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.

Transfusions as a potential blood clotting risk for women

We give a lot of attention to some forms of blood supply risk when we consent to a transfusion, but a newly-released study contains an additional factor we may want to discuss with our surgeons when we are talking about having a transfusion either before or after we have a hysterectomy.

In this study, researchers found that

Transfusion was associated with an increase in the odds of developing VTE in women (odds ratio, 1.8; 95% confidence interval, 1.2-2.6) but not in men (odds ratio, 0.9; 95% confidence interval, 0.5-1.9). In the absence of transfusion, female compared with male sex was not associated with an increased risk of VTE (odds ratio, 1.2; 95% confidence interval, 0.8-1.7).

What does this mean for us? We already know that a hyst (or any abdominal surgery) raises our risk of developing a postop blood clot, and that's why our doctors usually prescribe elastic stockings and/or pneumatic hose as well as anticoagulant therapy as a regular part of our immediate postop care.

But it could be that women who have a transfusion before surgery, perhaps to correct anemia from excessive bleeding, as well as those who require transfusion to compensate for blood lost during the operation, may be incurring an extra risk factor. And since blood clots are a very serious health threat as well as a reason why future HRT use may be forbidden, this is something to take into account when making the decision to permit a transfusion.

It's not necessarily a reason to turn one down, of course: sometimes blood loss can be life-threatening and there may be few other options for dealing with the situation. If a doctor knows that this elevated risk exists, there may well be specific measures to do with both detection and prevention that can be put in place that help reduce this added risk exposure. It's not a simple or straightforward decision, so it needs to result from a discussion with your own surgeon or doctor. But this new information is definitely something to be sure they've heard of and are taking into account in how they manage your overall treatment.

If you want to share the content of this study, it is:

Association Between Venous Thromboembolism and Perioperative Allogeneic Transfusion

Kent R. Nilsson, MD, MA; Sean M. Berenholtz, MD, MHS; Elizabeth Garrett-Mayer, PhD; Todd Dorman, MD; Michael J. Klag, MD, MPH; Peter J. Pronovost, MD, PhD

Arch Surg. 2007;142:126-132.

Post-op: bowel activity

When bowels are handled and disturbed, as happens during a hysterectomy or any other abdominal surgery, they shut down activity for a period of time. This is why women are often surprised to find that they are limited to only liquids for the first day or so after their hyst: this gives the bowels a rest and doesn't overwhelm them before they are ready to resume activity. Eating too soon will only cause the undigestible food to back up, producing vomiting that is not a real appealing prospect for anyone who has just had abdominal surgery--not a pleasant thing to contemplate.

How do we know that our bowels are returning to function? Our caregivers can hear the sounds of sloshing when they listen with a stethescope, and before long, we can feel or hear the passage of gas. This is such an important recovery milestone that it is one of the criteria for discharge: we have to actually pass gas to demonstrate that our bowels are capable of taking up their digestive functions again.

For many women, this signals the most frustrating and uncomfortable part of recovery, however: dealing with gas and constipation. Narcotic drugs, low physical activity levels, a low-fiber diet, not drinking enough, and, for those who are users, lack of caffeine all contribute to impaired bowel motility and enhance these gas and constipation effects.

But those causes also provide us with a good set of things we can do to limit these unpleasant symptoms of our bowels recovering. 

Pre-op: planning for the medications we'll be receiving

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 just generalities, so you'll need to do the work of talking with your doctor and fleshing out the details.

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 not be done unless it's ordered. You may be able to negotiate the actual laxatives used if you have specific preferences.

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.

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.

In the OR 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.

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 (NSAID) 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 NSAID) with your cardiologist as well as your surgeon, both in terms of operative use and home use of oral anti-inflammatories.

Postop pain control tends to be IV at first, then gradually moving to IM (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.

Many doctors will also place you on anticoagulant shots starting in the OR 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.

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 do not 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.

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 do 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.

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.

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.

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.

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:

• Rx list
• Herbal safety

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 all 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?

Operative uncertainties: why did I come out of the OR with a different diagnosis/surgery from the one I went in with?

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. How can this happen? they ask. They told me that these things "might" happen but were not likely.

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.

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 very 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.

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 OR with a whole shopping list of abdominal pathologies that remained elusive until the surgeon actually got a good, personal, eyeballs look.

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.

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.

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 that may be changing), 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 here) lest your doctor make a decision for you that you would not have favored had you been a party to it.

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.

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: but what if that does happen? What then? What are my choices? What will those choices mean for my future health? 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.

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.

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.

Pre-op decision: surgical route

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.

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.

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. 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.

There have traditionally been three factors, roughly, that determine suitability for the vaginal procedure:

1. 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."
2. 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.
3. 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.

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.

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).

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.

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.

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.

I understand that in vaginal surgery, the cervix is taken out . I want to keep everything that I possibly can.

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.

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.

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.

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).

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.

Postop: Pain

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.

You're entitled to a plan

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 pain management plan. 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.

Immediate postop pain management

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 anti-inflammatory 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 NSAID family (such as the 12-hour dose of naproxen), and does not carry the effects of the opiates (in either allergy or constipation).

[Update 12/20/04: FDA warning about naproxen: The FDA has issued warnings about possible heart damage that may be caused by using naproxen. More on this topic in this post.]

It is also reasonable to ask your anesthetist to medicate you for nausea 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 after surgery, such as your pain med, not things you received during surgery.

Two fairly common pain management setups are the patient-administered IV 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.

The epidural 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.

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.

How bad will it be?

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 really really careful 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.

The goal of pain management, 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.

What about the risk of addiction?

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.

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.

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.

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.

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.

Pain and medication on discharge from the hospital

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).

What about if my prescription runs out and I'm still hurting?

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.

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 may take them that often (if you need that level of pain relief), not that you must 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 most frequent 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.

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.

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.

Postop: bladder matters

One of the aggravations we may face in the first few weeks of our surgical recovery is a crampy bladder. This may feel like having an infection, it may seem like cramps after we urinate, we may have trouble telling when we need to go or we may feel as though we need to go very frequently. All of these are fairly normal things and are results of the trauma to our bladders during surgery.

They've been discussing this recently over at the Survivor's Guide to Surgical Menopause, a website and message list that focus on hormone and other longterm health needs of women who have had a hyst. Here's some of what Framboise, the moderator, had to say about bladders and what they undergo in surgery:

The bladder is basically a muscular organ held in place by a number of ligaments that tie it to other structures (but not the intestines) to keep it up in the abdominal cavity instead of pressing onto the vagina and rectum (or even hanging into their space, as happens in a prolapse). Even when the surgical approach is from beneath, as with a vaginal or laparoscopic procedure, because the two organs--bladder and uterus--are directly adjacent and share some blood vessels and nerves, to remove one does physically impact the other.

Even in those procedures, some of the supports for the top end of the vagina and bladder are shifted away from the uterine area and onto other anchor points. This process is involved and really is the important part of a hyst: it takes only moments to sever the uterus (assuming it isn't fused in place by scar tissue or its fibroids haven't caused it to engulf other organs) but the rest of the time to tidy up bleeding and supports. And this is what takes so long in the healing, by the way--all those tidying up things have to heal securely and fully for your abdominal contents to have proper ongoing support.

So in the most uncomplicated of hysts, the bladder's circulation and nerves are affected and it's had a lot of handling go on in the vicinity. In a more complicated hyst, such as for endo, the entire bladder may need to be cut free from enveloping scars or it may need to be peeled away from being squashed by massive fibroids or any number of even more exciting things (from the bladder's perspective).

As though that weren't enough to induce a months-long fit of the crabbies, surgery also means we have a catheter inserted into our bladders for, usually, about 24 hours (it's needed to keep the bladder fully emptied, except when it may be pumped full of sterile fluid to make it more visible during the surgery--needs differ according to the surgery, but a catheter is standard for several very good reasons). In addition to the risk of introducing infection, a catheter is a mechanical irritant to an organ that normally only has to deal with liquid content.

It's generally believed that the catheter is left in during the first postop day so save us from having to get out of bed to go to the bathroom. Unfortunately, that's a misconception. Instead, it's left in because it's typical that our bladders are in such a foul snit over the uproar of surgery that they flat go on strike and aren't likely to work properly until they get over it. In fact, one of the earliest postop recovery challenges is: can you pee on your own once the catheter is out? For most women, the answer is yes and they give the matter no more thought. For others, typically those who had more complicated procedures with more bladder trauma, that answer may be no for a few days. For those who had actual bladder procedures associated with their hyst (typically more intensive support repairs), it may be routine to keep a catheter even once they go home and need to use it for several weeks.

So, you can begin to see why a bladder is not a big fan of a hyst, even when things go well. And it's not an on/off function, where it suddenly decides to go back to working and that's the end of it. In fact, as healing progresses, nerves and blood vessels go through their own stairstep healing process and you can expect to see bladder crankiness come and go with these stages. This is all normal healing, but it can be immensely aggravating and even outright discomforting while its going on.

Making sure you don't let yourself get dehydrated for fear of cramps is important--you need to retrain your bladder to be tolerant of being full, especially now that there's room for it to do so without having to muscle an enlarged uterus aside. You may want to limit your caffeine during this time, since caffeine is a known bladder cramp stimulant. Many doctors will throw in a list of other foods that may be irritants, just on spec, but most women really don't see that spicy foods, for example, constitute that much of an irritant to their bladders. I rather think that these are sort of verbal filler, not that the doctors really feel that all our ills will be averted if we subsist on a diet of cream of wheat and skim milk (not to mention that five minutes later when you're discussing postop constipation they'll tell you to eat plenty of fruits, vegies and fiber *rolls eyes*).

One "old wive's tale" you may encounter is that it's normal for the bladder to "fall" or for women to become incontinent after a hyst. This is a dated outlook. Surgical procedures have gotten more sophisticated in dealing with the need for bladder support, and this is no longer a normal outcome. Often the helpful women who are sharing these stories have actually had their hysts, or heard about their friends' hysts, decades ago. While some bladder discomfort is normal, then, we're no longer looking at trading serious bladder impairment for removal of our diseased uterus.

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.

Postop: Should I call my doctor?

I see posting after posting in the online hyst forums describing all sorts of situations and asking this question. And the only possible answer is, invariably, yes.

Yes, if anything at all happens that worries you or makes you wonder whether or how your postop instructions apply, you should call your doctor.

Yes, you should call your doctor if it happens at 10 am on a weekday and yes, you should call your doctor if it happens at 1 am on Sunday. Every surgeon has a mechanism for taking calls and a relief on-call doctor who will be available if he is off. You may have to leave a message with an answering service and wait for a callback, but you can and should take your questions to a doctor. No one on a forum, no matter how well-educated or well-intentioned, has the information at hand to answer your questions safely and applicably. In fact, if your doctor or his on-call is in doubt because of the limitations of discussing things on the phone, he may ask you to come to the office or be seen in the Emergency Room just so that you can be evaluated more fully. Doctors understand the limitations of phone consultations; women on forums, however well-motivated they may be, tend not to.

"But I hate to disturb my doctor with what might be a silly question..." is an all-too-common response. Nonsense. You are paying the doctor for a service, and part of that service is postoperative supervision. Whether you have developed a complication requiring further treatment or whether your doctor failed to adequately instruct you on what to expect, the doctor is a contractor being paid for a specific service and you are entirely entitled to that full service for those big bucks.

There are things you can do to help make your call as effective as possible. First of all, before you even pick up the phone, jot down some notes. Write out as explicitly as possible what your worries or questions are. Include such background information as when you had your surgery, what surgery it was, what medications and hrt you are on (include when you last took them), what your temperature is or other pertinent information about your physical condition. Your doctor may take your call from a location where he doesn't have your chart or his notes available, and you don't want to rely upon his (crowded) memory for important details.

Doctors respond better to clear, objective information, not subjective responses. Saying in tears that "I feel totally horrible and I'm really worried!!!!" does not convey nearly as much helpful information to the doctor as "I am running a fever of 101, my head has been pounding for 6 hours despite taking [pain medication type and dose and time of last dose], and my incision looks red, puffy and is draining green pus that made a circle 1" in diameter on a dressing in the past 6 hours." The first comment will likely get a soothing response or a suggestion that you need an antidepressant; the second may see you with an office visit and an antibiotic prescription—very different results indeed.

So if you are describing your incision, you need to be prepared to report the following:

• location
• how long this has been going on/when you first noticed it
• color: red, pale, normal skin tone?
• temperature of the area: hot? same as surrounding tissues?
• presence or absence of local swelling, feeling of area: hard? soft? hard lump with distinct edges? dimensions of lump in inches/cm?
• sensation of area: hurts all the time? hurts when touched gently/pushed on? sharp pain or ache? burning pain or stabbing pain?
• smell: no particular odor? medicinal? foul or rotting meat odor?
• drainage description: clear pinkish-yellowish? bright red blood? old clotted blood? pus? green? yellow?
• drainage amount: size of stain on dressing in [whatever] amount of time, how many times you've changed what type of pad or dressing in past [whatever] amount of time?
• your temperature taken just before calling, as well as when you last took it and what it was then

If you think you are having hormonal problems, you need to be prepared to report the following:

• what you are taking for hrt
• when you take it and when you last took it
• what specific symptoms you are having that you attribute to your hormones: hot flashes? mood swings? rash? swelling? headache? nausea?
• for each symptom, further list: when it began, how many times you've had it, how long it lasts (for example: hot flashes started today, I have had 6 lasting 10-30 seconds each and each time more intense/causing heavier sweat or I have burst into tears inappropriately 4 times today and yelled at my kids when they really didn't deserve it twice)

By having this sort of information ready, you're giving your doctor the information he needs to identify and constructively deal with your problem, not your reaction to your problem. And that will make for a whole lot more satisfaction all around. And, hey, if it turns out to be something perfectly normal, then you have the reassurance and your doctor's learned a lesson about preparing you for what to expect that will benefit the next woman he treats. Everyone wins!

Ovarian failure following hysterectomy

If you have retained your ovaries when having a hyst, you may be surprised when your hormone output drops after surgery. Sometimes this simply represents slight ovarian insult from the damage to surrounding blood vessels and nerves during surgery, and as healing progresses, these symptoms abate.

But about 50% of the women who retain their ovaries experience menopause within five years of their surgery, irrespective of their age at the time of surgery. This means, for any given individual, a whole range of possible experiences from menopause right after surgery to menopause at whatever time it would otherwise have occurred. The most important thing we can gain from this statistic, though, is the validation that if we are experiencing menopausal symptoms sooner than we'd normally expect, this could be the reason.

It's common for this postop ovarian impairment to be referred to as "sleeping" on many hysterectomy message lists and forums, but the situation is not really as simple as this implication that they might "wake" back up again. While it's true that the impairment—which is actually a drop in their hormonal output—may resolve entirely with time and healing, that is not necessarily the case. Ovarian output is not an on/off function like a light switch. In fact, ovarian output may simply decrease somewhat and remain there; it may fluctuate considerably; it may just decline and keep on declining. There are many patterns of ovarian behavior and operative impairment does not necessarily cause any particular one. But whatever the pattern, if your output decreases below your level of hormone needs (which continue at a low level even though you no longer need to support fertility and uterine cycling), then you will experience some level of menopausal symptoms, proportional to the amount of shortfall in meeting your remaining needs.

It has been some women's unfortunate experience that their doctors are unfamiliar with this phenomenon and deny them any menopausal support on the grounds that because they still have ovaries, those ovaries must be working. If you are in this uncomfortable position, here is some of the documentation that might help you educate your doctor about this outcome.

• "A number of medical studies have documented that ovarian failure occurs frequently in retained ovaries following a hysterectomy... " (source)
• "Another worry is that hysterectomy with ovarian conservation may precipitate early menopause. This seems to be supported by a mean age of ovarian failure in hysterectomized women of 45.4 +/- 4.0 years (standard deviation (SD)) as opposed to a mean age of 49.5 +/- 4.04 years in a non-hysterectomized control group (5). According to the same study, the indication for carrying out a hysterectomy did not change the time of ovarian failure. Postal questionnaires sent to hysterectomized women, with ovarian preservation, suggest that 26.1% (8) to 39% show signs of ovarian failure (6). The type of incision appears not to have any bearing on the failure rate (8)." (source)
• The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. (Siddle N; Fertil Steril, 1987 Jan)
• Riedel HH, et al; Ovarian failure phenomena after hysterectomy. (J Reprod Med, 1986 Jul)
• Owens S, et al; Ovarian management at the time of radical hysterectomy for cancer of the cervix. (Gynecol Oncol, 1989 Dec)
• Habelt K, et al; [Symptoms of ovarian failure after hysterectomy in premenopausal women. A retrospective study based on postoperative perception of 245 women] (Zentralbl Gynakol, 1996)
• Menopause: The Journal of The North American Menopause Society, Vol. 5, No. 2, pp. 113-122, Hysterectomy, Ovarian Failure, and Depression, Gautam Khastgir, MD, FRCS, MRCOG, and John Studd, DSc, MD, FRCOG (abstract)
• "If a woman has a hysterectomy that leaves her ovaries in place, she has a 50% chance of suffering ovarian failure within five years of surgery. This is not age dependent." (source)
• Message list posting that cites numerous sources
• Relation between hysterectomy and subsequent ovarian function in a district hospital population, Quinn, A.J.; Barrett, T., Journal of Obstetrics & Gynaecology, Mar94, Vol. 14 Issue 2, p103 (source)
• Siddle N, Sarrel P, Whitehead M. The effect of hysterectomy on the age at ovarian failure identification of a subgroup of women with premature loss of ovarian function an literature review. Fertil Steril 1987 ; 47 : 94-100. (abstract)

Postop: home alone

While postop planning is important for any of us, I often see questions from women who have recently moved or are otherwise alone and facing recovery on their own. While recovering solo is not the optimum, real world constraints sometimes mean we don't get to pick the very best options and just have to muddle through as best we can.

All other things being equal, being able to stay with someone for a couple days or having someone stay with us for that time makes for a safer transition from the hospital. Of course, this means someone tolerable. This isn't the time to have your evil ex-mother-in-law who expects you to wait on her hand and foot, or a worthless kid who will spend all their time out visiting old highschool friends, or a dear friend who will actually tell you she's busy with her kids right then but do call back any time you need help.

What is it that we will need help with, in those first few days? Let's look at that. First of all, you will need someone to bring you home from the hospital. You will most likely feel overwhelmed by just the minimal baggage from your hospital stay, and it's likely there will be a stop on the way home to pick up a prescription for pain meds (will your pharmacy let your doctor call it in and deliver to your home? check it out beforehand). Just sitting in the car (with a thin pillow between your belly and the seatbelt, for a little protection) will be about all the thrills you'll be up to, right then.

Another benefit of having someone pick you up is that they can help listen to your discharge instructions and take charge of the paperwork. You'll have some sort of written instruction sheet, usually, plus a card with your followup appointment and a prescription. I can't tell you how often women mention losing one or another of these by the time they get home. You'll have enough to do to get your body swathed in some sort of undemanding clothing and into the car; let someone else do the detail stuff.

Once you're home, you'll want to head for bed. Nothing in the world feels quite so wonderful as getting home to your own bed. Nothing. But is that bed up a flight of stairs? Climbing is difficult because you actually use belly muscles to help life your knees, so your doctor may advise you to limit the number of times you go up and down in a day (you'll discuss this at your pre-op, right?). Regardless of the number of trips you're allowed, you can greatly ease the burden on your belly by backing up and down the stairs. That's right: going backwards. Obviously you'll need to hold onto the rail, you can't carry anything, and you need to keep your wits about you and go slowly. But it really does force you to take the lift with your thigh muscles, not your belly. The first time you do it, it's nice to have someone standing by to help steady you if things get too wobbly and exciting. It gets better with practice.

Some of the other challenges you'll be facing in the first couple days at home are getting to the bathroom, getting yourself fed, and taking a shower. Pretty basic things, these are, but they are all fairly demanding to a fresh postop.

It's important to prevent complications and encourage healing for you to walk frequently. In the first few days at home, that's fairly well taken care of just in bathroom and kitchen trips. But if your bathroom is on a different floor from your bed, you may want to reconsider where you sleep for awhile. While some women camp on a sofa or recliner during the day to be close to the bathroom, I feel it's the nighttime trips and the first morning trip with a cranky "I can't wait" bladder that expose us most to haste, trips and possible stumbles or falls. This is a bad idea. Think this through beforehand and make sure that you can sleep someplace on the same floor as a bathroom until you are thoroughly steady and reliable on the stairs before you cut yourself off from the bathroom this way.

One of your major tasks in the early postop days is getting enough to drink. How much is enough? Enough that your urine is very pale. This means that every couple hours or so you'll be making a potty stroll. That sounds like a lot, but since exercise is another of your goals, this is a nice twofer. And while some women recommend keeping an ice chest next to your bed with drinks and snacks, that begs the problem of how it gets there if you're on your own. In fact, walking down to the kitchen to get a snack or another drink is more good exercise. So going to get a drink and walking to the bathroom to get rid of your last drink should provide a nice little perpetual motion effect for you.

And then there's the shower (assuming you've been cleared to do so by your doctor--ask before you leave the hospital). Showering feels wonderful, but includes some special perils so it's good to have someone standing by outside the bathroom in case you need to call for help. What kind of perils? First of all, you're not going to be nimble climbing in and out, especially if it's a bathtub shower such that you have to climb over the side of the tub. Take your time and hang on. Putting a waterproof kitchen chair in the shower may give you something to steady on plus a way to sit down if you get woozy. This is a good time to get one of those ucky old rubber tub mats, too. With your balance thrown off by a wonky belly, you need all the help you can get staying on your feet. And remember to put towels within reach so you can dry off before you try to climb back out. You can do all this alone, but someone "on call" for the first time is just good sense. A fall or even a flailing about attempt not to fall is not a good idea.

So, to prepare for these early needs, you'll need to walk through what's needed in your home. In your bedroom, do you have a variety of pillows and covers available? Where are the spare sheets—you'll be wanting clean sheets at least once before you can comfortably root around in a crowded linen closet's upper shelves. Can you reach a reading light from in bed without stretching? Is your bedside table big enough for a drink, kleenex, book, glasses, music device, laptop, TV remote? If not, move one in, move a reading lamp in, pile spare linens around on the furniture. Don't be worrying about a little clutter, since what is much more important is conserving your energy for needed tasks. Believe me: tidy matters not nearly as much as convenient when you are postop.

And while you're looking your bedroom over, how about clothing? At least a couple clean gowns/jammies need to be grabable without pulling out a heavy dresser drawer. Where are your robe and slippers? You may want some loose caftan-like garments or sweats to wear during the day so you are presentable for any visitors.

How about your bathroom? A couple rolls of toilet paper and maybe some moist wipes (you may be dealing with some constipation) within reach of the toilet? Several sets of clean towels out where you can reach them? Mild bath products in small enough bottles to lift easily and toiletries out of tricky cabinets? Tub mat? How about making sure you have a selection of reading at hand by the toilet? How's the light at night—will you need a night light or a temporary lamp near the toilet? And while you're thinking nightlights, how's the route between bedroom and bathroom lit? When you're foggy from drugs and in a hurry with a crabby bladder, you may not want to stop to fiddle with light switches in the dark.

And then, the kitchen. You'll be wanting lots to drink, of course. It's good to limit caffeine, just because that is a bladder irritant. Fruit juice (cranberry is especially good because of it's infection-resisting qualities), diet sodas, powdered drink mixes are all good things. But remember that you can't life the big bottles: things need to be in small containers. If you use a powdered mix (like Crystal Lite and those sorts of things), mix the full package in a very small, say 8-oz container, and just dilute it with tap water to make up the strength to taste. If you're a fan of ice, can you easily get to your freezer? Before you leave for the hospital, how about getting several trays of ice emptied into a container so ice doesn't require wrestling with a tray?

Most women tend to want fairly simple, blandish food in the first couple weeks postop, no matter how spicy and exotic their taste normally is. It's fine to eat more frequent small meals, but it's very important to make sure you get lots of fiber and nutrients. This is a good time to stock up on small yogurts, dried fruit, and other (wholesome) nibbly stuff as well as freezing single-serving meals. Make sure you can get to the utensils you'll want to prepare/serve/eat with. And if your dishwasher takes a lot of bending/twisting to fill, consider a small stock of paper plates to tide you over the first week or two. In the first couple weeks, opening a package or nuking a single serving are going to be about the level of your enthusiasm for eating. Smoothies are a great recovery meal too, if you like them and can keep frozen fruit easy to reach.

After a week or so, the level of chaos and dust may start getting to the tidier amongst us. Personally, I can ignore the dustbunnies up until they are large enough to trip over, but I appreciate that others may have more delicate sensibilities. If you know that you are going to be unable to resist grabbing a dustcloth or vacuum, please plan ahead. This is not something you'll be cleared for yet and really isn't a good investment of your healing energy. If you just can't live in chaos, arrange for a maid service, offer to pay a college kid, or ask a friend or church group member for help doing the heavy tidying up and laundry for the first few weeks.

And if you have pets, you'll need to plan ahead for their needs as well. A dog on a leash is more than you can handle, even if they are very well-behaved. If you don't have a fenced yard or a long tether for them, you'll need to arrange for someone to come in to walk them however many times a day is needed. If you have hard-to-control dogs, especially ones that are incorrigible jumpers, you may even want to think about boarding them out for the first week or so of your recovery. If their food involves lifting heavy cans or bags, consider parceling out those kibbles into smaller plastic containers you can keep on a counter for a few weeks and/or freezing single-portion dog meals. For cats, make sure that the litter box is something you can reach without serious effort (bending/twisting is especially difficult). If you frequently change the whole box, you may need to arrange for someone to do this for you. Alternatively, consider clumping litter that will allow you to scoop the used out (into a covered pail you keep by the little box till someone can dump it for you) and refill by scooping a small amount from an open bag you keep nearby. If your cat food is in a heavy or awkward container, consider repackaging it for easier access. And to protect your belly from enthusiastic jumpers (it is a frightening thing for all concerned to be dozing on a sofa postop and have your small dog or cat suddenly jump up for a snuggle and land on your incision), get in the habit of resting a pillow on your belly whenever you are sitting or lying.

Communications are another thing to think about. If you're going to be spending most of your time alone, make sure that what you'll be wearing has a big pocket that will hold your cell or portable phone. If you fall or get too woozy to leave the bathroom or anything really scary happens, it will be well worth the inconvenience of carrying that phone around to have it right on your person. Program in a couple numbers for people who can come in an emergency, in a hurry. The odds of your needing this are very low, but it will give you a sense of control that can be a comfort. Otherwise, having your phone on you lets you answer the phone without feeling the need to heave yourself up out of wherever you just got settled to take another call from yet another telemarketer. Don't feel you have to be at the world's beck and call--if you don't have a recorder of some sort, this might be a good time to get one. Leaving the volume up so you can hear it wherever you're hanging out so you can screen your calls is a great way to husband your energy for your own needs.

It's also a good idea to think of other household chores you may not be able to manage. Does the yard need to be watered or mown? Will you need to have the front walk shoveled free of snow so the postman can bring your mail? Who's going to refill the birdfeeder or water the potted plants on the deck (no, it will not be you picking up that bag of feed or full watering can for a couple months)? How far away is your mailbox? Can you let a few days' worth of mail accumulate or should you have the Post Office stop delivery for a few days? Do you need to drop a rent check at the condo office? Will your library books need to be returned (most libraries will let you renew by phone, so check with them on this)? Is there a newspaper delivery you will need to put on hold? How about your garbage/recycling pickup? Got enough furnace fuel and cooking gas to last the next couple months?

And of course you'll want some entertainment. If the weather's good, you'll be able to walk outside as soon as you can extend your range beyond the bedroom-bathroom-kitchen circuit. This is a big boost to the spirits, so even if you're not normally an outdoor walker, go for the air and sun. Remember that in the winter the footing will be tricky, though. A (light) cane or walking stick plus good boots will make a lot of difference in your stability.

I'm sure you can figure out getting movies/DVDs, or a big haul of books from the library. Don't make this the occasion for all those weighty and improving books you've always meant to sit down and tackle, though. Anesthesia and drugs have a clouding effect on the brain, and for the first couple weeks, at least, you'll find that only the most trivial, easy to pick up and put down froth will hold your interest. And light reading refers also to the books themselves: a paperback is easier to lift and rest on your chest while you read reclining than a great unwieldy hardcover. Ditto projects. This will be a good time to get photos sorted and put in an album, but only if it really engages your interest. Simple needlework or crafts that can be done reclining are appealing, but anything that requires that you sit at a desk and work attentively, not so much. Sitting itself will not be comfortable (it's very fatiguing for the belly) for several weeks. A sofa you can sprawl on (put a hassock out if you have one) or a recliner with a good side table are where you'll be spending most of your time, and so your entertainment and projects will need to work in that sort of setting. This also goes for your computer, if you use a tower rather than laptop and plan to use it much.

After a couple weeks you'll be feeling friskier, even though not quite ready to drive on your own (that depends on what your doctor and insurance company have to say). This is when you'll want to take up those folks who offered to do things for you by asking for a lift to the grocery store. You won't be able to lift your bags or carry them into the house, so be sure your ride is okay with giving you a hand. It's also challenging to push a shopping cart, and many women report that the motorized carts are absolutely the way to make your first few shopping trips. Remember, if you've done your preop shopping well, you'll only be out for fresh vegies and fruit and dairy and such on this trip. Right?

So, really, your greatest needs for other folks are when you first are ready to go home plus rides on other needed errands, a little early supervision, pets/chores that you can't handle, occasional cleaning and laundry, and backup in case of problems. By preplanning and setting things up before you leave for the hospital, then, you should be able to handle your hyst recovery fairly independently if your postop course is typical. It's a good idea, however, to at least rough out a fallback plan in case you develop some sort of complication or find that because your surgery did not go as planned, you aren't quite as able to manage on your own as you'd hoped. Overall, though, your greatest challenge will be the same as women living with any size of family will face: moderating your activity to only that which you can manage without injury or robbing yourself of energy needed for healing. Please repeat after me: I will get only one chance to heal well, and so I'm going to do a conscientious job of it.

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.