Post-op: Getting back into shape

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

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

Postop: Sleep

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.

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.

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.

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.

And don't neglect the hormone link if you kept your ovaries. They may be undergoing a period of diminished output 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.

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.

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.

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.

1. Pain meds: 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 NSAID 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.
2. Napping: 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.
3. Exercise: We do need to engage in enough activity throughout the day to need 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.
4. Preparation: 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.
5. Patience: 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.
6. Sleeping pills?: 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 always 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.

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.

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 all our needs.

Postop: walking and the prevention of surgical complications

When and why you have to start walking in the immediate postop recovery period is a concern I frequently see women "voicing" in the online forums. This tends to get short shrift in the pre-op teaching, other than a fleeting mention that you'll be up and walking "right away" after surgery.

Right away most likely means on the day of your surgery, a few hours after you get to your room from Recovery. Generally the order is written for you to "dangle" first and then, a few hours later, to get up and walk. This means that the first effort will simply be to sit on the edge of the bed with your feet hanging over the side. In itself, this is a minor production, and you'll have the help of your nurse getting all of your tubes (IV and catheter, at least) organized. Your nurse will show you how to use the bed controls to raise yourself, then swing your feet over and down from a sideways position so that you put less stress on your belly. This is a very effective and important technique that you'll be using in the weeks ahead, so take your time and use the help and coaching to get the hang of it. Your nurse should stay with you the whole time you're sitting up, since it may make you a bit woozy and light-headed.

Later, usually the evening of your surgery, you'll actually get out of bed and stand and walk a few steps. Sound scary? It's really not grim. You'll have your pain medication, and most nurses know to medicate you before you move around so you'll be prepared. You may want to hold a towel or small pillow to your belly to help with the sensation that it will fall out. This is an illusion from muscle weakness, but you'll feel more confident holding onto it. Standing up starts just like dangling, only you'll go all the way to standing up. Go ahead and stand up straight: there's nothing useful in walking hunched over and your back will appreciate the chance to stretch that good posture provides.

The first time you walk, you may only go a few steps across your room or down the hall. Each time you get up, it's a little easier to go a little further. By your next postop day, you may be ready to walk on your own, but do ask for someone to accompany you as long as you feel at all woozy.

So why is this so important? The most critical part of walking is that it helps to prevent the complications that can come from any surgery, and particularly abdominal surgery (and this applies to those whose surgeries used the vaginal route: the surgical site is in your abdomen, and that's what counts here). When our lungs are depressed from anesthesia and dried out from getting oxygen and we lie extra still in one position (as we do when under anesthesia and then later under pain meds), secretions can pool up in our lungs and make a perfect medium for bacterial growth. Pneumonias and loss of lung function can follow, so changing position, deep breathing and moving about are important measures to prevent this.

Another surgical complication is blood clots. These are caused by, again, lack of the normal movements that exercise our blood vessels and keep blood from pooling and clotting. Abdominal surgery makes us especially prone to blood clots, so your surgeon may order you to wear special elastic stockings or pneumatic leggings to help take over that blood vessel exercising when you're less active during the first operative day. As you move around more, the normal motions and muscular activity will resume this function. Still, it's important to move and stretch your legs every hour or so while you're in bed and to try to remember to never cross your legs or ankles while you're lying around (this constricts blood flow, too). The more often you walk, the more you're working to prevent blood pooling and the clots it can lead to.

Another big benefit to walking is the way it helps your guts to start working again. It's normal for abdominal surgery to cause our intestines to more or less shut down. They are cranky organs, and just don't like to be handled and disturbed. It may take a day or two for them to get over their snit. During that time, you'll find your doctor and nurses listening to your belly with a stethoscope and asking you if you've passed gas yet. Your diet will typically be very light at first, mostly clear things like jello and broth and fruit juices, so that you don't overload your nonfunctional guts. Walking will help stimulate your intestines to get back to work, and once they do so, it'll help keep things moving along. Many women find that the gas that builds up in non-functional guts is the greatest source of postop discomfort for them, and walking is the best way to keep it moving on its way. As you walk more and your guts work better, your appetite will recover and your diet will be advanced to more fulfilling foods. It's typical that you won't be discharged from the hospital till you pass gas, thus demonstrating returning bowel function. The more you walk, the sooner you'll be outta there, then. This is a worthy goal.

Once you're home, walking regularly will keep your guts moving despite the constipating influences of pain medications and inactivity. Walking is also the best, gentle exercise for rebuilding your stamina. The more you lie around and don't use your muscles, the weaker you get—strength is a real use it or lose it proposition. By walking regularly and for increasing duration and distance, we keep from losing ground and, safely, push ourselves to recover.

How much is enough? In the first week at home, just walking around the house to the bathroom and kitchen and sofa and bed will probably be enough. By the end of that week, though, you should be making brief forays outside--perhaps up the driveway or around the yard for a lap or two. By the end of the second week, women who have been hearty walkers before are doing blocks; those who may be in poor physical condition should still be able to walk a block or more at this point. So long as what you reach for is healthy fatigue, not exhaustion or extra soreness, you're on track for a healthy recovery. If you get sore or you don't feel refreshed after napping on your return, you need to back off a bit and give your body time to gather the additional resources to recover and be ready to progress again. For the first month, walking is your best exercise, and duration/distance, rather than speed or steepness of terrain, should be your goals.

Healing

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

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

The earliest weeks of healing have three basic objectives:

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

Sex

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

Healing sensations and time

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

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

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

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

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

OMG, it takes how long?

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

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

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

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

My postop body

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

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

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

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

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

The scar

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

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

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

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

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

Recovery period: household chores

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

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

Healing and exercise

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A rough schedule of post-op recovery

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

Week 1: comfort, exercise and rest

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

Week 2: pacing your recovery

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

Week 3: not a setback

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

Week 4-6: more visible progress

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

Week 7-8: nearly there?

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

Month 3: why am I not all better yet?

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

Month 4-6: reaching 80%

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

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

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