.org/en-US/kb/enable-and-disable-cookies-website-preferences" style="color: #909090; text-decoration-line: none;">Firefox</a>.<br />
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We're not aware of any further information Blogspot/Google collects simply from your use of these pages, and they have not revealed any other data collection practices to site owners.<br />
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The Survivor's Guide to Surgical Menopause <a href="http://surmeno.blogspot.com/p/discussion.html" style="color: #909090; text-decoration-line: none;">discussion list</a> is hosted by <b>Google Groups</b>. They have an updated privacy message on a sticky post at the head of our discussion topics. So far as we've been able to research, use of Groups falls under <a href="https://policies.google.com/privacy" style="color: #909090; text-decoration-line: none;">Google's general privacy policies/data management</a>controls.<br />
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We use <b>Google Analytics</b> to collect and display some information about site use. This is set to retain only impersonal data and that for the shortest permitted time. Here is the overall <a href="https://support.google.com/analytics/answer/6004245" style="color: #909090; text-decoration-line: none;">general statement about Google Analytics and data privacy</a>. We have added code to our analytic feature "to anonymize the information sent by the tracker objects by removing the last octet of the IP address prior to its storage" (quote from <a href="https://developers.google.com/analytics/devguides/collection/gajs/methods/gaJSApi_gat#_gat._anonymizelp" style="color: #909090; text-decoration-line: none;">Google Analytics</a>). This purportedly makes it impossible to locate a user specifically. Google also offers an <a href="https://chrome.google.com/webstore/detail/google-analytics-opt-out/fllaojicojecljbmefodhfapmkghcbnh?hl=en" style="color: #909090; text-decoration-line: none;">opt-out extension for the Chrome browser</a>; there is a similar, privately-developed extension for <a href="https://addons.mozilla.org/en-GB/firefox/addon/google-analytics-blocker/" style="color: #909090; text-decoration-line: none;">Firefox</a>. They claim to block <i>all</i> recording of your use of the site.<br />
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You may additionally have other sites' trackers enabled that can follow you and record your use of this site. These are entirely outside of our control. You can limit the reach of these trackers, however, through the use of browser extensions such as <a href="https://absolutedouble.co.uk/trace/" style="color: #909090; text-decoration-line: none;">Trace</a> (we are not affiliated with them).<br />
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And that's as simple as we can make this. We apologize that all of the Google stuff is so complicated, but that's on them. We've spent hours trying to unravel it all...and gave up and deleted our ad account just because that was an even more horrific mess. If anyone is aware of other tracking originating through this site or has other privacy concerns, please do <a href="mailto:framboise.surmeno@gmail.com" style="color: #909090; text-decoration-line: none;">contact Framboise</a> and she'll do everything in her power to help.Framboisehttp://www.blogger.com/profile/02371182068166822871noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-85112660352732937162014-11-26T10:47:00.004-08:002014-11-26T10:47:59.077-08:00Time has passed; has anything changed?I just wanted to stop by to let you all know that although most of the posts here are a few years old, now, that doesn't mean they're outdated. I do review them from time to time to make sure the information contained in them hasn't been superseded by anything new and different.<br />
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Basically, the surgery remains the same and how we prepare and recover from it are still pretty much unchanged. If anything, there's more emphasis on the so-called minimally-invasive surgeries today, and while they can be good in some situations, we need to be careful to separate marketing-speak from what's in <i>our</i> own best interests.<br />
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If there's one thing that's changed in the past five years, it's been the number of surgery centers that have purchased robotic surgical equipment. But this carries an unfortunate cost for women. Although the robotic surgery is touted as being safer, less invasive, more precise and, especially, much faster to recover from, that's not actually been seen in use. In fact, according to a <a href="http://www.reuters.com/article/2013/02/19/us-robot-hysterectomies-idUSBRE91I18I20130219">Reuter's news article</a> that came out in 2013:<br />
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the tool didn't reduce complications linked to hysterectomy or otherwise improve women's outlook after surgery, researchers found. And it raised the cost of the procedure by almost one-third.</blockquote>
In fact, researchers who analyzed records of a large number of surgeries during the previous few years found that<br />
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The only advantage to robotic surgery was a drop in the proportion of women staying longer than two days in the hospital</blockquote>
Additionally, other studies have found that the surgery itself takes longer and in fact results in more pain than a conventional laparoscopic surgery. (<a href="http://www.medscape.com/medline/abstract/21979458">source</a>)<br />
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So why are these surgeries being promoted? This is an expensive piece of equipment and every moment when it's sitting unused, it's failing to return on that investment with profits for the medical center that purchased it. While robotic surgery does improve outcomes in some surgeries, a hyst is not one of those. That enticing advertising, then, is all about profits and not about your health.<br />
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Another interesting aspect to recent surgical techniques that reduce the size of abdominal or vaginal incisions is that the uterus has to be essentially ground into small particles before it can be removed via these tiny incisions and the tools that fit into them. Called "morcellation," this procedure is done via special tools called, not surprisingly, morcellator devices.<br />
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Since their introduction, there has been a worrisome trend of complications following on their use, especially when fibroids are present. In addition to damage to surrounding organs, the procedure appears to be quite effective at spreading previously-undetected malignant tissue to locations outside the uterus. This risk is now considered so well-demonstrated that hospitals are discontinuing the use of this tool in hysterectomies and other uterine surgeries and the major manufacturer of the devices has suspended their sale (<a href="http://www.reuters.com/article/2014/11/25/us-hca-holdings-morcellation-idUSKCN0J92MZ20141125?feedType=RSS&feedName=healthNews">source</a>). Clearly, this is something to check with your surgeon about: unlike robots, this is <i>not</i> something that is advertised and you may not be routinely informed that your surgeon plans to employ this technique.<br />
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But basically, while modern surgeries may result in smaller incisions, the internal healing remains the same. In fact, we see more women mystified about how long it's taking to recover than we did when abdominal incisions were the major route. I think that there's a real push to be "back to normal" within days if not weeks of surgery, even when women have to exhaust themselves to do so (and reduce the quality of their healing besides).<br />
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Is there still a role for traditional abdominal incision hysts? Oh yes, and a woman shouldn't feel like a failure because she doesn't qualify for a minimally-invasive procedure. Any time there's risk of cancer or actual confirmed cancer, we face requiring a radical hysterectomy, a much more extensive procedure that in part relies upon our surgeon's clear view of the entire abdominal contents. And for fibroids, well, given the risks associated with breaking up a fibroid-filled uterus, I think I personally would still opt for an incision that allows a uterus to be removed essentially whole.<br />
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Other than this, the only other major trend has been the ongoing decrease of hospital stays after hysts. To some degree, this is a result of the more minimal procedures; it's certainly also due to insurance companies not wanting to cover the costs of an extra day or two of monitoring and drugs. Additionally, it can in fact be considered a reflection of the fact that it's to some extent more dangerous to be in a hospital, exposed to infections carried by others, than to be at home. So long as we are clear on what to report to our doctors and take care to get the necessary fluids and walking/repositioning exercise, there's rarely anything magical about being in hospital that we cannot do for ourselves. <i>The most important aspect of safety in early recovery is recognizing complications</i>, most typically those of bleeding or early infection, and reporting them promptly. Remember: if you're in doubt, <i>it's always better to call than to wait and require emergency intervention</i>.<br />
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And finally, the only other piece of news I can offer is that our old Yahoo message list is long gone. But that doesn't mean that women's need to discuss their surgeries and ask questions is over and done with. Nope: we all can use some company at a time like this. So Framboise, over at the Survivor's Guide to Surgical Menopause, has opened <a href="http://surmeno.blogspot.com/p/discussion.html">their discussions</a> to those who are planning or who have had hysts of any kind. Feel free to join them and benefit from discussions with other women who have been where you are now.Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-83879065767222639222009-09-06T12:17:00.000-07:002014-11-26T09:38:49.293-08:00Advertising and your privacy here on the site<h3>
Privacy Policy</h3>
Your privacy is entirely safe with us. We collect no information ourselves; we set no cookies; we do not interact with your computer in any way other than to provide these page files on this web server for your browser to call up and read. We simply don't have any information about any of our readers that we could do anything with, even if we were so inclined, which we aren't.<br />
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We do have a site tracker/counter that registers things like how many pages are read and what sort of browsers read them. This information is collected but not identified according to any individual reader. It helps us understand how to code the pages so that you can read them more easily and tells us which subject areas draw the most interest. So the information we get that way is about how the site is used, not about the user. Aside from what you're interested in knowing, we don't really <i>want</i> to know anything about you.<br />
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We have a number of links that leave this site to take you to services, information pages, and commercial entities. Once you leave here, you're on your own. We go through everything once a year or so to prune dead links and make sure that folks we've linked to still look reputable. But otherwise, we have no influence on how they conduct their sites. It's up to you to research the privacy and other policies of any site you share information with. It's a scary world out there, and vigilance is always indicated. Always practice safe Internet: use a frequently-updated antivirus program, use a firewall, use an advanced browser like <a href="http://www.mozilla.org/" title="Takes you to their home page">Firefox</a> that blocks many malicious-code-containing ads and images, set all your mail clients to view messages first in plain text with no html, and never open emails from anyone you don't personally know and expect to hear from (and then warily). Exercise common sense.<br />
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Blogspot, which is owned by Google and provides (free) hosting for this website, does collect various categories of information depending on how you access their services. This isn't under our control, although you may opt out of their advertising-related information collection using the link in the section below. There's not much more we can do without a financial sponsor to pay for hosting that is fully under our control.<br />
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Advertising Policy</h3>
You'll notice that there are ads on this site. We use them to help raise money to meet the expenses of running this site and our message list. As with all content on the internet, including what you read right here, be discerning and look for the scientific backup.<br />
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We neither endorse nor disendorse any specific advertiser or products served up by the advertising service we're using. Google, as the advertising vendor, uses cookies to serve ads on this site using the <a href="http://www.doubleclick.com/privacy/faq.aspx" title="Takes you to the DoubleClick privacy faq">DoubleClick DART</a> cookie. This cookie use allows Google to serve ads to each reader based upon information it records (not including name, address, email address, or telephone number) during their visits to this site and others. You may opt out of the use of the DART cookie by visiting the <a href="http://www.google.com/privacy_ads.html">Google ad and content network privacy policy</a>.<br />
We do not work with any specific advertisers aside from the ad delivery service, Google. We receive no product samples, literature or press releases, and our books reviewed come from the public library. This means that we do not modify our content <i>in any way</i> to cater to the preferences of our advertisers.<br />
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If you notice any advertising that seems inappropriate for our site, <i>please</i> take a screen capture or copy down <i>all</i> of the content of the ad (and the url if you know how to do that) and tell us <i>exactly</i> when you saw it (date and time, please) so that we can look into the matter. Email this information to <a href="mailto:elddorie@yahoo.com" title="Opens an email to Dorie">Dorie</a>.<br />
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If you have other concerns about your privacy, the advertising or anything else you find here at the site, please <a href="mailto:elddorie@yahoo.com" title="Opens an email to Dorie">let me know</a>.Framboisehttp://www.blogger.com/profile/02371182068166822871noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-15509483293587298492009-07-21T13:20:00.000-07:002010-02-27T13:37:48.299-08:00Post-op: Getting back into shapeOne of the things women in the later stages of postop recovery often ask on <a href="http://health.groups.yahoo.com/group/HysterList/">our message list</a> 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.<br />
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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.<br />
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Physical Therapy</h3>
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.<br />
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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).<br />
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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.<br />
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Early recovery activity</h3>
We may not think of it as exercise, but many of the things we do early on are in fact just that.<br />
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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.<br />
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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.<br />
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<b>Walking is our first and most important exercise</b>, 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.<br />
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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.<br />
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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.<br />
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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, <b>we'll all vary on what the right amount of exercise is for our own bodies</b>. 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.<br />
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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.<br />
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Other early exercise</h3>
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.<br />
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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.<br />
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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.<br />
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Getting that belly flat</h3>
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.<br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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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 <i>do</i> 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.<br />
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Other exercises</h3>
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.<br />
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At the same time, we still need to limit the jouncing and shear motions to our abdominal contents. For this reason, <b>running and bicycling are not considered good early reconditioning activities</b>. 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.<br />
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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.<br />
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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.</blockquote>
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.<br />
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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 <i>and</i> avoiding injury than just taking the word of some jock at the gym.<br />
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For those looking to resume yoga practice, standing in <i>tadasana</i> or moving to sit in <i>balasana</i> 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.<br />
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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.<br />
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No firm rules other than good sense</h3>
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. <b>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.</b> 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.<br />
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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.Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-36074208241339385482009-05-01T14:55:00.000-07:002010-02-27T13:53:04.430-08:00For the guys and the women who live with them: hysterectomies, sexuality and old wives' talesA hysterectomy is a daunting prospect for many men, and there are several concerns that men whose partners are facing a hyst typically have.<br />
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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.<br />
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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. <br />
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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.<br />
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So there are some valid concerns here. Let's look at what is really involved.<br />
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Procreation and fertility</h3>
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.<br />
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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.<br />
<h3>
Before surgery</h3>
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 <i>very</i> 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.<br />
<br />
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.<br />
<br />
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.<br />
<h3>
After surgery</h3>
Following surgery, there is a two-fold recuperation period that should be observed.<br />
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 <a href="http://hyst.blogspot.com/2004/09/healing.html">elsewhere on this site</a>, 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.<br />
<br />
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 <i>any</i>thing that goes into the vagina.<br />
<br />
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 <i>literally</i> 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.<br />
<br />
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 <i>other</i> than penetration between the time when she is cleared for orgasm and when she is cleared for penetration.<br />
<br />
So it's not sex <cite>per se</cite> that is ruled out; it is only some forms of sex and that for the woman. <b>So long as a couple is willing to be flexible, this period does not necessarily need to be one of deprivation for a man.</b> 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.<br />
<h3>
Resuming sexual relations</h3>
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<h3>
Menopause means drying up down there, right?</h3>
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 href="http://hyst.blogspot.com/2004/09/ovarian-failure-following-hysterectomy.html" title="Takes you to more information about this topic here on this website">a good chance of entering menopause</a> 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.<br />
<br />
Let me stop right here and say: not true. <b>Sex goes on and female desire goes on.</b><br />
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.<br />
<br />
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 <a href="http://surmeno.blogspot.com/p/contents.html" title="Takes you to that site">Survivor's Guide to Surgical Menopause</a>. 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.<br />
<h3>
Local hormones: vaginal health</h3>
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.<br />
<br />
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 <i>feel</i> 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.<br />
<br />
Current research suggests that about <a href="http://www.medscape.com/viewarticle/561934_print" title="Takes you to the source of this figure on another website; free signup required to read">50-60% of menopausal women</a>, 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.<br />
<br />
Here's the good news and why it's so tragic that women and their doctors don't deal more openly with it: <b>it's fully treatable</b>. 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.<br />
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.<br />
<br />
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 <a href="http://surmeno.blogspot.com/2009/03/vaginal-dryness.html" title="Takes you to a post on that site about this topic">vaginal atrophy and its treatment</a> 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.<br />
<br />
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.<br />
<br />
Let me restate that: <b>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.</b> 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.<br />
Okay, so what about if that doesn't do it? Then what?<br />
<br />
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.<br />
<h3>
Structural damage</h3>
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.<br />
<br />
How could that happen? Several ways, in fact.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.)<br />
<br />
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.<br />
<h3>
But won't they shorten my vagina?</h3>
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.<br />
<h3>
Back to the hormone question</h3>
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 href="http://hyst.blogspot.com/2004/09/ovarian-failure-following-hysterectomy.html" title="Takes you to more information about that on this website">a 50% risk of entering natural menopause</a> within the following five years.<br />
<br />
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 <acronym title="PolyCystic Ovary Syndrome">PCOS</acronym> 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.<br />
<br />
Again, this issue of hormonal balance and adequacy is a very large and complex topic and you really belong over at the <a href="http://surmeno.blogspot.com/p/contents.html" title="Takes you to their table of contents">Survivor's Guide</a> for it. But let me run through a quick overview.<br />
<br />
<b>Estrogen provides the foundation for our libido and sexuality.</b> 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 <a href="http://www.medscape.com/viewarticle/540531_print" title="Takes you to this article; free signup required to read">Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause</a> 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.<br />
<br />
At the Survivor's yahoo group (which is linked from their website sidebar), they've characterised the difference between the two hormones' effects thusly:
<br />
<ul>
<li>Estrogen provides for feeling sexy, for desiring sex, for becoming aroused and experiencing orgasm;</li>
<li>Testosterone provides an itch for genital stimulation.</li>
</ul>
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.<br />
<br />
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.<br />
<h3>
So, in summary, there's good news and there's bad news</h3>
The good news about hormonal balance is that it <i>can</i> be addressed and if we do a good job of restoring estrogen coverage, we generally restore libido as well.<br />
<br />
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 <a href="http://surmeno.blogspot.com/p/contents.html" title="Takes you to their website">Survivor's Guide</a> yahoo group and too detailed to undertake here. That help exists there if you need it.<br />
<h3>
What are the odds?</h3>
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 <a href="http://health.groups.yahoo.com/group/HysterList/" title="Our list home page">our yahoo list</a> 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.<br />
<h3>
Sex afterward may be a bit different, though</h3>
One thing women often agree on, however, is that arousal and orgasm may feel somewhat different post-hyst. Not worse or better; just different.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<h3>
So much for the old wives' tales, then</h3>
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.<br />
<br />
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.<br />
<br />
Does that help with your concerns? Please feel free to come <a href="http://health.groups.yahoo.com/group/HysterList/" title="Takes you to the list home page">join our message list</a> to ask more questions on any of this if you need more information.Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-4573549403675838332007-06-05T11:26:00.000-07:002007-06-05T11:27:56.775-07:00How do they do that?<p>The <a href="http://surmeno.blogspot.com/2006/07/table-of-contents-by-topic.html" title="Takes you to that website">Survivor's Guide to Surgical Menopause</a> has tipped us to two interesting pages that give operative procedure details on:
<ul>
<li><a href="http://insidesurgery.com/index.php?itemid=356&catid=54" title="Takes you to that website">Salpingo-Oopherectomy</a> (Fallopian Tube and Ovary Removal)</li>
<li><a href=http://insidesurgery.com/index.php?itemid=355&catid=54"" title="Takes you to that website">Total Abdominal Hysterectomy</a> (Uterus Removal)</li>
</ul></p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>The <a href="http://www.simpy.com/user/surmeno/links" title="Takes you to that website">Survivor's Guide bookmark account</a> has other useful and interesting stuff about surgeries, too--go check out tags like "surgery" and "hysterectomy."</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-72961817882304020992007-03-01T11:23:00.000-08:002007-03-01T11:31:03.654-08:00Transfusions as a potential blood clotting risk for women<p>We give a lot of attention to some forms of blood supply risk when we consent to a transfusion, but a newly-released <a href="http://archsurg.ama-assn.org/cgi/content/abstract/142/2/126" title="Link to abstract on publisher's site">study</a> 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.</p>
<p>In this study, researchers found that<blockquote cite="http://archsurg.ama-assn.org/cgi/content/abstract/142/2/126">Transfusion was associated with an increase in the odds of developing <acronym title="venous thromboembolism (blood clot)">VTE</acronym> 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 <acronym title="venous thromboembolism (blood clot)">VTE</acronym> (odds ratio, 1.2; 95% confidence interval, 0.8-1.7).</blockquote></p>
<p>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.</p>
<p>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 <acronym title="hormone replacement therapy">HRT</acronym> use may be forbidden, this is something to take into account when making the decision to permit a transfusion.</p>
<p>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. </p>
<dl><dt>If you want to share the content of this study, it is:</dt>
<dd><a href="http://archsurg.ama-assn.org/cgi/content/abstract/142/2/126" title="Link to abstract on publisher's site">Association Between Venous Thromboembolism and Perioperative Allogeneic Transfusion</a></dd>
<dd>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</dd>
<dd>Arch Surg. 2007;142:126-132.</dd> </dl>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1158860973717095152006-09-21T10:07:00.000-07:002010-02-27T13:57:00.617-08:00Post-op: bowel activityWhen 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.<br />
<br />
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 <i>the</i> criteria for discharge: we have to actually pass gas to demonstrate that our bowels are capable of taking up their digestive functions again.<br />
<br />
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.<br />
<br />
But those causes also provide us with a good set of things we can do to limit these unpleasant symptoms of our bowels recovering. <br />
<a name='more'></a><br />
First of all, getting off of <b>narcotics</b> 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 <i>really</i> need the level of relief narcotics provide.<br />
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<b>Activity</b> 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.<br />
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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. <b>Fiber</b> 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.<br />
<br />
With all of that fiber, though, we have to drink <b>plenty of liquids</b>. 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 <i>do</i> belch up that gas (yeah, recovery isn't pretty).<br />
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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.<br />
<br />
New research has also given us another tool: <a href="http://femailhealthnews.blogspot.com/2006/09/bowels-dont-like-to-be-touched-and.html"><b>chewing gum</b></a>. 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.<br />
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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.<br />
<br />
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 l<b>axatives</b> are not a good substitute for fiber and activity--they just are things that can help you make good use of those tools.<br />
<br />
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.<br />
<br />
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.Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1150772450137868492006-06-19T20:00:00.000-07:002009-07-21T15:03:00.886-07:00Psychological Aspects of Pelvic Surgery<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>I'd like to add to this by pointing to a continuing education module for doctors that has recently been posted on <a href="http://www.medscape.com/">medscape</a> (free registration will be required to access it): <a href="http://www.medscape.com/viewprogram/5529_pnt">Psychological Aspects of Pelvic Surgery</a>. As the article notes:</p><blockquote>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.</blockquote>
<p>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 <span style="font-style: italic;">could</span> 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 <span style="font-style: italic;">exactly</span> 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, <span style="font-style: italic;">all</span> 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.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1103608982704933382006-04-19T21:54:00.000-07:002007-01-25T10:28:37.662-08:00FDA warning on naproxen, ibuprofen, other NSAIDs<p>In case you haven't seen it elsewhere, the US Food and Drug Administration has just issued a warning that naproxen may be implicated in the same sort of heart problems as have just caused them to pull Vioxx and Celebrex. Since many women have used this for postop pain control after a hyst, thanks to its 12-hour duration of action, it's something that we should all be aware of. That doesn't mean you can't use it, but you should definitely discuss the matter with your doctor before doing so. I don't know if this will ultimately include other non-steroidal anti-inflammatories or even aspirin, so keep an eye on the news. This link may not be good for long, but you can read more on the story <a href="http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=7145299&pageNumber=0" title="Reuters article">here</a>.</p>
<p><strong>Update</strong></p>
<p>The above link, originally published in 12/04, is indeed dead now. But the FDA has finally and officially strengthened the warnings on naproxen, ibuprofen and a whole host of other non-steroidal anti-inflammatory drugs (NSAIDs). You can read the story in greater detail <a href="http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=7145299&pageNumber=0">here</a>, with all of the new precautions. </p>
<p>The main import for us is the addition of the cardiovascular risk warning, especially that of heightened clot risk. Since our surgery makes us more susceptible to clots (any abdominal surgery does; it's not specific to a hyst) and initiation of <acronym title="hormone replacement therapy">hrt</acronym> can also raise our clot risk, these things all coming together do pose an interesting quandary in pain management and our ability to discontinue narcotics (which contribute to the dreaded postop constipation) as soon as possible. There are no firm answers here, but certainly a need to discuss this with your surgeon preoperatively, when you are still (relatively) lucid—not when you are at home clutching your generic discharge instruction sheet that was actually composed four years ago and never updated, and having second thoughts about what was really said in the uproar of checking out of the hospital.</p>
<p><strong>Another update</strong></p>
<p>As of 9/06, the latest thinking seems to be that naproxen may provide a lesser risk than some of the more high-powered <acronym title="non-steroidal anti-inflammatory drugs">NSAID</acronym>s. Still, because this is an issue that is still in flux and so many individual risk factors may come into play, it looks like the best policy remains "ask first."</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1129586225780268632005-10-17T13:47:00.000-07:002009-07-21T14:58:15.083-07:00Pre-op: The hospital pre-op appointment<p>Often referred to as "the pre-op," this is different from <a href="http://hyst.blogspot.com/2004/09/questions-for-your-pre-op-appointment.html">pre-op appointments with your surgeon</a>. At that appointment (or several appointments) you explore the reasons for your hyst, make plans for many optional parts of your surgey and followup care, and sign (after discussing) your surgical consent.</p>
<p>But for "the pre-op" you'll most typically be going to the hospital and/or the office of the anesthesia group that will be providing that portion of your surgical services. Here's what you can expect at each.</p>
<h3>At the hospital</h3>
<p>You can expect to be spending some time with the billing office, getting your registration and billing information recorded and signing the multitude of forms the hospital requires before accepting you as a customer. You should bring in or be prepared to provide such information as your insurance billing details, next of kin/emergency consent contact, who will be the contact during the time you are in surgery, living will (if you have one), and any special needs you may have (a translator? assistive devices for basic communications? religious practice needs? visitor restrictions for personal safety or preference?). If you are not covered by insurance, be sure to be prepared to set up a payment schedule and ask for a discount for paying cash; bring your credit card as well.</p>
<p>You may be given paperwork to bring back with you upon admission. Be sure to check what the procedures required on the day of your admittance are: when your surgeon told you to be there at 8 am, he meant to begin the stuff <em>he</em> is concerned with; the hospital office may also need your time then, and you don't want to be late for your surgeon because of competing demands for your time. This is also a good time to ask whether you will need to stop at the billing office on your way out of the hospital when you are discharged: at some hospitals this is routine (and tiresome) and other hospitals take care of all of this at your pre-op visit, freeing you to just cruise out whenever your doctor gives the okay. Be sure to ask when checkout is during the day, lest you end up paying for an extra day's stay because you lingered an unnecessary half hour over the limit. If you plan to ask for a copy of your hospital records, this is also a good time to ask the procedure for obtaining them (although you may be referred to another department for this).</p>
<p>If you have not already had these done at your doctor's office, you may also be asked to visit the lab, x-ray and ekg to have routine pre-op studies done. Not all of these are required for all women, but generally some or all of them are simply part of a last-minute check to make sure that other problems will not interfere with your surgical procedure. Aside from the stick for blood, none of them are invasive or especially uncomfortable.</p>
<p>If you are being typed and cross-matched for blood that will be held for a possible transfusion, you may be given an ID bracelet and required to put it on. This is dorky-looking but necessary--it holds your half of the <span style="font-style: italic;">only</span> key that assures that the held blood has been tested for compatibility with your own. If you lose your key, the blood is wasted (and you'll be charged for it) as well as not available should you need it; re-matching you will take time that you may be ill-able to afford in an emergency. If wearing a paper bracelet for several days is especially distasteful for you for some reason, you may be able to negotiate having it placed around your ankle instead. If that is the case, be <em>sure</em> to let everyone know where it is on the day you're admitted (where everyone means your doctor, the circulating nurse in the operating room, and anesthesia) and ask that it be noted on the front of the chart when you are being checked in.</p>
<h3>Anesthesia</h3>
<p>The other part of "the pre-op" is generally a visit to someone from the anesthesia group. This is a special medical practice, separate from your surgeon. Typically this service is provided by a pool of doctors (anesthesiologists) and perhaps nurses (anesthetists), and you will be billed separately by this group for their services. The practitioner you see may not be the one who will care for you during your surgery, but he will write notes and perhaps some orders that will go in your chart for the person actually in the <acronym title="operating room">OR</acronym>.</p>
<p>This appointment is primarily an interview, although it is likely that the practitioner will examine your head and neck, and look into your mouth (or at your back, if you are having a spinal--and some of the following will not be applicable if that is the case). This is to identify any problems that may make putting the tube into your lungs (through which they will maintain your respirations once you are under general anesthesia) tricky. In particular, you will be asked if you have any dental appliances or chipped teeth--it's important to let them know this so that they can avoid damaging them with the instruments being used.</p>
<p>Other things anesthesia will discuss include previous experiences you've had with anesthesia and other health conditions you may have that might affect your toleration of anesthesia drugs. This is also the time to share any fears you may have about anesthesia, review any meds you may be given to relax you beforehand, and to discuss nausea in the immediate postop recovery period. If you are prone to nausea, let them know: it's possible to medicate you <em>before </em>you start puking, which can be A Very Good Thing when having abdominal surgery. If you have had bad experiences in the past with pain medications, like itchy/rash reactions, do be sure to let them know this, even if it's not a real allergy.</p>
<p>Anesthesia will review with you the timing of when you may last eat/drink anything (not <em>what</em> you may eat or drink--this may be up to your surgeon). Fasting is very very important to prevent vomiting during the process of going under--something that can cause pneumonia--so be sure you understand your restrictions and that they are for your benefit. If you plan to take some regular meds or supplements in the fasting hours before surgery, please check these with anesthesia and ask what/how much you may take them with if they are oral meds. Diabetics or asthmatics have a special need to review what they will be taking before surgery, what their normal maintenance regimens are, and how their needs will be managed during surgery and recovery. The whole goal of this appointment is to make anesthesia as successful and little stressful for you as possible, so the more you can help your anesthetist, the better things will go for you.</p>
<p>And one last note about all of the pre-op contacts you may have just before or the day of surgery: don't be surprised if, over and over, you are asked specifically what procedure you are having (and if something is happening only to one side, like only one ovary to be removed, you'll be asked to point to the involved side). This is a constant process of checking who you are and that the right person is having the right surgery--it's a much more positive identifier than asking a nervous or groggy person a question like "are you [mumbled name]?" that they might answer without really grasping. And, because it's a hyst, you may be asked several times whether you are pregnant and if you understand that having this surgery means you cannot ever again get pregnant. While this may seem like an extra added torment to many of us, it does, ultimately, protect the rights of women to understand what they are choosing. If our aggravation pays for one woman getting the message who may not previously have fully understood the implications of what she has consented to, well, don't you think it's worth it for her sake?</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1128719932878889312005-10-07T13:58:00.000-07:002007-01-25T10:31:40.347-08:00Pre-op decisions: Keeping your cervix, revisited<p>The decision to keep one's cervix may have just gotten a little simpler for some women...or their daughters, at least. As you may have noted in our <a href="http://hyst.blogspot.com/2004/09/pre-op-decisions-keep-my-cervix-or-not.html">previous discussion of this topic</a>, a certain number of women opt to have their cervix removed not because of specific cervical pathology but because they want to be protected from the risk of developing cervical cancer in the future. For these women, <a href="http://www.newsday.com/news/health/ny-hsvacc074458454oct07,0,1065744.story?coll=ny-health-headlines">news released this week</a> about a new vaccine that offers protection from the most common causes of cervical cancer may allow them to make that decision differently.</p>
<p>I'm not sure yet how and when this is going to play out. The vaccine hasn't been approved yet, but given the large test sample and the overwhelmingly positive results, I'm having a hard time believing the US <acronym title="Food and Drug Administration">FDA</acronym> is going to drag their feet in approving this.</p>
<p>The manufacturer notes that this vaccine "should" be given before a young woman becomes sexually active to "ensure" protection. This doesn't address its use in women who are already sexually active but perhaps are not yet infected and who could conceivably benefit from that protection. As with so many things to do with a hyst, this will need to be a personalized decision: weighing the risks of having been infected against the inpact cervical removal might have on one's sexual response. But as time goes by and more of the women who are faced with the need for a hyst have been protected by this vaccine, that decision to ditch a cervix for prophylactic reasons may become less urgent for many. And, all things considered, that's good news.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1124214633790553292005-08-16T10:09:00.000-07:002009-06-11T12:43:40.965-07:00Pre-op decisions: we'll just take out those ovaries so you won't have to worry about cancer<p>If you are planning your hysterectomy, or even just investigating what it would mean for you, and your doctor offers you this "recommendation," you may want to ask him to step back and explain himself in a <em>lot</em> more detail.
</p>
<p>It used to be the practice that when women were facing a hyst, a surgeon would suggest that because her ovaries "aren't needed" any more, she should have them removed now so as to remove the risk of later getting ovarian cancer. In many cases, this would include the suggestion that "most" women who retain ovaries only end up needing another surgery later to remove them anyway.
</p>
<p>Today we know that this kind of a sales pitch is not only medically inaccurate but is in fact a strategy that holds greater odds of shortening a woman's life than the alternative. And, slowly, doctors who keep up with the news in this field are revising their recommendations to a more accurate representation of the various risks.
</p>
<p>Much of this turnaround can be credited to this study, published in the May, 2009 issue of the journal Obstetrics & Gynecology: "<a href="http://journals.lww.com/greenjournal/Fulltext/2009/05000/Ovarian_Conservation_at_the_Time_of_Hysterectomy.11.aspx" title="Download a copy">Ovarian Conservation at the Time of Hysterectomy and Long-Term Health Outcomes in the Nurses’ Health Study</a>." For something that may be a little less intimidating to read, you might try this article at webmd: "<a href="http://women.webmd.com/news/20090421/hysterectomy-spare-ovaries-boost-health" title="Takes you to the article">Hysterectomy: Spare Ovaries, Boost Health?</a>." Yet another good resource is the anonymous but probably related to the study website <a href="http://www.ovaryresearch.com/index.htm" title="Takes you to the site home page">OvaryResearch</a>, which focuses on the study and discussion it's stimulated as well as an earlier version of it that appeared in 2005.
</p>
<h3>Okay, enough with the citations: what's this about?
</h3>
<p>The study, which involved a very large pool of women (that's good, because it means the results are more likely to really reflect us all), found that rather than lowering deaths from cancer, prophylactic oophorectomy (that's the fancy way of saying taking out ovaries for the sake of prevention) in fact had a higher risk of death from all causes but mostly heart disease and lung cancer. That's right: <strong>removing our healthy ovaries at <em>any</em> age does not lengthen our lives or improve our health</strong>.
</p>
<p>Further, although breast and ovarian cancer <em>rates</em> were lower in women who had their ovaries removed, the risk of death from <em>all</em> types of cancer was higher in these women. So, yes, the very thing we feared and chose this option in hopes of preventing is actually <em>more</em> likely to happen to us than if we'd left well enough alone.
</p>
<p>And the rates of death are highest for women who never supplemented their hormones after the surgery. All those women who valiently toughed out menopausal symptoms because they thought it was the right and "natural" thing to do were in fact working with their doctors to shorten their own lives.
</p>
<p>Tragic, right? And we're talking a big tragedy here: about 300,000 women a year choose to have this surgery under the impression that it will help them live longer, healthier lives. According to the main study author, that's "50% of women who have a hysterectomy between ages 40-44...and 78% of women between ages 45-64," even though it's well demonstrated that post-menopausal ovaries continue to contribute to our hormonal support, a support that's lost when we take those ovaries out.
</p>
<h3>But wait! What about women at real risk for cancer?
</h3>
<p>Yes, of course there are women for whom the risks boil down to high expectation of death by breast or ovarian cancer vs later death by these risks of lost hormones. That's a special situation and no one is suggesting that preventative removal of ovaries might not be the right choice for them.
</p>
<p>But it needs to be an <em>informed</em> choice. That means not just making the assumption that because there's "a lot of cancer" in one's family that we are, personally, at risk for these specific cancers. It requires genetic testing and evaluation by an oncological specialist, not an assurance of a gyn surgeon who heard the word "cancer" and got spooked into a slash-and-burn mentality.
</p>
<h3>Can't I just take something to make up for that risk?
</h3>
<p>For many of us, the idea of cancer is so terrifying that it shorts out our brains. Especially if we're younger women and few of our peers have died of things we attribute to aging, we may not feel that the risk of heart attack or stroke is all that vivid or personal.
</p>
<p>One of the <a href="http://www.ovaryresearch.com/professional-responses.htm#letter2">objections</a> to the recommendations of this study, that more women keep healthy ovaries, is that this risk can be treated medically with statins, drugs that lower cholesterol and lipids that are believed to be a major cause of heart disease, and bisphosphonates, drugs that preserve bone density. As the study author <a href="http://www.ovaryresearch.com/professional-responses.htm#reply">replies</a>, however, these drugs have notorious dropout rates, just as <acronym title="hormone replacement therapy">HRT</acronym>s do. Taking out a healthy body part <em>and</em> replacing it with drugs that must be taken for the rest of our lives and may have significant side effects of their own: if we look at it that way, how much sense does that make?
</p>
<p>And then there are the women who want to do it "all naturally." What do they do? Exercise and healthy eating are important lifestyle strategies for minimizing cardiovascular and osteoporosis risks, but alone they probably aren't enough for most women, not to mention that they too are something that sounds better in concept than they are actually adhered to for every remaining day of our lives. Menopausal nutraceuticals, the raw plant estrogenic compounds that are sold to reduce hot flashes in natural menopause, are relatively ineffective in coping with the level of symptoms seen with the larger drop in hormone levels due to ovarian removal. And they entirely fail to address many of the more serious effects of hormone deficiency...such as the ones that lead to the risks cited in the study. In fact, this is not a natural situation and there is <em>no</em> natural solution that makes up for it.
</p>
<h3>But my ovaries are diseased: what should I do?
</h3>
<p>No one is suggesting that women should not treat existing ovarian disease with surgery. But this study does suggest that we should balance our treatment options against the risks, and those risks are more sizable than our previous understanding led us to believe.
</p>
<p>Some ovarian disorders don't require removing the whole ovary to treat, and these are poorly paid back by the increased risks.
</p>
<p>But some disorders do require removal for definitive treatment. Sometimes, other diseases are best treated by removing our ovaries. In these cases, however, we still need to understand the costs of that treatment and we need to understand how to mitigate those costs, whether that's drugs or <acronym title="hormone replacement therapy">HRT</acronym> or simply accepting that we have chosen that direction for our lives rather than the one that would have resulted from our ovarian disease.
</p>
<p>We need to know that not having ovaries means more than not having ovarian disease.
</p>
<h3>You have to make up <em>your</em> own mind</h3>
<p>This is a complex issue. Many things that can go wrong with our ovaries still don't require that we give up our ovaries. Nothing going wrong with our ovaries <em>really</em> doesn't seem to require their loss. The things at the other side of that equation, heart and lung disease chief among them, kill many, many more women every year.
</p>
<p>Just as we don't necessarily believe the car salesman that the extras he's recommending will do anything more than provide him with higher profits, so we shouldn't necessarily believe the person we'll be paying to do our surgery that the extras he's recommending are more valuable to us than him. This is where second opinions are so important, getting an opinion from a doctor who doesn't profit from that advice. And where we're worried about cancer risks, we should talk with an oncologist to make sure we're evaluating our own risk accurately and not just spooked by the word itself.
</p>
<p>This study did nothing to simplify our decision with respect to a hyst except for one thing: we simply shouldn't accept "as long as you're having a hyst" as a good reason to give up our ovaries. Because when you hear that phrase, you now know enough to hear the unspoken rest of it: "as long as you're having a hyst, why not let me give you a higher chance of an early death by heart disease or cancer?" And we simply don't need that.
</p>
<p style="font-style: italic">[Note: This essay was revised in June 2009 to include the results of the May 2009 study.]</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1124209582746094072005-08-16T09:13:00.000-07:002014-11-26T10:49:29.053-08:00Table of contents by topic<h3>
General information</h3>
<ul style="list-style-type: none;">
<li><a href="http://hyst.blogspot.com/2004/09/hysterectomy-terms-and-abbreviations.html">Hysterectomy terms and abbreviations</a></li>
<li><a href="http://hyst.blogspot.com/2007/06/how-do-they-do-that.html">How do they do that?</a></li>
<li><a href="http://hyst.blogspot.com/2009/05/for-guys-and-women-who-live-with-them.html">For the guys and the women who live with them: hysterectomies, sexuality and old wives' tales</a></li>
<li><a href="http://hyst.blogspot.com/2014/11/update.html">Time has passed; has anything changed?</a></li>
</ul>
<h3>
Pre-op concerns and decisions</h3>
<ul style="list-style-type: none;">
<li><a href="http://hyst.blogspot.com/2004/09/questions-for-your-pre-op-appointment.html">Questions for your pre-op appointment</a></li>
<li><a href="http://hyst.blogspot.com/2004/09/preop-concerns.html">Preop concerns</a></li>
<li><a href="http://hyst.blogspot.com/2004/09/pre-op-decisions-keep-my-cervix-or-not.html">Pre-op decisions: Keep my cervix or not?</a></li>
<li><a href="http://hyst.blogspot.com/2005/10/pre-op-decisions-keeping-your-cervix.html">Pre-op decisions: Keeping your cervix, revisited</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/pre-op-packing-list.html">Pre-op: Packing list</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/is-hysterectomy-like-c-section.html">Is a hysterectomy like a C-section?</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/bladder-suspension.html">Bladder suspension</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/pre-op-decision-surgical-route.html">Pre-op decision: Surgical route</a></li>
<li><a href="http://hyst.blogspot.com/2004/11/pre-op-fear.html">Pre-op: Fear</a></li>
<li><a href="http://hyst.blogspot.com/2004/12/pre-op-what-if-i-am-getting-sick-right.html">Pre-op: What if I am getting sick right before surgery?</a></li>
<li><a href="http://hyst.blogspot.com/2005/01/pre-op-planning-for-medications-well.html">Pre-op: Planning for medications we'll be receiving</a></li>
<li><a href="http://hyst.blogspot.com/2005/06/hysterectomy-or-cancer-are-you-sure.html">Hysterectomy or cancer: Are you sure?</a></li>
<li><a href="http://hyst.blogspot.com/2005/08/pre-op-revisiting-question-of-keeping.html">Pre-op: Revisiting the question of keeping healthy ovaries</a></li>
<li><a href="http://hyst.blogspot.com/2005/10/pre-op-hospital-pre-op-appointment.html">Pre-op: The hospital pre-op appointment</a></li>
<li><a href="http://hyst.blogspot.com/2006/06/psychological-aspects-of-pelvic.html">Psychological Aspects of Pelvic Surgery</a></li>
</ul>
<h3>
Post-op concerns</h3>
<ul style="list-style-type: none;">
<li><a href="http://hyst.blogspot.com/2004/09/healing.html">Healing</a></li>
<li><a href="http://hyst.blogspot.com/2004/09/postop-home-alone.html">Post-op: Home alone</a></li>
<li><a href="http://hyst.blogspot.com/2004/09/ovarian-failure-following-hysterectomy.html">Ovarian failure following hysterectomy</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/postop-should-i-call-my-doctor.html">Post-op: Should I call my doctor?</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/postop-walking-and-prevention-of.html">Post-op: Walking and the prevention of surgical complications</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/postop-bladder-matters.html">Post-op: Bladder matters</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/postop-pain.html">Post-op: Pain</a></li>
<li><a href="http://hyst.blogspot.com/2004/10/postop-sleep.html">Post-op: Sleep</a></li>
<li><a href="http://hyst.blogspot.com/2006/09/post-op-bowel-activity.html">Bowel activity</a>: gas and constipation</li>
<li><a href="http://hyst.blogspot.com/2004/11/will-i-be-in-menopause.html">Will I be in menopause?</a></li>
<li><a href="http://hyst.blogspot.com/2006/04/fda-warning-on-naproxen-ibuprofen.html">FDA warning on naproxen</a>; <a href="http://hyst.blogspot.com/2006/04/fda-warning-on-naproxen-ibuprofen.html">update</a></li>
<li><a href="http://hyst.blogspot.com/2005/01/operative-uncertainties-why-did-i-come.html">Operative uncertainties: Why did I come out of the <acronym title="Operating Room">OR</acronym> with a different diagnosis?</a></li>
<li><a href="http://hyst.blogspot.com/2009/07/one-of-things-women-in-later-stages-of.html">Post-op: Getting back into shape</a></li>
</ul>
<h3>
About this site</h3>
<ul style="list-style-type: none;">
<li><a href="http://hyst.blogspot.com/2009/09/advertising-and-your-privacy-here-on.html">Advertising and your privacy here on the site</a></li>
</ul>
Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1119491920499155402005-06-22T18:45:00.000-07:002007-01-25T10:43:45.687-08:00Hysterectomy or cancer: are you sure?<p>I happened across an interesting <a href="http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=8864089&src=rss/healthNews">news item</a> today, a report of a newly released study in the June 2005 issue of <span style="font-style: italic;">Psychosomatic Medicine</span>.</p> <blockquote><p>Many women who have their uterus removed for benign conditions may mistakenly believe that, unless they have the surgery, they're likely to develop cancer, a new study suggests.</p>
<p>Researchers found that among more than 1,100 women who underwent hysterectomy for non-cancerous conditions, 29 percent said they had "a lot" of fear that they would develop cancer, without the surgery. The large majority, 80 percent, reported at least "a little" fear. </p></blockquote>
<p>The report goes on to question whether this misunderstanding is rooted in the explanations doctors are giving their patients for their options. For some of the most common reasons for a hyst, there are other treatment options that may be applicable, but women may not choose them out of (a groundless) fear of cancer.</p>
<p>So for every woman who is contemplating this surgery, it's vitally important that you ask your doctor explicitly why he is recommending this treatment approach and what explicitly are the consequences of not treating it this way. If you hear the word tumor (as is often used in discussing fibroids), are you sure whether you are talking benign (harmless) or malignant (can kill you)? If not, ask your doctor: is my condition cancer? will I get cancer if I don't do this? Your doctor knows what he's talking about, but his assumption that you do too may not be well-founded. It's always better to say something like "just to be sure I understand what we're talking about here, <span style="font-weight: bold;">do I have cancer now or will I in the future if I don't have a hyst?</span>" than to undergo medical treatment that may be more extreme than you really want because you didn't get the unspoken message.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1105905503121588832005-01-16T11:34:00.000-08:002009-07-21T14:41:03.246-07:00Pre-op: planning for the medications we'll be receiving<p>In the course of some discussions we've been having on the list, I've realized how difficult--and yet how important--it can be to make sure that our medication preferences, sensitivities, and allergies are taken into account in the planning process. While most of us know about pre-existing allergies and know that we need to tell our doctors, anesthesiolgists and caregivers about them, it's more of a grey area in the case of sensitivities or strong preferences. How can we anticipate what we might be given in order to tell our doctors what we need them to know when we have, for the most part, little idea of what we'll be getting? I thought that you might like to know the general outlines of what you can expect in terms of medications throughout your surgical experience. Mind you, these are <em>just </em>generalities, so you'll need to do the work of talking with your doctor and fleshing out the details.</p>
<p>Starting with the at-home pre-op phase, many women are told to use a specific laxative bowel prep, with various doctors preferring different combinations of agents. Some doctors do not order this, and it should <em>not</em> be done unless it's ordered. You may be able to negotiate the actual laxatives used if you have specific preferences.</p>
<p>In the in-hospital pre-op process, you will probably receive a sedative/amnesiac agent (Versed is one commonly used, but there are many others and it's a matter of physician/anesthesiologist preference) and this may be mixed with other drugs, such as atropine, that dry up your nasal/oral secretions and assist with anesthesia (generally those receiving a general get this). Once your IV is started, you may also be given an initial dose of an antibiotic.</p>
<p>One other thing that might pose a problem for some women in the pre-op surgical routine is exposure to a skin cleanser called Betadine. This is an iodine-based scrub that is typically used to prep before incisions. Not only is it used to scrub your belly if you're having an abdominal incision, but you may be asked to douche with it beforehand, in order to begin decreasing the number of bacteria in your vagina. This can be a harsh agent and there are a certain number of women who are simply allergic to it. If you've not encountered it before or not used it on delicate vaginal tissues, ask for a sample betadine scrub so you can do a test before using the douche. I know that I can have betadine on regular skin without any problem at all, but when I tried a little test scrub on my labia, the burning was horrific even though I washed it off immediately! I reported this to the prep nurse the next day when she tried to send me off to do the douche, and she agreed that the doctor would not want to do surgery if the prep left me blistered and burning. There are other cleansers they can use, so if you're in any doubt, ask your doc at your preop and ask for a sample to test out yourself at home before committing to placing it where it is not, ahem, easily removed.</p>
<p>In the <acronym title="operating room">OR</acronym> you will receive a great many drugs, depending upon the anesthesia you choose. These are under the control, for the most part, of your anesthesiologist, and that is who you need to discuss this part with if you have any specific drug concerns. As a rule, general anesthesia today is much less stressful on the body than it was even a decade ago, so your mother-in-law's account of her reaction to surgery she had 40 years ago may not be entirely predictive of your experience. Spinal or epidural anesthesia also involves drugs given systemically as well as locally, so you will again have to review with your anesthesiologist exactly what his plan is.</p>
<p>In Recovery, you may receive an antinausea drug (it's possible to request preoperatively that you be medicated for nausea before you experience it, if you're worried about the possibility or previous experience leads you to believe you're prone to vomiting). You will receive pain medication IV (typically morphine or demerol) and perhaps, depending upon elapsed time, another dose of antibiotic. If your doctor is one who favors this approach, you may also be given IV Toradol, which is an anti-inflammatory of the aspirin-ibuprofen (<acronym title="non-steroidal anti-inflammatory drug">NSAID</acronym>) family. Given the recent questions raised about the Cox-2 family of drugs and heart disorders, if you have any cardiac disease, you should discuss the use of this entire family (Cox-2 and <acronym title="non-steroidal anti-inflammatory drug">NSAID</acronym>) with your cardiologist as well as your surgeon, both in terms of operative use and home use of oral anti-inflammatories.</p>
<p>Postop pain control tends to be IV at first, then gradually moving to <acronym title="intra-muscular">IM</acronym> (shots, usually in the big muscle of the butt) or perhaps straight to oral. Morphine and demerol remain the most common but there are other agents that may be used. Some doctors continue the additional Toradol so long as you have an IV. Women who retain a spinal may be also getting morphine via that mode. When the transition to orals is made, they typically are one of the codeine blends although some women go straight to oral anti-inflammatories.</p>
<p>Many doctors will also place you on anticoagulant shots starting in the <acronym title="operating room">OR</acronym> and continuing for at least a day until you are up and around enough that the risk of clotting is lowered. These are tiny sticks into the fat pad of your belly, and may be the source of small bruises you'll see there. Because these shots are given early in our recovery when we're pretty bleary, many of us don't remember them at all and wonder about the tiny bruises. The drug is called heparin.</p>
<p>In the postop (in-hospital) period there may be several more doses of antibiotic and usually the introduction of stool softeners once you can take oral meds (once your bowels have begun making sounds signifying they are functioning). Additional vitamins or iron supplements may be ordered for those whose blood counts are low (but <span style="font-style: italic;">do not</span> resume taking your own vitamins till you get the okay from your doc--if you double up on some of them because you're taking yours and getting some from the hospital, you can set yourself up for bleeding and other risks). If you are having problems with gas the best remedy is walking but some doctors will also order Gas-X or similar drugs to help ease the discomfort.</p>
<p>And those are all the usual things I can think of that might be a problem. Obviously if you take drugs for other problems, you'll be resuming those postoperatively and should be sure that you <span style="font-style: italic;">do</span> get them if they are needed and that you get the doses you normally take unless you and your doctor have discussed making some temporary change. You may need to remind your doctor about pre-existing prescriptions, especially if they are prescribed by other doctors, so they don't forget to resume them in your postop orders. Don't assume that they are being omitted for some good reason unless you have specifically discussed doing so with your doctors--docs forget things that are outside their own routines for their surgeries, and it's up to us, ultimately, to guard our own interests.</p>
<p>It's a good idea for each of us to think through whether any of these drug families are a problem for us--if so, early discussion with our doctor and/or anesthesiologist will help alleviate the risk of negative reactions when you are least likely to want them: during or immediately after surgery. What if you've never had any of them? Our caregivers are alert for negative reactions, but we have a certain burden on us to report them as well. For example, if you are sensitive/allergic to morphine, you may experience annoying itching of your nose and eventually itching all over. So it's a good idea, if you start itching and have a morphine pump, to speak up early and often in asking to change to something else.</p>
<blockquote><p>I know that I got one push of my morphine pump done by the nurse as I was getting into bed when I got to my room from Recovery, and I spent over 24 hours trying to rub my nose off my face. Luckily I didn't need the morphine again--Toradol was plenty of control for me even with a fairly sizable abdominal incision--and so it was not something I had to deal with. But this is someplace where having a friend or family member in the hospital can help us: in those first postop hours when we're too snowed to put things like this together or to advocate strongly for our needs, someone with us who can help us deal with these things can be very valuable.</p>
<p>My sister was the one who made the nose/morphine connection for me (I hadn't noticed I was doing it--yeah, that's how groggy), and so when I got up and the nurse went to hit the pump, she intervened and asked me if I felt I needed the morphine in the light of the reaction I might be having. I agreed that no, I felt as though I could try it without, and so I went staggering merrily off down the hall with the two of them following along shepherding my assorted catheter/IV/whatever (in retrospect I think that maybe the morphine made me more than a touch goofy, too, but at least I was up and moving). And by the next morning I was more alert and thoughtful and could take care of myself again, even though my concentration was as impaired as anyone's whose just had a general. So that is a little cautionary tale for those who are wondering what this actually works out to be like, if we have a mild sensitivity reaction.</p></blockquote>
<p>To help you do some drug-related research, if you are unclear on exactly what drugs are related, what they include and what side effects they carry, these links might be useful:</p>
<ul><li><a href="http://www.rxlist.com/">Rx list</a></li>
<li><a href="http://www.herbalsafety.utep.edu/">Herbal safety</a></li></ul>
<p>The main takeaway point here is that it's up to us to judge how we're responding to what we're getting, not only in terms of whether we are getting, say, adequate pain relief from our meds, but whether they are suiting us in other ways as well. Remember that there are alternatives for <em>all</em> drugs, so gritting your teeth and putting up with something is really not necessary for anything other than the convenience of your caregivers. And that's not who it's about, is it?</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1104607612219744612005-01-01T11:15:00.000-08:002007-01-25T10:50:13.223-08:00Operative uncertainties: why did I come out of the OR with a different diagnosis/surgery from the one I went in with?<p>I read many comments from women who are surprised to wake up from surgery without their ovaries when they thought they were only having their uterus removed, or who find that they have a whole new shopping list of diagnoses that they never expected when they went in. <span style="font-style: italic;">How can this happen?</span> they ask. <span style="font-style: italic;">They told me that these things "might" happen but were not likely.</span></p>
<p>Doctors really get in a bind between trying to prepare you for all the eventualities and to steer you so that you're not totally overwhelmed with fear of things that just aren't likely at all. It's a hard call, and it's made vastly more difficult because the diagnostic tools we have just aren't that accurate.</p>
<p>That's right: for all the ultrasounds and MRIs and CAT scans and all those advanced tests, there's just nothing that is anywhere near as accurate as opening us up and looking around. It's a <span style="font-style: italic;">very</span> common thing for women to go into the OR with one diagnosis and come out with either a different one entirely or a whole raft of unexpected discoveries.</p>
<p>For example, endo seems to be a surprise discovery in about half (that's a seat-of-my-pants guesstimate based on what I read online, not a firm statistic) of the women who have a hyst and endo--it's never suspected or diagnosed pre-operatively in a surprising number of cases. Another surprise diagnosis is adenomyosis, which will turn up in a hyst done for fibroids or endo without ever having shown up well in diagnostic imaging. Sometimes extensive scarring or damage from other disorders, as in a case where large fibroids actually damage ovarian circulation, is what makes the deciding difference in the operative plan, and yet scarring is virtually invisible to most diagnostic techniques. Women who have suffered from pains and miseries all their lives and who were told they simply had to put up with it as their lot in being women often are astounded and validated when they return from the <acronym title="Operating Room">OR</acronym> with a whole shopping list of abdominal pathologies that remained elusive until the surgeon actually got a good, personal, eyeballs look.</p>
<p>The fact is, a preoperative diagnosis, while informed by every skill the doctor can bring to bear, remains only an educated guess. I think this is one reason why, unless the diagnosis is very well-defined indeed, women may be well served by having that abdominal incision. I know that I felt that since I was having the surgery one way or another, I wanted to know that as of that date, there were no more lurking surprises that might have been missed by the more limited vag approach (well, that plus the fact that my uterus was roughly the size of a steamer trunk and I strongly suspect they brought in a fork lift after I was anesthetized to get that monster out). I don't think that this is in itself necessarily a compelling enough reason to choose this route, but it is certainly an added peace of mind that helps offset those first few days when the incision is most troubling.</p>
<p>So I would have to say, after the years I've been involved in the hyst community online, that a pre-op diagnosis is only a "best guess" and that a wise woman and her doctor consider it a very open-ended proposition. And because our ovaries are rather fragile organs, I think that however much we may hope to keep them, they have to be considered at high risk for possible removal.</p>
<p>A prudent woman facing surgery should make her feelings known very clearly to her surgeon on what her stance is on ovarian pathology. I think most of us would okay removal immediately if cancer were suspected. Short of that, however, are a lot of grey-area calls. Do you want suspicious ovaries removed "just in case" or do you want them biopsied with the option of later (minor surgery with laparoscope) removal if indicated? Many doctors feel that after age 45 ovaries represent more liability than value (although <a href="http://www.sciencedaily.com/releases/2006/09/060915103831.htm">that may be changing</a>), on the premise that our bodies need hormones for nothing other than fertility. Many women in menopause disagree with this, and it's something that it's best to think out in advance (a brief hormone education that might help you explore this further is <a href="http://surmeno.blogspot.com/2006/07/table-of-contents-by-topic.html">here</a>) lest your doctor make a decision for you that you would not have favored had you been a party to it.</p>
<p>At the very least, you can ask your surgeon: under what conditions during the surgery will you remove my ovaries--what are the decision points for you? And if you disagree or think the matter requires evaluation at the time of surgery, you can modify your operative permit to include the specification that if ovarian removal is indicated based upon surgical findings, you only will grant consent for it through [your personal rep named in the permit, whom you have prepped with your views in great detail and whom you trust to carry out your wishes as best they can]. In such a case, the surgeon would have to contact that person (who would obviously be standing by in the waiting room through the surgery), explain the situation, and receive their consent for whatever option is proposed. This is not an unheard-of option, and one that women who have strong feelings about their ovaries have successfully taken.</p>
<p>So while there are unknowns we all face when we go into surgery, good planning and frank "what if" discussions with our doctors can help make sure we're better prepared for those uncertainties. When your doctor runs through that list of "possible but not likely" outcomes, stop him and ask: <span style="font-style: italic;">but what if that does happen? What then? What are my choices? What will those choices mean for my future health?</span> And if you feel you need to, you can add language to your operative permit to specify that in a "what if" situation, the doctor will perform the option you prefer.</p>
<p>We can't eliminate the unknowns--they're part of the package--but we can prepare for them as well as possible so that the fear of them beforehand and the way we deal with them afterwards are at least less stressful for us. And we certainly can use a little stress reduction as we're facing this surgery.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1103392995812582942004-12-18T09:25:00.000-08:002007-01-25T10:56:03.141-08:00Pre-op: What if I am getting sick right before surgery?<p>So you've got your surgery scheduled, been through the pre-op appointments, got your prep ready to go and have the time when you're supposed to report to the hospital. And then it begins about a week before surgery: first a tickly throat, then a little sinus congestion, pretty soon a cough and before you know it, you're coming down to the wire and you're undeniably getting a big nasty ol' virus.</p>
<p>And this is the time of year when we see this most. The holiday season and early January seem to be popular times to schedule a hyst, but that's right at a time when holiday preparation stresses plus the higher exposure from shopping and visiting make us both more vulnerable and more available to pick up any little respiratory bug that's going around. And, of course, least wanting to see this happen. But it does, frequently.</p>
<p>The first thing to do is admit that <strong>wishful thinking is most likely not going to be an effective tactic</strong>. Waiting and hoping that it will go away is only going to take you down to the wire without having made any preparations for dealing with the situation. Here's the bottom line right away: yes, <strong>your surgery will canceled if you are sick when you arrive at the hospital</strong>. And that's as it should be: plans are one thing, but in some cases it simply <em>isn't safe</em> to have anesthesia and surgery when you are already ill. Is keeping to a schedule to die for, literally? Rationally: not. I'm not saying you don't deserve a few tantrums on the subject--<em>it is</em> woefully unfair. But there you have it.</p>
<p>So how do you cope with this? By admitting what's going on as soon as you notice it. Don't hide your head in the sand and do the wishful thinking thing. Instead, at the first suspicion of illness, start taking mega-good care of yourself. Most winter illnesses are viral, which means that antibiotics won't help them. The most important thing to do with a viral illness is supporting your own immune system's work in fighting it off. These are old trite remedies, but they remain the best:</p>
<ul>
<li><strong>Do</strong> get plenty of fluids.</li>
<li><strong>Do</strong> rest when you are tired (I know, that's hard to do when you merge pre-op panic with holiday panic, but go back up and reread that bottom line if you're waffling).</li>
<li><strong>Do</strong> turn to the fruits and vegies for vitamins and get plenty of them, every day before surgery.</li>
<li><strong>Don't</strong> chug the vitamin pills: some of those may be on your list of things to stop pre-op because of effects they may have on blood clotting.</li>
<li><strong>Don't</strong> eat aspirin or tylenol thinking you're helping out: your body uses a mild fever to help fight infection, so unless it's very high, it's helping rather than hurting.</li>
<li><strong>Don't</strong> gobble cold remedies or herbs: many of them also suppress your own defenses or contain things that are contraindicated before surgery.</li>
</ul>
<p>If you are down to that final week and counting, coming down with something also means that <strong>you need to call your surgeon</strong>. Yes, it does. Waiting until Friday night after office hours are over before you finally admit that you're not going to be well by your 7 am Monday surgery call cuts it too fine. That robs you of planning and effective treatment time, and is discourteous to the surgical staff who are expecting to see you in the OR on Monday morning. If you are in that final week and feeling the first sneaky tendrils of viral invasion or you've been fighting something all last week and aren't sure you're going to make it in time, pick up the phone at the start of that week and make your confession.</p>
<p>Your doctor will be the best person to advise you on whether you need to be evaluated in the office and on what particular remedies may or may not be safe preoperatively. And by bringing him in early, you are being both considerate of his time and giving him a chance to help that surgery actually be able to happen as scheduled. The antibiotics you receive during surgery are <em>not</em> going to turn a chest cold around and your anesthesiologist <em>isn't </em>going to want to work with someone with a head and chest full of snot. If you are down to the wire and it's the weekend before a Monday surgery, go ahead and call the office number and tell the answering service you have a Monday surgery, are sick, and need to speak with the on-call person covering for your doctor. Don't try to second guess your doctors with just <em>how</em> sick you are: the decision on how sick is too sick is a specialized one they need to make.</p>
<p>And if you need to reschedule, the person who has let their doctor and hospital staff know in advance that this is a pending situation and a possibility is going to get <em>way</em> better service than someone who shows up at the hospital Monday morning in no shape to go to the <acronym title="Operating Room">OR</acronym>. And <em>don't</em> you want your surgical team on your side? I thought so.</p>
<p>Please do the mature and responsible thing, here. If you're suspecting illness and you're down to the final week before surgery, get in touch with your doctor and stay in touch. Make arrangements on Friday (or right before a holiday) if you think the situation will remain volatile through the weekend before a Monday/post-holiday surgery. It happens. Your doctor knows it; your <acronym title="Operating Room">OR</acronym> team knows it. No one will blame you--<em>if</em> you do everything responsible to keep everyone informed and seek advice early. They'll get you rescheduled as soon as possible if you have to cancel. That's not ideal, but that's better than trying to go into the OR already sick. That's not good for <em>any</em>body involved.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1100312361391982702004-11-12T17:44:00.000-08:002009-07-21T14:22:34.535-07:00Pre-op: Fear<p>It's a truism of hysterectomies that the waiting for the surgery is the worst part of the whole thing. And like any truism, there's a great deal of validity in that statement. For most of us, a hyst may be our first experience of major surgery. For others, we know it's a gamble for better health and so it's reasonable to be edgy. Frankly, anyone who<span style="font-style: italic;"> isn't</span> worried at the prospect of a hyst is more worrisome to me.</p>
<p>But for other women, the fear is deeper and both more specific and more disabling. I read comments like "I'm terrified of anesthesia. I'm sure I'll never wake up." Or "I'm really having second thoughts because I don't want to be turned into a menopausal demon." I've read about women who have jumped up off of the cart headed to the OR and turned around and gone home. I've read about women who have canceled and rescheduled their surgeries so many times they are finally "fired" by their surgeon. For some women, fear is immobilizing.</p>
<p>But a lot of the time, there are things we can do to deal with this level of fear...and need to. When we face surgery with the strong conviction that we are going to die or when we are terrorized by the image of a hot flash as the fast track to doom, we're setting ourselves up with stress and worry to just make the entire situation worse. It's been well proven that lowering stress contributes significantly to our health during surgery and our recovery.</p>
<p>Instead, we can take back control of a terrifying part of surgery. Whatever it is, we can't eliminate the uncertainty, but we can really whack away at the terror. And we need to.</p>
<h3>Is this surgery the right thing for me?</h3>
<p>Take for instance ambivalence about the surgery itself. It's normal to have some doubts, but our overwhelming sense before we consent to surgery needs to be that this is the last best hope for health for us after having exhausted all lesser approaches. We have to be sure that this is the right thing for us to do. That doesn't mean that our surgeon needs to think this or our relatives need to think this. We have to believe it strongly enough to embrace the surgery with hope, not helpless doom. Until we're there, we're not ready. If you feel as though this decision is being urged on you and you ought to go along with it, you're not ready. If you don't feel you've explored all the options, you're not ready.</p>
<p>How do you get more ready? See more doctors. There's a good reason why your insurance company willingly pays for second or even third pre-op opinions, and it works to your benefit. You may have to see several doctors and listen to several explanations before you hear one that clicks and suddenly makes things fall into focus. That doesn't mean you can't use your first doctor as your surgeon--it just means you needed to do more research. Different doctors bring different interpretations and different communication skills. It's only prudent when looking at an irreversible surgery that we seek a broad range of opinions. It makes it much more possible to develop that necessary sense that what we choose—and that we <em>are</em> choosing—when we have explored our options more thoroughly.</p>
<h3>Anesthesia fears</h3>
<p>It's common to have a deep fear of losing control when faced with the idea of anesthesia. That's reasonable and protective, so long as it's not disabling. But if you have a deep-seated belief that it's not going to work for you, then don't go there. Talk with your doctor and anesthesiologist about other options, like spinal anesthesia. With that method, you are numb and indifferent but not totally unconscious. Maybe this would let you feel less cut off from your life, make the whole experience more survivable. It's a viable option if it reduces your fears.</p>
<h3>Fears about after the surgery</h3>
<p>What comes after a hyst is such an unknown for most of us. I'm doing what I can by posting on this website to make the experience a little clearer, give women a few more practical details of what they may expect. I've posted before about <a href="http://hyst.blogspot.com/2004/10/postop-pain.html">pain</a>, and how you can help control your fears about it by making plans beforehand.
</p><p>But that same technique applies to other aspects of healing. If you are having your ovaries removed and sudden menopause is your fear, don't let your doctor brush off your worries with the classic "you'll just take this little pill and everything will be fine." You've heard stories from your relatives and co-workers; you have been reading; maybe you've already looked at my recommended hormone/hrt resource, the <a href="http://surmeno.blogspot.com/2006/07/table-of-contents-by-topic.html">Survivor's Guide to Surgical Menopause</a> and their mailing list--you're not sure it's going to be that simple. Well then, don't let your doctor brush you off. Ask for details of his plan: when will you begin hrt, what if you experience symptoms before then, how will you know if it's not working, when will you change things if there is a problem, what will you change to? Or, even better, let your doctor know what you want for hrt and when you want to start it and how you want it to work for you.</p>
<p>Work together with your doctor(s) on a plan that covers all your worries and lays plans out for any contingency you are bothered about. Maybe you'll need those plans and maybe you won't. But pre-op fears are eased when we regain a sense that even if we don't know exactly what will happen, we're prepared to deal with it. And for that reason alone, it's worth the time and effort because we'll have a happier, healthier surgical experience when we're not facing featureless doom. It's okay to be nervous, but if you're seriously disabled by fears, you're not ready until you've laid them aside.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1099970632495841522004-11-08T19:14:00.000-08:002009-07-21T15:28:26.548-07:00Will I be in menopause?<p>Women making plans for a hysterectomy often ask whether having a hyst will mean that they will go through menopause and what that will mean for them if they do. I can tell you right away that if you have your ovaries removed, you will, irrespective of your age, be in menopause when you wake up from anesthesia. If you retain your ovaries, you stand a good chance of postponing menopause for some undefined time, but <a href="http://hyst.blogspot.com/2004/09/ovarian-failure-following-hysterectomy.html" title="Takes you to a previous post on this topic">as we've previously looked at here</a>, there's no guarantee just how long that time will be.</p>
<p>This might be a good place to define just what menopause really is. Menopause is nothing more than your levels of ovarian hormones dropping below that level that supports fertility. When menopause happens naturally (that is, without surgical intervention), our ovaries don't just throw a switch and never produce another hormone again. Instead, a long slow decline begins a decade or more before actual menopause and continues for many years, if not decades after that. Menopause is simply one point on that long slope of hormone output, even if it happens to be one we can clearly see because we stop having periods. Because a woman in natural menopause continues to produce lower levels of hormones that continue to support her remaining, non-fertile hormone needs, she may not have very many or very disruptive symptoms.</p>
<p>But in surgical menopause, when our ovaries are removed, we go from ovarian function (either fertile or naturally menopaused, depending where we are preoperatively) to no ovarian output at all. That doesn't mean we have no hormones at all, however. In menopause, our belly fat contains special cells that can produce a weak estrogen called estrone. Our adrenal glands can also make estrogen from other hormone precursors, although the amount we can produce that way is somewhat dependent upon what other competing tasks the adrenal glands are facing at any particular moment. Whether or not that is enough remaining capacity to meet our non-fertile hormone needs or not, it is definitely enough of a drop that we should be considered menopausal.</p>
<p style="font-style: italic;" class="question">Does menopause mean I'm just going to become old and wrinkled and sexless overnight?</p>
<p>No. That depends upon your genetic makeup (how women in your family age at menopause might be a helpful clue for what you can expect) and how well your hormone needs are met in menopause. No matter how you get there, menopause is a major life change—the biggest one we experience after puberty. This signals a number of things to your body and will affect a variety of metabolic systems. You most likely will lose collagen and find that your skin gradually becomes dryer, more delicate and more prone to showing wrinkles, although how rapidly this develops may be somewhat mitigated by genetics and meeting hormone needs. It's typical that our body shape changes as we take over estrogen production with belly fat: we may thicken in the middle and find that metabolic down-setting causes us to gain weight that it is difficult to lose without dietary modification and exercise. And there are other changes that may slowly develop. While we're not plunged into elderly bodies overnight, the fertile part of our lives <em>is</em> over and this will signal changes.</p>
<p style="font-style: italic;" class="question">Do I really have to take <acronym title="hormone replacement therapy">HRT</acronym> for menopause? If it only lasts a few months, can't I just put up with the hot flashes and wait it out? I really hate to take drugs if I don't have to.</p>
<p>First of all, let's dispose of that "only a few months" myth. Somehow, doctors have convinced themselves that it only takes a few months to adjust to menopausal hormone levels and thus recommendations for the use of hrts are for just long enough to make this transition. But this is a gross oversimplification for many women, and especially so for those without ovaries. In fact, there are two aspects of menopause that determine how it affects us and how long those effects last.</p>
<p>In terms of overall experience of menopause, the suddenness of the transition definitely affects the number and severity of symptoms we experience. Our bodies don't really approve of hormonal fluctuations, and the sharper the fluctuation, the more dramatically our bodies will express their disapproval with symptoms. An especially rapid change prevents us from making the many small, slow accommodations to life with low estrogen levels and estrogen provided by non-ovarian means. Generally speaking, a surgical menopause is a much greater challenge to the stability our bodies want and will cause more symptoms from the transition.</p>
<p>The other aspect of symptoms has to do with how well our remaining hormone needs are being met. Remaining needs? Yes, our ovarian hormones do many things besides prepare our uterus to receive a fertilized egg. In fact, they are used throughout our bodies in nearly every system. I can't go into all of these details here, but you can read much more about hormones and what they do at the <a href="http://surmeno.blogspot.com/2006/07/table-of-contents-by-topic.html" title="Takes you to the referenced website">Survivor's Guide to Surgical Menopause</a>. I would encourage any woman facing surgical menopause to read through this material, as this is an important topic for our ongoing health and one we typically know very little about.</p>
<p>The thing about hormone needs is that while they may decrease with age, they do not disappear altogether. So if you are failing to meet your hormone needs, then you can expect symptoms to persist. You don't "get over" the need for basic bodily processes, and if you never provide the support your body needs to carry them out, you'll continue to experience the symptoms of those systems malfunctioning.</p>
<p>But it's also very important not to confuse <acronym title="hormone replacement therapy">HRT</acronym> with drugs. It's easy to do, since they both require a doctor's prescription to obtain and they both are manufactured by pharmaceutical companies. But a drug does something to interfere with a normal body process, with the intent thereby of "fixing" something that is being a problem for us. In the case of hormones, however, we're not interfering with a normal process; we're providing the raw materials to support normal function in the face of a surgically-induced shortage. Taking supplemental ovarian hormones is more akin to someone who is hypothyroid taking thyroid hormone supplements or someone who is diabetic taking insulin (another hormone). <acronym title="hormone replacement therapy">HRT</acronym>s are just different forms of either our exact hormones or a near-match chemical that has similar actions in the body.</p>
<p>Whether or not you need to take hormones (and I include in this category prescription, non-prescription and food sources: if it can act to meet hormone needs in the body, it <em>is</em> an <acronym title="hormone replacement therapy">HRT</acronym>) is pretty much up to you and what you define as the level of health and comfort you wish to experience during menopause. If taking hormones is more distasteful to you than hot flashes and other symptoms, there's really no reason you <em>have </em>to take them. There can be some pretty serious risks to health on either side of the take-or-not <acronym title="hormone replacement therapy">HRT</acronym> question, so you should research hormone actions, consider them in the light of your own personal health risk profile, and decide for yourself how you want to deal with hormone needs. There are drugs that can alleviate some of the symptoms of hormone deficit and there are other health practices that can help limit some of the risks. It's all up to you how you choose to deal with these needs.</p>
<p>And of course we've all heard of the happy, healthy elder who never took hormones and was just fine. I'm really delighted for her, but I have to point out that this cannot be achieved by force of will. We have little control over how well our body is genetically programmed to cope with supplying hormone needs. If yours isn't up to the task, you're not a failure and I would hope you don't punish yourself with guilt. Hormone needs, I repeat, represent basic physical processes, not optional comfort measures. We are not wimps when we choose health and wellbeing in our menopausal years.</p>
<p style="font-style: italic;" class="question">I've heard that I should get my hormone levels checked before surgery, so that I can just take enough <acronym title="hormone replacement therapy">HRT</acronym> afterwards to get back to where I know I was feeling good.</p><p>Sure, you can spend a few hundred dollars to be tested. But unfortunately, premenopausal hormone levels fluctuate constantly, perimenopausal hormone levels fluctuate wildly, and even postmenopausal hormone levels are only a momentary snapshot. There's no way to know to what extent any hormone level test corresponds to how you feel because of that moment-to-moment variability. Furthermore, if you were fertile, your needs once you are no longer supporting fertility will not be the same. With no uterine cycling to support, that level of hormones will be a gross excess postop. </p>
<p>The other flaw with that premise is that you can look at a test and know how much to put back into the system in <acronym title="hormone replacement therapy">HRT</acronym>. Alas, but it's not that simple. There are so many intersecting influences here that there is just no feasible correlation between levels and supplementation needs. I'm not going into the details here since the Survivor's Guide does it much more thoroughly. What I want to leave you with is the simple statement that it just doesn't work that way. If you want more about the why of it, you'll need to follow the discussions over there.</p>
<p style="font-style: italic;" class="question">If it's being menopausal that makes me look old and ugly, can't I just take as many hormones as I used to have so that I stay young looking?</p>
<p>Nope, not a good idea. One of the things we learn in menopause with <acronym title="hormone replacement therapy">HRT</acronym> is that while enough is wonderful, more than enough is hellish. Hormonal excess raises our risks of negative effects and causes some quite unpleasant, if not dangerous, symptoms. And regardless of the risks, <acronym title="hormone replacement therapy">HRT</acronym> just can't turn back time. Your body recognizes ovarian loss or natural menopause as a life transition and behaves accordingly. While <acronym title="hormone replacement therapy">HRT</acronym>s have come a long way since they were first introduced, they remain a relatively crude tool. You can't entirely fool your body with them and they won't reset the clock. Menopause awaits all women; the only part we get to pick is how we respond to the needs it creates.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1099163854583724552004-10-30T10:51:00.000-07:002007-01-25T11:08:00.532-08:00Postop: Sleep<p>Most of us get the message that rest is pretty important to our recovery. It can be frustrating, then, to find that sleep is ridiculously elusive in that first postop month or so.</p>
<p>There are a lot of factors that are working to keep us from falling and staying asleep. It takes weeks to get all of the drugs from surgery out of our systems. It's common during the time we're clearing the remains of anesthesia to have vivid dreams, nightmares and disturbed sleep from these drugs' effects on our brains. There's nothing to do about this, really, other than wait out our own body's ability to get rid of the last lingering traces.</p>
<p>Stress is an important part of this too. Stress disorders many of our daily hormone cycles and can have destabilizing effects on our brain chemistry. Normally we rely on our circadian rhythms to guide us through our sleep and wake periods, and when they are upset, so is sleep. As we get further from surgery and relax into our healing, chemicals in our brains normalize and our bodies return to a more normal daily cycle. Unfortunately, fretting about sleep only adds to our stress and prolongs the process of readjustment.</p>
<p>Speaking of hormones, our ovarian hormones play a significant role in sleep. Not only do daily cycles of estrogen affect the other daily ups and downs of the hormones that guide our sleep, but estrogen itself can act on our brains to make sleep difficult. Too little estrogen often makes it hard to stay asleep, and a woman with low levels may find herself waking frequently during the night. Too much estrogen, on the other hand, tends to have a stimulating effect somewhat like caffeine, and we feel the same thing as if we'd had a double-extra just before bedtime: spinning wheels may make it hard to fall asleep, even though once we get there, we tend to stay asleep most of the night.</p>
<p>And don't neglect the hormone link if you kept your ovaries. They <a href="http://hyst.blogspot.com/2004/09/ovarian-failure-following-hysterectomy.html" title="Takes you to an entry on this topic in this blog">may be undergoing a period of diminished output</a> due to the local trauma of surgery, effectively putting you into a temporary state of menopause. Whether or not they recover, the disruptions can make sleep difficult to maintain.</p>
<p>Then too, the very nature of our recovery also influences our sleep patterns. In the hospital, we are (of good necessity) awakened frequently and spend a lot of time in a drowsing state. By the time we get home, we're more active but still may spend a lot of the first week more in bed than out of it. This trains our bodies away from a day/night cycle of long awake periods and long sleep periods. Since we are so inactive, we have less of a need for sleep. By fulfilling our sleep needs in short incremental naps through the day, we may arrive at a nominal bedtime only to find that we really don't need to sleep. This training effect can take weeks to undue.</p>
<p>It's hard to get comfortable when you've just had abdominal surgery. Whether or not you have an abdominal incision, you may have a lot of difficulty getting comfortably situated in bed. It's also hard to move around and reposition yourself, so that rolling over to a new position, something that would normally cause no waking at all, now brings you to full consciousness as you laboriously untangle from pillows and covers to slowly seek another position. If you've been doing a good job drinking enough during the day and/or you're still experiencing bladder crankiness, you'll probably be waking up more to go to the bathroom, too. And because it's more of an effort to get up and get to the bathroom and then settled back down again, that's going to wake you more thoroughly than it would have pre-op and so it'll take longer to get back to sleep.</p>
<p>That's a lot of things working against good, lasting sleep at night. And while it's all fine to know what the cause of this might be, more pressing at 2 am in a bout of the floppy-wakefuls is what to do about it.</p>
<ol>
<li><strong>Pain meds:</strong> Narcotic pain meds may seem like a good thing to take at bedtime to force us to relax and sleep. But they generally last only 4-6 hours, leaving you wakeful and sore before the time when you may think you're ready to get up for another day. A more durable approach to pain is the oral anti-imflammatory that has a 12-hour life, like naprosyn. Taking that before bedtime gives you plenty of medication life to let you rest comfortably through till the morning, without the wakeful effects of having it wear off. Be sure to check with your doctor, though, if you're unsure whether you can or should be using a drug from the <acronym title="non-steroidal anti-inflammatory drug">NSAID</acronym> family. After the first few postop days, using the narcotics when you're about to be especially active (and increase your discomfort) makes more sense than using them when you are in bed.</li>
<li><strong>Napping:</strong> It's important to get enough rest, yes, but that doesn't need to mean napping every hour through the day. During the first few weeks postop, we should be working towards more and more time awake during the day. Pacing our activities so that we spend some time exercising and then some time in sedentary, undemanding activity before getting up again is a good healing pattern. Getting exercise and then sleeping and then getting up for another hour is training our bodies away from a sleep-at-night pattern.</li>
<li><strong>Exercise:</strong> We do need to engage in enough activity throughout the day to <em>need</em> to sleep at night. Every day we need to walk a little further or on a little steeper terrain or make another cautious trip up and down stairs or something that challenges our bodies to grow stronger and helps cut down the incidence of postop constipation and complications. Every activity needs rest and no activity should leave you still tired after resting, but it's important to keep challenging yourself. It's better to repeatedly engage in small activities than go for one gut-burning grind a day, too. By making ourselves healthily tired, we're readier for sleep at night. If there's no reason to sleep, we won't.</li>
<li><strong>Preparation:</strong> We can clue our bodies when we are expecting sleep and ease the process of falling asleep. Before we had surgery, we most likely did this by our normal evening routines. Surgery disrupts this, so we need to consciously re-establish sleep-promoting practices. Changing into sleepwear (wear sweats or a caftan or something else comfy for lounging during the daytime), going through teeth and skin care routines, reading in bed--these are some of the things we often do normally that we let slide postop. We can also signal our bodies to relax by having a warm drink of something soothing. Sleepy tea blends (no caffeine!) or warm milk or products like ovaltine all contain mildly sedating agents that can help us through those first few moments of falling asleep. Positive imaging and relaxation routines can make sure we're not fighting ourselves, letting our worry over falling asleep work against us by keeping us alert.</li>
<li><strong>Patience:</strong> It's also important not to try to force ourselves to sleep just because the clock says it's time. When we're not sleepy, lying in bed fretting only makes us more wakeful. When we wake up during the night, tossing and fuming prolongs the time it takes to return to sleep. If you're not so sleepy your eyes would prefer to be closed, you may not need to be asleep. Give yourself an honest time, and then get up or do something else. Maybe you just need to turn on the light and read; maybe you need to get up and go for a pee and a drink; maybe you should get up and watch a movie from a nice recliner where it won't matter if you finally doze off. Even if all you do is get up, read half a chapter and then go to bed to fall asleep, you won't feel as though you've had nearly the struggle for sleep as if you'd instead flopped around in bed fussing for that amount of time. The idea is to set yourself up to be relaxed about sleeping so you quit being your own worst enemy.</li>
<li><strong>Sleeping pills?:</strong> Forcing yourself to sleep because you think you should when your body isn't wanting to is not really helping to re-establish your own innate sleep patterns. If our sleep is so disordered that we truly are going days and days without any sleep (not just keeping ourself from needing to sleep by cat-napping five minutes at a time all through the day), then there is something more going on that we need to talk with our doctor about. It's <em>always</em> better to deal with the underlying problem than to put a drug bandaid on top. If your doctor finds that there is no physical problem or hormonal imbalance interfering with your sleep and feels you need medication to break your present, dysfunctional sleep cycle, then short term use of drugs may be warranted. But do your health a favor: don't just make reaching for a bigger hammer to knock yourself out your first response to the problem.</li></ol>
<p>These all sound like pretty simplistic things, but none of them really offers a "quick fix." I know very well that we often prefer the easy solution of a prescription to solve anything we perceive as a problem. But the sources of postop insomnia aren't going to go away quickly or be cured by one simple thing. We need to give ourselves time to regain our normal patterns and to clear the effects of surgery from our systems. Postop insomnia is generally something that requires healing, not treatment.</p>
<p>It's easy to believe that we need to heal our surgical incisions because of the discomfort they cause us. It's harder to see the need to heal other systems in our bodies when we can't see those "cuts" in our normal function. But postop insomnia is another signal that our bodies haven't gotten over surgery yet and need our active support. Part of a good recovery is rebuilding ourselves to take care of <em>all</em> our needs.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1098914896268279652004-10-27T14:56:00.000-07:002009-07-21T14:15:22.610-07:00Pre-op decision: surgical route<p>The vaginal vs abdominal route is endlessly debated. Going for the bottom line right away, the "right" answer is clearly: the one that gives your surgeon the absolute best field of vision/access for what you need done.</p>
<p>That said, it's widely believed that the vag route, because it skips that belly incision, has an easier recovery. In the very first few days, that may be the case, but it's been my observation that over the entire recovery period, there's not a whole lot of difference.</p>
<p><strong>The key point to remember is that it is the internal healing that is the big job, and that is the same whichever surgical approach is used.</strong> In fact, I've noted time and again that it's the women who have a vag hyst who are more prone to overdoing in the early stages, just because they aren't looking at that incision and treating themselves as cautiously. Some difference does exist between a bikini and a vertical incision, since the latter extends further up into the belly and is more noticeable with muscular effort. But even so, the length of time incisional healing affects you is really brief compared to the interior healing. So try not to agonize over this one.</p>
<p>There have traditionally been three factors, roughly, that determine suitability for the vaginal procedure:</p>
<ol style="list-style-type: decimal;">
<li>Is there room to get the uterus out through that route? Obviously, with very large fibroids and for many women who have never given birth, that answer would be "no."</li>
<li>How experienced is the doctor with that version of the procedure? A vaginal procedure is in fact much more complex. Experience counts in avoiding negative surgical outcomes and quality of final results.</li>
<li>Can the doctor see everything he needs to? The vaginal route obviously involves a more limited field of view. Those needing ovarian evaluation or considered cancer possibilities often require the better visibility of abdominal incisions.</li>
</ol>
<p style="font-style: italic;" class="question">I was told that since the doctor couldn't "see" everything that he was doing, in many cases, there was damage done to the other organs.</p>
<p>Exactly. The addition of a laparoscope helped this somewhat, as that technique became more common, but this is still a much more remote viewing that calls for considerably more expertise on the part of the doctor and relies much more on the soundness of the pre-op diagnosis (as opposed to visually checking everything out).</p>
<p style="font-style: italic;" class="question">I have fibroids in and around the outside of my uterus. I don't want anything missed. Also I read that they are finding that a lot of nerve damage is being done to and around the vagina and sex is often affected greatly.</p>
<p>So many things are relative to your own particular anatomy, what exactly the pathology is for which you are having the procedure, and your own surgeon's practice level. But in general, yes, because of the awkward approach angle, there tends to be more manipulation of internal organs and nerves and such than with the abdominal approach. And because things are harder to see, there is a greater chance of missing things or causing damage with a vaginal approach. Additionally, women who have spent hours in the stirrups for surgery are more likely to experience back pain or back/leg nerve irritation in their immediate postop period.</p>
<p>In fact, the vaginal procedure, as a rule, takes longer (longer time under anesthesia) and requires more internal work (sutures, healing) than the abdominal. The more rapid initial bounce-back due to not having the abdominal incision is not always a service, since the internal healing that goes on is greater, even if less obvious. More women with vag than abdominal hysts end up going back for revisions when they have damaged this or that during the healing process by doing too much before they are ready and/or getting an incomplete heal. The famous 6-8 week recovery period is for the internal healing, not the superficial incisional healing—something that it is all too easy to overlook with the vaginal procedure.</p>
<p style="font-style: italic;" class="question">I understand that in vaginal surgery, the cervix is taken out . I want to keep everything that I possibly can.</p>
<p>Yes, it must be, because of the way the surgery is done. Many abdominal hysts also remove the cervix, and by and large the problems that used to be associated with this, of later losing support for internal organs, are eased by more current techniques that emphasize reattaching the tendons to provide good abdominal floor support. The argument now focuses solely on whether or not you have a strong cervical stimulation component in your orgasms. Those who do will probably miss it; those who don't will probably get along just fine without it. Remember, of course, that with cervical retention you will continue to get a light period (and may need hrt to cycle you, if you have your ovaries removed); you will also continue to need regular pap testing for cervical cancer.</p>
<p>My own decision was for an abdominal, even though I was offered a vag (reluctantly). Because my pre-op diagnosis was unclear about the actual state of my ovaries, I wanted the doctor to be able to examine things thoroughly. He was relieved, since the vag route was only conditional, with an abdominal to follow if he found anything suspicious that needed further exploration. I did, however, bargain with him that he would start with a horizontal incision (the "bikini cut"), which I feel disrupts abdominal muscle fibers less and promotes faster recovery of abdominal tone. We agreed that he would start there and only extend to a vertical (making a "T" incision) if what he saw warranted further removal of affected organs. This was written into the operative permit, specifically.</p>
<p>As it turned out, I did not need the vertical extension as my ovaries were only rather suspicious and not yet fully malignant, and he was able to do a thorough examination of the entire abdominal cavity from the horizontal incision once he got that mammoth uterus out of the way. For me, the peace of mind in knowing that such a thorough exam had been done more than made up for the additional inconvenience of the incision.</p>
<p>And, truly, I didn't have a lot of recovery difficulty. I was walking within a couple hours of returning to my room, and within two weeks was walking a mile or more without problems. I switched to oral anti-inflammatories within 24 hours of surgery, never using either the IV morphine or other narcotics (I did get regular doses of IV Toradol, a potent anti-inflammatory, in the first 24 hours). Among other things, I credit this with not having had problems with gas or a first bowel movement (although I did hit heavy fluids, fiber, and a couple stool softeners to ease things along, in addition to the activity).</p>
<p>So for me, the decision was to do nothing to compromise either my surgeon's best possible technique or best possible examination, and in return for that I found the abdominal incision to be no dire cost. Everyone will have different experiences, but those are the things I found worthwhile to weigh in making the decision.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1098754965997423492004-10-25T18:39:00.000-07:002007-01-25T11:18:23.680-08:00Bladder Suspension<p>Did your doctor say you might be a candidate for this procedure? Here's what he's talking about:</p>
<ul style="list-style-type: disc;">
<li>Brief <a href="http://www.yoursurgery.com/ProcedureDetails.cfm?BR=7&Proc=6">overview of the procedure</a>, with drawings. Not to much from a patient viewpoint but a place to start.</li>
<li>Good <a href="http://www.augs.org/i4a/pages/index.cfm?pageid=214">summary of the different procedures</a> and recovery process</li>
<li>A <a href="http://www.perspectivesinnursing.org/v1n1/Johnson.html">nursing care review</a> that spells out what kind of information your health care providers should be offering you</li>
<li>An interesting <a href="http://www.wdxcyber.com/nurine11.htm">followup article</a> (read well down the page)</li>
<li>Finally, here's a <a href="http://www.google.com/search?&q=bladder%20suspension">search results link</a> if you really want to read up a storm</li></ul>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1098488016321137442004-10-22T16:31:00.000-07:002007-01-25T11:21:35.034-08:00Is a hysterectomy like a C-section?<p>Although many women come to a hysterectomy as novices to surgery entirely, a certain number have previously had a child delivered by Caesarian section. Because this is an abdominal surgery affecting the uterus, it's natural to try to compare the two experiences as part of envisioning what hyst recovery will entail. However obvious this comparison may seem, the fact is that they really aren't equivalent surgeries.</p>
<p>First, there is the experience of the C-section itself. There are so many variations in pain tolerance, not to mention both birth and hyst experiences that I don't quite know how to find a common ground. There are women who are inconvenienced by both; women who can say yes, it wasn't a picnic but I survived it okay; and women who think it was the most exquisite agony they ever experienced or could conceive of experiencing.</p>
<p>What I <em>can</em> tell you is that from reading many years of women's reactions, the majority admit discomfort, a great many admit pain of some degree that was of limited duration and dealt with adequately by analgesic drugs, and a very limited few (and most often those are ones with especially complex suegeries, poor care, or who develop complications) report truly unbearable or excruciating pain. Depending upon how you experienced childbirth, you may have gained a clue about your own tolerance for pain.</p>
<p>The other aspect, and it's a very important one in developing your expectations of how your hyst will go, is that because you're talking major surgery (that is: cutting, removing, rerouting stuff internally), you are talking a much more prolonged recovery than childbirth, where it is more a matter of simply returning to a previous state (even in a Caesarian, there is little disruption of abdominal contents other than to heal some very basic incisions). <strong>It's a common myth that a hyst is "just like a Caesarian" and this really can lead to shock and disappointment later</strong> (or, among friends, co-workers, and the whole other rest of the world who may feel free to comment on your condition).</p>
<p>But in the course of a hysterectomy, your bladder is peeled loose from your uterus, many things are cut (nerves, ligaments, blood vessels), your ovaries and their supporting structures may or may not be removed, your vagina will be given an artificial ending, and all of the support that used to derive from your uterus and its attachments has to be relocated to hold up the end of the vagina, the bladder, and your guts. On top of this, your other organs are handled, pushed out of the way, rinsed off, and then reassembled. There are sutures and sutures and staples and multiple closures to hold all these things back together again. The tissue damage is higher, you are under anesthesia longer and with more drugs, and your risks of infection are higher. And that's assuming you aren't also having endo removed, scarring cut apart, bladder suspension, or rectocele/cystocele repairs done. So this surgery is much more complex than just making a slit, removing the uterine contents, and sewing the slit closed again. And it takes a correspondingly longer time to heal and heal well.</p>
<p>I'm not trying to intimidate you here, but rather to make sure that you're clear on what to expect. It's not by any means an impossible or even wildly difficult experience, but it is important to be realistic in all your expectations...so it's very good that you are thinking and looking for a conceptual framework to base your expectations on.</p>
<p>But "much worse" is not exactly how I would term it. It will take longer to get a good recovery, so if you measure success in time elapsed, you will indeed find this one more demanding. Pain? There is no excuse for either one to hurt more than the other, for pain relief is pain relief, irrespective of cause. Don't settle for less than you need, but also remember that it is not the role of pain medication to make you oblivious. A reasonable objective is that you will be in minimal discomfort while lying still and tolerable discomfort when moving around and right significant discomfort if you do something inadvisable for your level of healing. It is also reasonable to expect that you will be aware of and guarding your surgical site from discomfort for the longer healing period.</p>
<p>But many many women report that their hyst post-op discomfort was really not much worse than significant period cramps and in many cases was considerably easier than the chronic gynecological pain some women experience. Your goal as you heal is to be guided by your discomfort, such that if you begin to experience it, you need to slack off and not stress your healing.</p>
<p>Maybe this will help you get a better handle on the situation ahead of you than just the scary "worse" label. It's doable, it's work, it's not pleasant but it's not gruesome. There is always someone who has complications, who has a bumbling doctor or inept staff, who has a different personal or cultural definition of pain tolerance, and those with problems always have more to say about something than those who found an event manageable. If you can try to hang onto this sort of perspective, I think you'll find that you too will be able to handle this surgery pretty satisfyingly.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.comtag:blogger.com,1999:blog-8418409.post-1097704421459438842004-10-13T14:25:00.000-07:002009-07-21T15:26:07.094-07:00Postop: Pain<p>Because many of us come to a hysterectomy as surgery novices, one of the things that worries us most is the prospect of pain. Chat around at the water cooler or the hairdresser's and you'll hear plenty of scary stuff. But is that realistic? No, not really. Let's look at what we're facing.</p><h3>You're entitled to a plan</h3><p>No matter what previous experiences you may have had with surgeries and pain, a minimum expectation of the pre-op planning process is that you and your doctors develop a <strong>pain management plan</strong>. You should know how they anticipate dealing with the expected pain, what they plan to do if that is not adequate, and what alternatives they are holding in reserve. You should also know when you may have medication and how to get it, including what to take home with you and what to do if you run out. This is very very basic (however much doctors take it for granted and don't discuss it), and you have every right to ask for a discussion of it and to participate in making those decisions.</p><h3>Immediate postop pain management</h3><p>One thing that can be beneficial in dealing with pain in the first hours after surgery is the use, from the Recovery Room on, of a relatively new <strong>anti-inflammatory</strong> called Toradol. It is given IV, regularly, and it seems to keep the level of pain down such that narcotics may not be required or may be required only in lesser amounts than when they are used alone. It also seems to ease the transition to oral meds, particularly of the long-acting <acronym title="non-steroidal anti-inflammatory drug">NSAID</acronym> family (such as the 12-hour dose of naproxen), and does not carry the effects of the opiates (in either allergy or constipation).
</p> <p><span style="font-weight: bold;">[<span style="color: rgb(255, 0, 0);">Update 12/20/04: FDA warning about naproxen</span>: </span>The FDA has issued warnings about possible heart damage that may be caused by using naproxen. More on this topic in this <a href="http://hyst.blogspot.com/2004/12/fda-warning-on-naproxen.html">post</a>.]
</p> <p>It is also reasonable to ask your anesthetist to medicate you for <strong>nausea</strong> before you wake up in Recovery, rather than waiting for you to request such medication because you are already nauseated. If you make this request at your pre-op appointment, they should be willing to honor it. And, generally speaking, if you can get past the immediate post-op period, nausea should no longer happen to you. In fact, nausea after the first few hours typically means you're being nauseated by something you're receiving <em>after</em> surgery, such as your pain med, not things you received <em>during</em> surgery.
</p><p>Two fairly common pain management setups are the <strong>patient-administered IV</strong> and the epidural block. The former is a pump, connected to your IV, that contains morphine or demerol—very potent narcotics. The pump is set for a maximum dose per hour, but you may trigger it to deliver a dose whenever you need it, up to that maximum. This allows you to pre-medicate before doing something that you feel might cause pain (like getting up) and allows you to control the amount of medication you get. This pump is typically used for one to two days, and is gradually replaced by oral medication.</p><p>The <strong>epidural</strong> involves a pump supplying numbing medication into your spinal area, to block sensation from the lower part of your body. It is generally used in conjunction with spinal anesthesia. Women who use it tend to speak very highly of it, especially in terms of promotion of early mobility. It is only left in place for a day or two.
<p>Another, lesser-used but still valuable technique is injecting the area of your incision with numbing medications or running a small continuous drip of medication to that area. This may or may not need to be your total pain coverage.
</p><h3>How bad will it be?
</h3><p>The goal of pain management is not oblivion. Even the best drugs cannot obliterate your awareness that you've had major surgery and your body wants you to be <em>really really careful</em> with it. There are also some tradeoffs with narcotic pain medications that need to be kept in mind: too much will cause you to stop breathing, and excessive use can cause respiratory suppression and pneumonia predisposition as well as increasing postop constipation.
</p><p>The <strong>goal of pain management</strong>, then, is making the discomfort tolerable. Note that I don't say "pain." Rather, you are aiming for a level of not-too-bad when lying still and tolerable while moving and "ouch!" with injudicious movement. You have a right to this amount of coverage, but you may need (or you may need someone with you who will do this) to advocate for your needs with busy nursing staff. If your nurses are not responsive to your needs or you feel you are undergoing excessive delays in obtaining medication, you should contact your doctor to let him know this. Even during the night, there will be an answering service that can have the doctor on call for your surgeon's practice get back to you. You should not be left in pain due to lack of medication and the medication your doctor orders for you should provide adequate relief. If you have received your limit of pain medication without obtaining acceptable relief, your doctor should be able to switch to a different drug. We all have different physical responses to different drugs, and so some drugs work for some of us better than for others. The goal should be adequate pain relief.</p><h3>What about the risk of addiction?</h3><p>The addictive potential of postop narcotics is very low because you are taking them for pain relief, not for the sensation of taking the narcotics themselves. Taken in the amount necessary to control pain, the pain "uses up" much of the action of the narcotic and it does not provide the sensations that cause addicts to seek it out. The duration of postop use is not at all close to the amount of time required to create any physical addiction. Neither you nor your doctor should stint on your legitimate use of narcotic medications for pain relief.
</p><p>That does not, however, mean that you should not take them for the shortest necessary time. Narcotics carry negative effects as part of their normal mechanism of actions. For example, they are quite constipating. Since gas and bowel motility are some of the most pressing concerns in the first couple postop weeks, it doesn't make sense to continue adding to that problem by taking narcotics longer than necessary.
</p><p>The usual practice is to be on IV or injectable (narcotic) pain meds for a day or two postop. These are gradually replaced by oral drugs, usually those containing a narcotic such as codeine. Codeine and other oral narcotics have the same constipating effects as the injectables. So while they may be good at controlling pain, they are also not a great long term management drug. Many women go directly from injectables/IV narcotics to oral anti-inflammatories, or use anti-inflammatories to stretch the effects of oral narcotics. In the first few postop weeks at home, anti-inflammatories can gradually replace narcotics while providing still-adequate coverage. </p><p>One of the most convenient anti-inflammatory drugs is naprosyn (naproxen), because it has a 12-hour duration of action. This means you can take it at bedtime and still wake up with some in your system in the morning. Using the 4-6 hour anti-inflammatories can mean waking up in the morning in discomfort. Since some asthmatics or those with cardiovascular disease may be sensitive to this whole family of drugs, be sure to ask your doctor about what drugs you should take even when you are ready to leave the narcotics.</p>
<p>Now, all of this presupposes that you are not already on a pain management program or do not have an addictive problem. If this is the case, then you will obviously need to involve your therapists in your operative planning so that you meet your increased pain control needs without derailing your present level of control. The fact of a previous narcotic addiction should not mean that you cannot control your pain during your recovery, but it will obviously mean that you have a greater need for pre-planning and monitoring the situation.
</p><h3>Pain and medication on discharge from the hospital
</h3><p>By the time you are released from the hospital, you should be able to get around and get by, within the limits of exercise tolerance, on fairly mild oral medications. The gas/constipation problem is the source of the most discomfort in the first post-op week or so, and it yields better to specific medications/approaches (lots of fiber, drinking lots and lots of liquids, exercise, stool softeners) than to pain meds (and opiates are especially bad in that they slow your bowel activity down and compound the problem).
</p><h3>What about if my prescription runs out and I'm still hurting?
</h3><p>Your doctor sends you home from the hospital with a standard prescription. That doesn't mean that this is all you can have. If you have used the pills as directed and find that you are running out and will need more, call your doctor's office and let them know. Often, they are more than willing to call a refill to your pharmacy. Other times, they may suggest alternatives that will be effective for the point you're now at in recovery. Whatever the plan, don't feel you have to suffer once the first prescription runs out.</p><p>Do be sure, however, that you understand how and how often your take-home pain meds are to be taken. Typically the prescription reads something along the lines of "Take 1-2 every 4-6 hours as needed." That means that you <em>may</em> take them that often (if you need that level of pain relief), not that you <em>must</em> take them that often (to get any relief). All too often women in the fluster of getting ready to be discharged from the hospital are handed a fistful of papers and hear only "2 every 4 hours" and just tear through their prescription and wonder why, a few days later, the prescription that they thought was to last them till their two-week checkup is all used up. Those dose intervals are the <em>most frequent</em> at which you can safely use that medication; it's fine if you don't need to take it that often or if you find that you need only 1-2 in a whole day, just to give a little extra boost to your non-prescription medications.</p><p>On the other hand, if you need more medication than that or you feel that even at the largest/most frequent dose you're not getting adequate coverage, it's a good idea to call your doctor about this as well. Your prescription is based on your doctor's expectations of how you should be doing, given your surgery and the speed/extent of recovery he sees when he visits you in the hospital. If you are not progressing as he thought you might, you may need a recheck to be sure everything is going as it should. Your doctor makes treatment decisions based on what he sees in the hospital; he can't see you once you are at home, so if things change, it's your responsibility to let him know that.
</p><p>You should expect, and demand if necessary, a reasonable and adult discussion of these things at your pre-op appointment. If your doctor is not willing to allow your participation in pain management planning or to discuss his plans with you, then you might be well advised to seek another consult. A surgery is about your needs, not the doctor's.</p>Doriehttp://www.blogger.com/profile/00305979128484958496noreply@blogger.com