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.

Pre-op: The hospital pre-op appointment

Often referred to as "the pre-op," this is different from pre-op appointments with your surgeon. At that appointment (or several appointments) you explore the reasons for your hyst, make plans for many optional parts of your surgey and followup care, and sign (after discussing) your surgical consent.

But for "the pre-op" you'll most typically be going to the hospital and/or the office of the anesthesia group that will be providing that portion of your surgical services. Here's what you can expect at each.

At the hospital

You can expect to be spending some time with the billing office, getting your registration and billing information recorded and signing the multitude of forms the hospital requires before accepting you as a customer. You should bring in or be prepared to provide such information as your insurance billing details, next of kin/emergency consent contact, who will be the contact during the time you are in surgery, living will (if you have one), and any special needs you may have (a translator? assistive devices for basic communications? religious practice needs? visitor restrictions for personal safety or preference?). If you are not covered by insurance, be sure to be prepared to set up a payment schedule and ask for a discount for paying cash; bring your credit card as well.

You may be given paperwork to bring back with you upon admission. Be sure to check what the procedures required on the day of your admittance are: when your surgeon told you to be there at 8 am, he meant to begin the stuff he is concerned with; the hospital office may also need your time then, and you don't want to be late for your surgeon because of competing demands for your time. This is also a good time to ask whether you will need to stop at the billing office on your way out of the hospital when you are discharged: at some hospitals this is routine (and tiresome) and other hospitals take care of all of this at your pre-op visit, freeing you to just cruise out whenever your doctor gives the okay. Be sure to ask when checkout is during the day, lest you end up paying for an extra day's stay because you lingered an unnecessary half hour over the limit. If you plan to ask for a copy of your hospital records, this is also a good time to ask the procedure for obtaining them (although you may be referred to another department for this).

If you have not already had these done at your doctor's office, you may also be asked to visit the lab, x-ray and ekg to have routine pre-op studies done. Not all of these are required for all women, but generally some or all of them are simply part of a last-minute check to make sure that other problems will not interfere with your surgical procedure. Aside from the stick for blood, none of them are invasive or especially uncomfortable.

If you are being typed and cross-matched for blood that will be held for a possible transfusion, you may be given an ID bracelet and required to put it on. This is dorky-looking but necessary--it holds your half of the only key that assures that the held blood has been tested for compatibility with your own. If you lose your key, the blood is wasted (and you'll be charged for it) as well as not available should you need it; re-matching you will take time that you may be ill-able to afford in an emergency. If wearing a paper bracelet for several days is especially distasteful for you for some reason, you may be able to negotiate having it placed around your ankle instead. If that is the case, be sure to let everyone know where it is on the day you're admitted (where everyone means your doctor, the circulating nurse in the operating room, and anesthesia) and ask that it be noted on the front of the chart when you are being checked in.

Anesthesia

The other part of "the pre-op" is generally a visit to someone from the anesthesia group. This is a special medical practice, separate from your surgeon. Typically this service is provided by a pool of doctors (anesthesiologists) and perhaps nurses (anesthetists), and you will be billed separately by this group for their services. The practitioner you see may not be the one who will care for you during your surgery, but he will write notes and perhaps some orders that will go in your chart for the person actually in the OR.

This appointment is primarily an interview, although it is likely that the practitioner will examine your head and neck, and look into your mouth (or at your back, if you are having a spinal--and some of the following will not be applicable if that is the case). This is to identify any problems that may make putting the tube into your lungs (through which they will maintain your respirations once you are under general anesthesia) tricky. In particular, you will be asked if you have any dental appliances or chipped teeth--it's important to let them know this so that they can avoid damaging them with the instruments being used.

Other things anesthesia will discuss include previous experiences you've had with anesthesia and other health conditions you may have that might affect your toleration of anesthesia drugs. This is also the time to share any fears you may have about anesthesia, review any meds you may be given to relax you beforehand, and to discuss nausea in the immediate postop recovery period. If you are prone to nausea, let them know: it's possible to medicate you before you start puking, which can be A Very Good Thing when having abdominal surgery. If you have had bad experiences in the past with pain medications, like itchy/rash reactions, do be sure to let them know this, even if it's not a real allergy.

Anesthesia will review with you the timing of when you may last eat/drink anything (not what you may eat or drink--this may be up to your surgeon). Fasting is very very important to prevent vomiting during the process of going under--something that can cause pneumonia--so be sure you understand your restrictions and that they are for your benefit. If you plan to take some regular meds or supplements in the fasting hours before surgery, please check these with anesthesia and ask what/how much you may take them with if they are oral meds. Diabetics or asthmatics have a special need to review what they will be taking before surgery, what their normal maintenance regimens are, and how their needs will be managed during surgery and recovery. The whole goal of this appointment is to make anesthesia as successful and little stressful for you as possible, so the more you can help your anesthetist, the better things will go for you.

And one last note about all of the pre-op contacts you may have just before or the day of surgery: don't be surprised if, over and over, you are asked specifically what procedure you are having (and if something is happening only to one side, like only one ovary to be removed, you'll be asked to point to the involved side). This is a constant process of checking who you are and that the right person is having the right surgery--it's a much more positive identifier than asking a nervous or groggy person a question like "are you [mumbled name]?" that they might answer without really grasping. And, because it's a hyst, you may be asked several times whether you are pregnant and if you understand that having this surgery means you cannot ever again get pregnant. While this may seem like an extra added torment to many of us, it does, ultimately, protect the rights of women to understand what they are choosing. If our aggravation pays for one woman getting the message who may not previously have fully understood the implications of what she has consented to, well, don't you think it's worth it for her sake?

Pre-op decisions: Keeping your cervix, revisited

The decision to keep one's cervix may have just gotten a little simpler for some women...or their daughters, at least. As you may have noted in our previous discussion of this topic, a certain number of women opt to have their cervix removed not because of specific cervical pathology but because they want to be protected from the risk of developing cervical cancer in the future. For these women, news released this week about a new vaccine that offers protection from the most common causes of cervical cancer may allow them to make that decision differently.

I'm not sure yet how and when this is going to play out. The vaccine hasn't been approved yet, but given the large test sample and the overwhelmingly positive results, I'm having a hard time believing the US FDA is going to drag their feet in approving this.

The manufacturer notes that this vaccine "should" be given before a young woman becomes sexually active to "ensure" protection. This doesn't address its use in women who are already sexually active but perhaps are not yet infected and who could conceivably benefit from that protection. As with so many things to do with a hyst, this will need to be a personalized decision: weighing the risks of having been infected against the inpact cervical removal might have on one's sexual response. But as time goes by and more of the women who are faced with the need for a hyst have been protected by this vaccine, that decision to ditch a cervix for prophylactic reasons may become less urgent for many. And, all things considered, that's good news.

Pre-op decisions: we'll just take out those ovaries so you won't have to worry about cancer

If you are planning your hysterectomy, or even just investigating what it would mean for you, and your doctor offers you this "recommendation," you may want to ask him to step back and explain himself in a lot more detail.

It used to be the practice that when women were facing a hyst, a surgeon would suggest that because her ovaries "aren't needed" any more, she should have them removed now so as to remove the risk of later getting ovarian cancer. In many cases, this would include the suggestion that "most" women who retain ovaries only end up needing another surgery later to remove them anyway.

Today we know that this kind of a sales pitch is not only medically inaccurate but is in fact a strategy that holds greater odds of shortening a woman's life than the alternative. And, slowly, doctors who keep up with the news in this field are revising their recommendations to a more accurate representation of the various risks.

Much of this turnaround can be credited to this study, published in the May, 2009 issue of the journal Obstetrics & Gynecology: "Ovarian Conservation at the Time of Hysterectomy and Long-Term Health Outcomes in the Nurses’ Health Study." For something that may be a little less intimidating to read, you might try this article at webmd: "Hysterectomy: Spare Ovaries, Boost Health?." Yet another good resource is the anonymous but probably related to the study website OvaryResearch, which focuses on the study and discussion it's stimulated as well as an earlier version of it that appeared in 2005.

Okay, enough with the citations: what's this about?

The study, which involved a very large pool of women (that's good, because it means the results are more likely to really reflect us all), found that rather than lowering deaths from cancer, prophylactic oophorectomy (that's the fancy way of saying taking out ovaries for the sake of prevention) in fact had a higher risk of death from all causes but mostly heart disease and lung cancer. That's right: removing our healthy ovaries at any age does not lengthen our lives or improve our health.

Further, although breast and ovarian cancer rates were lower in women who had their ovaries removed, the risk of death from all types of cancer was higher in these women. So, yes, the very thing we feared and chose this option in hopes of preventing is actually more likely to happen to us than if we'd left well enough alone.

And the rates of death are highest for women who never supplemented their hormones after the surgery. All those women who valiently toughed out menopausal symptoms because they thought it was the right and "natural" thing to do were in fact working with their doctors to shorten their own lives.

Tragic, right? And we're talking a big tragedy here: about 300,000 women a year choose to have this surgery under the impression that it will help them live longer, healthier lives. According to the main study author, that's "50% of women who have a hysterectomy between ages 40-44...and 78% of women between ages 45-64," even though it's well demonstrated that post-menopausal ovaries continue to contribute to our hormonal support, a support that's lost when we take those ovaries out.

But wait! What about women at real risk for cancer?

Yes, of course there are women for whom the risks boil down to high expectation of death by breast or ovarian cancer vs later death by these risks of lost hormones. That's a special situation and no one is suggesting that preventative removal of ovaries might not be the right choice for them.

But it needs to be an informed choice. That means not just making the assumption that because there's "a lot of cancer" in one's family that we are, personally, at risk for these specific cancers. It requires genetic testing and evaluation by an oncological specialist, not an assurance of a gyn surgeon who heard the word "cancer" and got spooked into a slash-and-burn mentality.

Can't I just take something to make up for that risk?

For many of us, the idea of cancer is so terrifying that it shorts out our brains. Especially if we're younger women and few of our peers have died of things we attribute to aging, we may not feel that the risk of heart attack or stroke is all that vivid or personal.

One of the objections to the recommendations of this study, that more women keep healthy ovaries, is that this risk can be treated medically with statins, drugs that lower cholesterol and lipids that are believed to be a major cause of heart disease, and bisphosphonates, drugs that preserve bone density. As the study author replies, however, these drugs have notorious dropout rates, just as HRTs do. Taking out a healthy body part and replacing it with drugs that must be taken for the rest of our lives and may have significant side effects of their own: if we look at it that way, how much sense does that make?

And then there are the women who want to do it "all naturally." What do they do? Exercise and healthy eating are important lifestyle strategies for minimizing cardiovascular and osteoporosis risks, but alone they probably aren't enough for most women, not to mention that they too are something that sounds better in concept than they are actually adhered to for every remaining day of our lives. Menopausal nutraceuticals, the raw plant estrogenic compounds that are sold to reduce hot flashes in natural menopause, are relatively ineffective in coping with the level of symptoms seen with the larger drop in hormone levels due to ovarian removal. And they entirely fail to address many of the more serious effects of hormone deficiency...such as the ones that lead to the risks cited in the study. In fact, this is not a natural situation and there is no natural solution that makes up for it.

But my ovaries are diseased: what should I do?

No one is suggesting that women should not treat existing ovarian disease with surgery. But this study does suggest that we should balance our treatment options against the risks, and those risks are more sizable than our previous understanding led us to believe.

Some ovarian disorders don't require removing the whole ovary to treat, and these are poorly paid back by the increased risks.

But some disorders do require removal for definitive treatment. Sometimes, other diseases are best treated by removing our ovaries. In these cases, however, we still need to understand the costs of that treatment and we need to understand how to mitigate those costs, whether that's drugs or HRT or simply accepting that we have chosen that direction for our lives rather than the one that would have resulted from our ovarian disease.

We need to know that not having ovaries means more than not having ovarian disease.

You have to make up your own mind

This is a complex issue. Many things that can go wrong with our ovaries still don't require that we give up our ovaries. Nothing going wrong with our ovaries really doesn't seem to require their loss. The things at the other side of that equation, heart and lung disease chief among them, kill many, many more women every year.

Just as we don't necessarily believe the car salesman that the extras he's recommending will do anything more than provide him with higher profits, so we shouldn't necessarily believe the person we'll be paying to do our surgery that the extras he's recommending are more valuable to us than him. This is where second opinions are so important, getting an opinion from a doctor who doesn't profit from that advice. And where we're worried about cancer risks, we should talk with an oncologist to make sure we're evaluating our own risk accurately and not just spooked by the word itself.

This study did nothing to simplify our decision with respect to a hyst except for one thing: we simply shouldn't accept "as long as you're having a hyst" as a good reason to give up our ovaries. Because when you hear that phrase, you now know enough to hear the unspoken rest of it: "as long as you're having a hyst, why not let me give you a higher chance of an early death by heart disease or cancer?" And we simply don't need that.

[Note: This essay was revised in June 2009 to include the results of the May 2009 study.]

Hysterectomy or cancer: are you sure?

I happened across an interesting news item today, a report of a newly released study in the June 2005 issue of Psychosomatic Medicine.

Many women who have their uterus removed for benign conditions may mistakenly believe that, unless they have the surgery, they're likely to develop cancer, a new study suggests.

Researchers found that among more than 1,100 women who underwent hysterectomy for non-cancerous conditions, 29 percent said they had "a lot" of fear that they would develop cancer, without the surgery. The large majority, 80 percent, reported at least "a little" fear.

The report goes on to question whether this misunderstanding is rooted in the explanations doctors are giving their patients for their options. For some of the most common reasons for a hyst, there are other treatment options that may be applicable, but women may not choose them out of (a groundless) fear of cancer.

So for every woman who is contemplating this surgery, it's vitally important that you ask your doctor explicitly why he is recommending this treatment approach and what explicitly are the consequences of not treating it this way. If you hear the word tumor (as is often used in discussing fibroids), are you sure whether you are talking benign (harmless) or malignant (can kill you)? If not, ask your doctor: is my condition cancer? will I get cancer if I don't do this? Your doctor knows what he's talking about, but his assumption that you do too may not be well-founded. It's always better to say something like "just to be sure I understand what we're talking about here, do I have cancer now or will I in the future if I don't have a hyst?" than to undergo medical treatment that may be more extreme than you really want because you didn't get the unspoken message.

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.

Pre-op: What if I am getting sick right before surgery?

So you've got your surgery scheduled, been through the pre-op appointments, got your prep ready to go and have the time when you're supposed to report to the hospital. And then it begins about a week before surgery: first a tickly throat, then a little sinus congestion, pretty soon a cough and before you know it, you're coming down to the wire and you're undeniably getting a big nasty ol' virus.

And this is the time of year when we see this most. The holiday season and early January seem to be popular times to schedule a hyst, but that's right at a time when holiday preparation stresses plus the higher exposure from shopping and visiting make us both more vulnerable and more available to pick up any little respiratory bug that's going around. And, of course, least wanting to see this happen. But it does, frequently.

The first thing to do is admit that wishful thinking is most likely not going to be an effective tactic. Waiting and hoping that it will go away is only going to take you down to the wire without having made any preparations for dealing with the situation. Here's the bottom line right away: yes, your surgery will canceled if you are sick when you arrive at the hospital. And that's as it should be: plans are one thing, but in some cases it simply isn't safe to have anesthesia and surgery when you are already ill. Is keeping to a schedule to die for, literally? Rationally: not. I'm not saying you don't deserve a few tantrums on the subject--it is woefully unfair. But there you have it.

So how do you cope with this? By admitting what's going on as soon as you notice it. Don't hide your head in the sand and do the wishful thinking thing. Instead, at the first suspicion of illness, start taking mega-good care of yourself. Most winter illnesses are viral, which means that antibiotics won't help them. The most important thing to do with a viral illness is supporting your own immune system's work in fighting it off. These are old trite remedies, but they remain the best:

• Do get plenty of fluids.
• Do rest when you are tired (I know, that's hard to do when you merge pre-op panic with holiday panic, but go back up and reread that bottom line if you're waffling).
• Do turn to the fruits and vegies for vitamins and get plenty of them, every day before surgery.
• Don't chug the vitamin pills: some of those may be on your list of things to stop pre-op because of effects they may have on blood clotting.
• Don't eat aspirin or tylenol thinking you're helping out: your body uses a mild fever to help fight infection, so unless it's very high, it's helping rather than hurting.
• Don't gobble cold remedies or herbs: many of them also suppress your own defenses or contain things that are contraindicated before surgery.

If you are down to that final week and counting, coming down with something also means that you need to call your surgeon. Yes, it does. Waiting until Friday night after office hours are over before you finally admit that you're not going to be well by your 7 am Monday surgery call cuts it too fine. That robs you of planning and effective treatment time, and is discourteous to the surgical staff who are expecting to see you in the OR on Monday morning. If you are in that final week and feeling the first sneaky tendrils of viral invasion or you've been fighting something all last week and aren't sure you're going to make it in time, pick up the phone at the start of that week and make your confession.

Your doctor will be the best person to advise you on whether you need to be evaluated in the office and on what particular remedies may or may not be safe preoperatively. And by bringing him in early, you are being both considerate of his time and giving him a chance to help that surgery actually be able to happen as scheduled. The antibiotics you receive during surgery are not going to turn a chest cold around and your anesthesiologist isn't going to want to work with someone with a head and chest full of snot. If you are down to the wire and it's the weekend before a Monday surgery, go ahead and call the office number and tell the answering service you have a Monday surgery, are sick, and need to speak with the on-call person covering for your doctor. Don't try to second guess your doctors with just how sick you are: the decision on how sick is too sick is a specialized one they need to make.

And if you need to reschedule, the person who has let their doctor and hospital staff know in advance that this is a pending situation and a possibility is going to get way better service than someone who shows up at the hospital Monday morning in no shape to go to the OR. And don't you want your surgical team on your side? I thought so.

Please do the mature and responsible thing, here. If you're suspecting illness and you're down to the final week before surgery, get in touch with your doctor and stay in touch. Make arrangements on Friday (or right before a holiday) if you think the situation will remain volatile through the weekend before a Monday/post-holiday surgery. It happens. Your doctor knows it; your OR team knows it. No one will blame you--if you do everything responsible to keep everyone informed and seek advice early. They'll get you rescheduled as soon as possible if you have to cancel. That's not ideal, but that's better than trying to go into the OR already sick. That's not good for anybody involved.

Pre-op: Fear

It's a truism of hysterectomies that the waiting for the surgery is the worst part of the whole thing. And like any truism, there's a great deal of validity in that statement. For most of us, a hyst may be our first experience of major surgery. For others, we know it's a gamble for better health and so it's reasonable to be edgy. Frankly, anyone who isn't worried at the prospect of a hyst is more worrisome to me.

But for other women, the fear is deeper and both more specific and more disabling. I read comments like "I'm terrified of anesthesia. I'm sure I'll never wake up." Or "I'm really having second thoughts because I don't want to be turned into a menopausal demon." I've read about women who have jumped up off of the cart headed to the OR and turned around and gone home. I've read about women who have canceled and rescheduled their surgeries so many times they are finally "fired" by their surgeon. For some women, fear is immobilizing.

But a lot of the time, there are things we can do to deal with this level of fear...and need to. When we face surgery with the strong conviction that we are going to die or when we are terrorized by the image of a hot flash as the fast track to doom, we're setting ourselves up with stress and worry to just make the entire situation worse. It's been well proven that lowering stress contributes significantly to our health during surgery and our recovery.

Instead, we can take back control of a terrifying part of surgery. Whatever it is, we can't eliminate the uncertainty, but we can really whack away at the terror. And we need to.

Is this surgery the right thing for me?

Take for instance ambivalence about the surgery itself. It's normal to have some doubts, but our overwhelming sense before we consent to surgery needs to be that this is the last best hope for health for us after having exhausted all lesser approaches. We have to be sure that this is the right thing for us to do. That doesn't mean that our surgeon needs to think this or our relatives need to think this. We have to believe it strongly enough to embrace the surgery with hope, not helpless doom. Until we're there, we're not ready. If you feel as though this decision is being urged on you and you ought to go along with it, you're not ready. If you don't feel you've explored all the options, you're not ready.

How do you get more ready? See more doctors. There's a good reason why your insurance company willingly pays for second or even third pre-op opinions, and it works to your benefit. You may have to see several doctors and listen to several explanations before you hear one that clicks and suddenly makes things fall into focus. That doesn't mean you can't use your first doctor as your surgeon--it just means you needed to do more research. Different doctors bring different interpretations and different communication skills. It's only prudent when looking at an irreversible surgery that we seek a broad range of opinions. It makes it much more possible to develop that necessary sense that what we choose—and that we are choosing—when we have explored our options more thoroughly.

Anesthesia fears

It's common to have a deep fear of losing control when faced with the idea of anesthesia. That's reasonable and protective, so long as it's not disabling. But if you have a deep-seated belief that it's not going to work for you, then don't go there. Talk with your doctor and anesthesiologist about other options, like spinal anesthesia. With that method, you are numb and indifferent but not totally unconscious. Maybe this would let you feel less cut off from your life, make the whole experience more survivable. It's a viable option if it reduces your fears.

Fears about after the surgery

What comes after a hyst is such an unknown for most of us. I'm doing what I can by posting on this website to make the experience a little clearer, give women a few more practical details of what they may expect. I've posted before about pain, and how you can help control your fears about it by making plans beforehand.

But that same technique applies to other aspects of healing. If you are having your ovaries removed and sudden menopause is your fear, don't let your doctor brush off your worries with the classic "you'll just take this little pill and everything will be fine." You've heard stories from your relatives and co-workers; you have been reading; maybe you've already looked at my recommended hormone/hrt resource, the Survivor's Guide to Surgical Menopause and their mailing list--you're not sure it's going to be that simple. Well then, don't let your doctor brush you off. Ask for details of his plan: when will you begin hrt, what if you experience symptoms before then, how will you know if it's not working, when will you change things if there is a problem, what will you change to? Or, even better, let your doctor know what you want for hrt and when you want to start it and how you want it to work for you.

Work together with your doctor(s) on a plan that covers all your worries and lays plans out for any contingency you are bothered about. Maybe you'll need those plans and maybe you won't. But pre-op fears are eased when we regain a sense that even if we don't know exactly what will happen, we're prepared to deal with it. And for that reason alone, it's worth the time and effort because we'll have a happier, healthier surgical experience when we're not facing featureless doom. It's okay to be nervous, but if you're seriously disabled by fears, you're not ready until you've laid them aside.

Bladder Suspension

Did your doctor say you might be a candidate for this procedure? Here's what he's talking about:

• Brief overview of the procedure, with drawings. Not to much from a patient viewpoint but a place to start.
• Good summary of the different procedures and recovery process
• A nursing care review that spells out what kind of information your health care providers should be offering you
• An interesting followup article (read well down the page)
• Finally, here's a search results link if you really want to read up a storm

Is a hysterectomy like a C-section?

Although many women come to a hysterectomy as novices to surgery entirely, a certain number have previously had a child delivered by Caesarian section. Because this is an abdominal surgery affecting the uterus, it's natural to try to compare the two experiences as part of envisioning what hyst recovery will entail. However obvious this comparison may seem, the fact is that they really aren't equivalent surgeries.

First, there is the experience of the C-section itself. There are so many variations in pain tolerance, not to mention both birth and hyst experiences that I don't quite know how to find a common ground. There are women who are inconvenienced by both; women who can say yes, it wasn't a picnic but I survived it okay; and women who think it was the most exquisite agony they ever experienced or could conceive of experiencing.

What I can tell you is that from reading many years of women's reactions, the majority admit discomfort, a great many admit pain of some degree that was of limited duration and dealt with adequately by analgesic drugs, and a very limited few (and most often those are ones with especially complex suegeries, poor care, or who develop complications) report truly unbearable or excruciating pain. Depending upon how you experienced childbirth, you may have gained a clue about your own tolerance for pain.

The other aspect, and it's a very important one in developing your expectations of how your hyst will go, is that because you're talking major surgery (that is: cutting, removing, rerouting stuff internally), you are talking a much more prolonged recovery than childbirth, where it is more a matter of simply returning to a previous state (even in a Caesarian, there is little disruption of abdominal contents other than to heal some very basic incisions). It's a common myth that a hyst is "just like a Caesarian" and this really can lead to shock and disappointment later (or, among friends, co-workers, and the whole other rest of the world who may feel free to comment on your condition).

But in the course of a hysterectomy, your bladder is peeled loose from your uterus, many things are cut (nerves, ligaments, blood vessels), your ovaries and their supporting structures may or may not be removed, your vagina will be given an artificial ending, and all of the support that used to derive from your uterus and its attachments has to be relocated to hold up the end of the vagina, the bladder, and your guts. On top of this, your other organs are handled, pushed out of the way, rinsed off, and then reassembled. There are sutures and sutures and staples and multiple closures to hold all these things back together again. The tissue damage is higher, you are under anesthesia longer and with more drugs, and your risks of infection are higher. And that's assuming you aren't also having endo removed, scarring cut apart, bladder suspension, or rectocele/cystocele repairs done. So this surgery is much more complex than just making a slit, removing the uterine contents, and sewing the slit closed again. And it takes a correspondingly longer time to heal and heal well.

I'm not trying to intimidate you here, but rather to make sure that you're clear on what to expect. It's not by any means an impossible or even wildly difficult experience, but it is important to be realistic in all your expectations...so it's very good that you are thinking and looking for a conceptual framework to base your expectations on.

But "much worse" is not exactly how I would term it. It will take longer to get a good recovery, so if you measure success in time elapsed, you will indeed find this one more demanding. Pain? There is no excuse for either one to hurt more than the other, for pain relief is pain relief, irrespective of cause. Don't settle for less than you need, but also remember that it is not the role of pain medication to make you oblivious. A reasonable objective is that you will be in minimal discomfort while lying still and tolerable discomfort when moving around and right significant discomfort if you do something inadvisable for your level of healing. It is also reasonable to expect that you will be aware of and guarding your surgical site from discomfort for the longer healing period.

But many many women report that their hyst post-op discomfort was really not much worse than significant period cramps and in many cases was considerably easier than the chronic gynecological pain some women experience. Your goal as you heal is to be guided by your discomfort, such that if you begin to experience it, you need to slack off and not stress your healing.

Maybe this will help you get a better handle on the situation ahead of you than just the scary "worse" label. It's doable, it's work, it's not pleasant but it's not gruesome. There is always someone who has complications, who has a bumbling doctor or inept staff, who has a different personal or cultural definition of pain tolerance, and those with problems always have more to say about something than those who found an event manageable. If you can try to hang onto this sort of perspective, I think you'll find that you too will be able to handle this surgery pretty satisfyingly.

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.

Pre-op: packing list

Since many of us come to a hyst as our first surgery, we're not even prepared for the experience of being a hospital patient and may have little idea of what we'll need to take with us when we're admitted. Your "closet" will have only room for a single outfit (to go home in) and your belongings must fit on the surface of a small table plus, perhaps, a small drawer, so anything more than that is going to be a clumsy bother. Most of your time will be spent sleeping, drowsing, or walking, so you simply won't need much with you.

Some things you might bring to the hospital with you

1. Pre-op instructions/permits/papers, any pre-registration forms you filled out, copy of your health insurance card
2. Glasses, hearing aides, dental appliances you can't do without. Be sure to bring cases or containers for all, and any necessary cleaning materials. If you don't have to have it, though, don't bring it. You most likely will not be allowed to keep them with you until you reach your room after surgery, so if it's irreplaceable, leave it in the keeping of your partner while you're in the OR.
3. Toiletries: you'll get a toothbrush and soap and lotion as part of the obligatory personal care kit. You will probably get to shower before you go home, but you aren't going to feel like indulging in a lot of frivolity. Pampering yourself sounds more attractive now than it will be when just water flowing over your body will be a delicious treat and simply standing up the height of your physical ambitions. Just bring the bare necessities (we're only talking a couple days, here): conditioning shampoo, deodorant, moisturizer, hairbrush. Two things that you may find especially helpful, though, are lip balm and a moisture (scented water) spray.
4. Hair: if you have very long hair, consider arranging for it to be braided or French-braided before surgery and again the day after surgery: you’ll enjoy not having to wrestle with it. You’re going to need to pamper your hair very seriously for several months post-op if you have general anesthesia (it is very hard on hair), so if you must have a perm, get it a week or so beforehand so you can go awhile after without having to repeat it. Most hairdressers won’t use any chemical processing on the hair of someone who has had surgery for several months. Take a very gentle hairbrush with you, so you can keep the “bedhead” rats gently detangled.
5. Your own sleepwear: not really needed. You’ll want to wear the hospital gowns for at least a little while rather than risk staining your own, and it’s much simpler to put on a second gown backwards than to wrestle your IV into the arms of a bathrobe. Forget struggling with jammie bottoms: bending over is not going to be high on your list, and they are kind of strangling when sliding around in a hospital bed. If you must, make it loose, simple, and no more than knee length. You'll also most likely be wearing heavy elastic stockings or pneumatic leggings and have a catheter for the first day, so jammie bottoms are only going to be in the way.
6. Slippers: slip on, with non-slippery soles (as in: rubber). No matter how cute, anything else is a liability and aggravation. Washable is good, so you can de-hospitalize them when you get home.
7. Books, magazines, tapes or CDs or mp3s and player (extra batteries): you’ll probably want some entertainment, but make it really undemanding. Anesthesia dulls the mind, as do the medications you’ll be taking post-op. This is the time to read frothy stuff and listen to gently soothing music. Anything more will be Too Much Work.
8. Mini-office in a large envelope: notebook for jotting down doctors’ instructions, names to write thank-you notes, keep track of post-op appointments; pens, address book with the phone numbers of anyone you might want to chat with (don’t rely on memory—it’ll be addled by anesthesia); small calendar; consider a mini-recorder to tape your doctor’s visit because you will not remember what he said.
9. A small huggable stuffed animal or small pillow with washable cover. Hugging something to your tummy supports it while you do the coughing and deep breathing necessary to keep your anesthesia-surpressed lungs from getting pneumonia. Also, you will want a small cushion between you and the seatbelt when you go home. Don’t have one? A large bathtowel or small throw works equally well if tightly folded.
10. Clothing: send what you wore to the hospital home with whomever you came with as soon as you undress into your gown in pre-op. There isn’t room in your room for much stuff or a suitcase. Bring something loose and comfortable to wear home. Large panties (a size or two larger than normal, that come up to the waist) are helpful. Make sure you can get into your bra without gymnastics. Slip-on non-slippery-sole shoes. Sweats or a long, loose dress (my personal fave) are best—you won’t be zipping up those levis over that tummy for a few weeks. Remember: this only enough to get you from the hospital to your home without being arrested for indecent exposure; you’re not going on a Royal Progression. Don’t bring: panty hose, garments with back closures, anything snug about the middle. Also, remember that you will need to get back out of this clothing at home, when you are tired from the trip: tight pull-over-the-head things are so difficult to remove that you may end up spending days in them before you can extract yourself. It's perfectly fine to go home in a gown and bathrobe or loose coverup, too.
11. Self-adhesive mini-pads: most of us have a little drainage and these beat the daylights out of the industrial-strength elastic belt and mega-pads the hospital stocks for the maternity ward. Enjoy the thought, when you buy them, that they represent the last time you’ll do business on that aisle of the store!
12. Comfort stuff: eyeshade and earplugs so that you can sleep when you want to, not when your roommate wants. Big bandaids or cut-off sock tops for your elbows (they will be your primary mode of transport in your bed, and those sheets quickly begin to feel lie sandpaper). Backscratcher (if you are prone to itchies)—it also makes a nice extension hand.

Some things you shouldn’t take to the hospital

1. Jewelry of any kind. You may want a watch afterwards, but get someone to bring it in for you after the surgery. Don’t bring any personal adornments—they just get in the way and you won’t want to bother. Check at your pre-op appointment with anesthesia as to whether they will allow you to keep a wedding ring on: some will, taped; others won’t. It’s best to leave your ring in the keeping of your spouse than risk it being lost by someone whose job it really isn’t to keep track of stuff like that. Most anesthesiologists will also require that you remove nail polish and any nail adornments on both toes and fingers—check with yours at your pre-op appointment if this is important to you. Although it’s not something you can leave at home, don’t come in with fresh tattoos or piercings: your doctor may postpone your surgery out of concerns for infection. If your plans include these, discuss them with your doc pre-op (there may also be a time guideline for how long he would like you to wait after surgery, as well). Speak with anesthesia at your pre-op about the possible need for removal of nose, tongue or nipple ornaments; if you are having an abdominal incision, speak with your surgeon about any navel, labial or other operative-area jewelry pieces.
2. Checkbook, credit cards, driver’s license—anything you won’t be using. In fact, leave the whole wallet home: there is no security for your belongings. Bring a small amount of cash for vending machines, pay phone or snacks from the hospital coffee wagon. If you plan to make a large number of long distance calls, you may wish to bring a pre-paid phone card to cover them if you don't have a cell phone.
3. Demanding handwork projects, that challenging book you’ve been meaning to find time to read, anything that takes concentration and involves multiple pieces. They are too hard to keep track of and you won’t have the concentration. Save those for when you are home.
4. Hair dryer, styling stuff: too much effort to hold your arms up that long. Figure out a no-effort hairstyle or braid your hair. Really, no one expects you to look great: go for clean and tidy and the world will consider you radiant.
5. Makeup: ditto.
6. Your own prescription or over-the-counter medications or vitamins/supplements. You should have discussed these in detail with both your physician and your anesthesiologist at pre-op appointments. Do not bring anything in with you unless you and your doctor have previously agreed that you do so. The doctor will also need to write “patient may take own [med]” as an order in your chart in order to protect the hospital staff from liability for any mistake you may make with your own meds.
7. Contact lenses. Use your glasses instead. You will be dropping off to sleep at odd intervals and it’s too hard to get to a schedule of taking them in and out. The care for them is too involved and bothersome as well, and the hospital is full of Bad Germs. It’s only a few days and there’s nothing much you need to see anyway.
8. Abdominal binder, surgical stockings—unless your doctor has specified you should do so. If he wants you to have these, he’ll arrange for them in hospital. Ask him at pre-op: different doctors have different procedures, and reasons for them.

Things to do

1. Listen, take notes (or use a mini-recorder), say thank you. Ask for a copy for your records.
2. State your needs clearly. If they are not met in a reasonable amount of time, ask for the charge nurse. The management tree from there is head nurse, then nursing director.
3. You have the right to question and refuse anything. Ask what that medication is for. If a medication doesn’t look the same as the last dose did or you don’t think you’ve been taking it, ask to see the order for it. If you really think it’s wrong or you really don’t want it, simply state “I refuse this medication. You may note this in my chart and I will discuss it with my doctor on his next visit.” Do not be intimidated at “causing extra work” by asking a nurse to double-check your medication: that is their job and legal obligation.
4. Similarly, if you are in pain and you have had all the ordered medication (or have other medication needs), politely insist that your doctor be notified that it is not providing adequate relief and request another medication order. The fact that it is the middle of the night and the nurse would have to wake the doctor is not an excuse for delaying this. You are paying the doctor and the hospital very well, and not suffering excessively is part of what you are paying them for. If your nurse is resistant, work up the management tree. If necessary, call your doctor's answering service yourself (have that number in your phone notebook) and ask that the on-call doctor covering for your surgeon get back to you asap.
5. Never let your IV run dry. Remind the nurses when it's getting low and really get noisy if it gets to the bottom of the bag. You're the one who gets another stick if it clots off.
6. Move around in bed, with special attention to stretching and flexing your legs, often. In this application, "often" means hourly.
7. Walk. Then walk some more.
8. Deep breathe and cough; use the blow toy as you are shown—these are making you well, so don't skimp. Hourly is good.
9. Drink until your pee is nearly colorless.
10. If your temperature goes up, drink, breathe and walk more. The walking and drinking are also the remedy for gas and constipation.
11. Stand up straight when you walk. Contrary to the way you may feel, your guts are not going to fall out onto the floor.
12. Don’t let yourself be overwhelmed with visitors. Before surgery, suggest that your friends call you to see if you want company rather than just popping in. Visitors are exhausting, especially in the first day or two, so tell them that it will most likely be a few days before you’ll have the energy to enjoy their visit. Also, if there are obnoxious family members or “friends” you don’t want to see, or you want a graceful way to keep the entire 86 members of your family from camping out in your room for four days, ask the nurses to post your room as “no visitors” with your spouse (or single other designated Acceptable Visitor) okayed by you as the exception. If folks are determined to send flowers, suggest that they wait to do so until you go home, where you can enjoy them properly. Hospital rooms are just too small to hold very many things, and that’s not when you will be most appreciative. If they want to do something while you’re in the hospital to show their concern, suggest they have a double-latte milkshake delivered to your room instead ;)

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)

Pre-op decisions: Keep my cervix or not?

When considering a hysterectomy, there are several options that may be up to you when the decision is made just which parts of what are to be removed. Women who are having a vaginal hysterectomy don't get this choice: their cervix has to be removed in order to obtain access to the uterus through the vagina. But for women having an abdominal procedure, it is sometimes possible to leave the cervix, the muscular join between the uterus and vagina. If the cervix is not retained, then the top of the vagina is closed with a "cuff" or a special turned-over seam very like the French seaming on the inside of most jeans legs. Let's look at some of the concerns with the cervix decision.

Cervical cancer

There are several considerations related to cancer. If you have or are at high risk for cervical cancer, your surgeon will most likely advise that you have it removed. Removal of your cervix will greatly lower your risk of this particular cancer, although you will continue to need pap smears to monitor vaginal health. Sometimes women question whether they should have it removed just to eliminate the chance of cancer. Cervical cancer has some highly specific risk factors and otherwise fairly low risks for the rest of the population, so you need to do some research on cervical cancer to see if you feel you fall into that population. If you do not, it may not be anything to worry about. [update to this topic]

Mechanical concerns

Because the cervix is an integral part of the muscular support of the upper vagina and uterus, there used to be considerable feeling that removing the cervix made shifting that support more complicated and more prone to failure. This would, in turn, lead to a need for further (future) surgery to tack those organs back up. Most current surgeons use newer operative techniques for supporting these organs, and so this is less of a concern today than it was a decade ago. If you are talking with women about their experiences with this, be sure you know when they're talking about and how skilled/current their surgeon was. Assuming that you have normal tissue health generally, it is unlikely to be a problem for you if your surgeon is up to date and skilled.

Mini-periods

If you keep your cervix, you will probably continue to experience small "mini-periods" or episodes of light spotting. This is because there will be a little retained uterine tissue along the edges that may continue to cycle if you keep your ovaries or if your HRT fluctuates. It's just not possible to separate cervix from uterus with total accuracy—they are each a continuation of the other, in terms of tissue differentiation—and so while your surgeon will do his best, the division may not be 100% accurate. Some women find these mini-periods deeply troubling; others aren't the slightest bit bothered by them. Knowing that this may happen will go a long way towards letting you take them in stride.

Sex

And then there's sex. Some women feel that cervical stimulation is an important part of their sexual response and orgasm. For those women, loss of the cervix may alter the nature of their orgasmic sensations, although not necessarily their ability to experience them. Many women are also concerned that removal of their uterus will remove that sense of muscular contraction that accompanies orgasm. That is not the case: while your uterus is removed, other abdominal muscles still respond in that way and, again, it may be a little different, but it is not necessarily diminished or less satisfying. So for any woman, the question may come down to her own appraisal of how important her cervix is to her sexual satisfaction. For those who find cervical stimulation uncomfortable rather than pleasurable, there's certainly no loss at all in having it removed.

Another concern in removing your cervix is vaginal length. The top of the vagina, you'll recall from a couple paragraphs above, is stitched into a cervix-like gathered knot called a "cuff." This actually consumes very little tissue. A certain number of women when they first get the okay to resume intercourse, however, find that they feel as though they are very very short now. This is a function of healing, not a too-short vagina. It takes a long time—months to a year—for vaginal tissue to regain its proper elasticity around the incisions. Normal vaginal tissue is very elastic, and the area around the incision is going to be stiff and unyielding for some time. This gives you much more of a sensation of an abrupt "end" than you normally experience. This will pass with time, but doctors rarely warn women of this and it causes more needless misery than nearly anything else to do with a hyst. Unless you are having major reconstructive repairs of rectoceles or cystoceles (tears in the vaginal wall that let bladder or rectum protrude in), this is only going to be a temporary healing phase. If vaginal length is for some reason a particular concern for you, discuss this aspect of your surgery with your doctor in your pre-op appointments and plan together how best to deal with it.

Pap smears

And, finally, there's the need for pap smears. If you keep your cervix, you will continue to need regular pap smears on whatever schedule you've always used. But, if you have your cervix removed, you will still need regular pap smears, albeit possibly on a less frequent schedule. As with the mini-period, there's no clear line between cervix and vagina and there is a risk of retaining some cervical cells in with the new vaginal cuff. That means a small risk remains of developing cervical cancer in those cells. There is also, some doctors feel, enough of a chance of developing vaginal cancer that they advocate exams and testing to check for that as well. You might want to ask your doctor about your post-op testing needs in each scenario and how he evaluates your risk level as part of making your decision.

Those are the main concerns with keeping or having your cervix removed. We'll each weight them differently, so it's definitely worth thinking through how each factor affects your individual body rather than just relying on other women's opinions of how they were affected by cervical removal or not. This is one of the areas where the outcomes of our surgery are partially under our control, so it's worth some deep consideration and discussion with your surgeon or regular gynecologist.

And just in case you like visual aids or aren't entirely certain what we're talking about, here's a photo of a cervix, speculum view, and a drawing of a uterus, etc showing the cervix.

Preop concerns

Many of us come to this surgery as complete novices and when our doctors' appointments are rushed, we don't always get to explore all the questions we might have. Today I'm going to look at some of the questions I see asked a lot on HysterList.

What if I'm having my period when it comes time for surgery?

Don't sweat it. It is truly irrelevant to the surgery, so long as you don't get such a head start on things that you get anemic right beforehand. Call your dotor's office and check, but I suspect that their only concern would be that you wear a pad, rather than using tampons, just to limit what's had a chance to grow in there (sorry to be gross). But many women have gone to the OR wearing a pad, and it will be dealt with once you are anesthetized. It's not something that the OR crew is going to give a second thought to, really.

Look at it this way: how better to celebrate than to go in gushing and to come out spotting?!

Does the nausea go away before they release you from recovery or will the nausea continue?

It depends on whether the nausea is in response to anesthesia, in which case it'll go away, or the pain meds you're getting, in which case it may linger as long as you get that particular drug. Generally speaking, if it lasts more than a few hours after you get back to your room, you need to consider asking for a pain med switch.

Can we shave ourselves prior to coming to the hospital or must we let them do it?

Yikes, no! Be sure sure sure you ask your doctor about this. Some will okay it, but others feel that the slightest nick exposes you too much to the risk of infection. I've seen surgeons walk out of the room and cancel a surgery when they found self-shaved patients. Don't get all modest—the nurses in pre-op are very low-key about this and won't make you feel like a spectacle and by and large will do a better job than you can. And many docs no longer feel a full shave is necessary: mine just had the nurse run one swath across the top with the clippers, down to about 1/4", to keep the hair ends out of my just-above-pubes-line incision. And I was pretty grateful later, when all I had to suffer the crazy-itchies-stickery-grow-back from was that little line.

What is a "bowel prep"? Does everyone having a hysterectomy have to have this done?

It's some method of cleaning out your large intestine, whether laxative or enema or one of the new "lytely" drinks. The objective is to lower the bacterial counts in the bowel and to prevent post-op constipation.

Please do not do this unless instructed to by your physician.

I apologize for shouting, but this is very important. Not every surgeon wants their patients to go through this, and because it can have serious effects on your operative/post-op fluid status, it's very important that you do exactly as he tells you so your status is exactly as he expects.

Think I'm over-dramatizing? Consider this story:

In the chat room of a big hysterectomy board a couple years ago all of the "knowledgeable and experienced" women present encouraged a poor scared pre-op lady to do her own bowl prep "just to be safe" even though her doc had not ordered one for her. She did this according to their instructions, and was so dehydrated from the process that she required many extra hours and considerable extra treatment in the Recovery Room before she was stable enough that she could go to her room. Yes, from just a little bowel prep, and the surgeon/anesthesiologists' assumptions about her status that she made incorrect by her actions.

So please, discuss this with your own surgeon, who best knows how he plans to do the surgery and what your own physical condition is. And if he does want you to do a prep, he will specify the agent and when and how it is to be taken. If for some reason you don't get these directions, call the office, call the on-call service—call until you do get clear, personal directions on how your own surgeon wants this procedure done. It's for your own good, and, really, isn't the best possible surgical outcome what we're all rooting for?

Why would your doctor not want you to do this prep? Many surgeons believe it's an outdated concept in that you cannot sterilize the bowel in the time and with ordinary measures, so the risks of the stress are worse than the risks of puncture and contamination. Obviously, women with rectal repairs don't fit into this picture, and may have special preps.

The same thing, by the way, goes for pre-operative douches and any other schemes you might cook up or have helpful folks recommend. Aside from a good diet, cutting down on caffeine, and major hydration, you should only do what your doctor tells you to do: no more, no less.

My doctor said to take a fleets enema the night before and also a betadine douche. Why can't the enema and the douche be taken on the morning of the surgery?

There may be more prep then, but the really crucial thing is the timing. You need to not be responding to the enema as they are taking you into the OR, and you need to have had all that douche drained out and the bacteria as discouraged as possible (takes time) before surgery.

Also, is a betadine douche sold over the counter?

Yes, it should be. I suggest buying all your prep items at least several days beforehand, so that if your chosen outlet is out of them, you have time to locate them without being in a pre-op panic.

Also, if you have never had a betadine douche, test a little on your inner labia for about 15 minutes, just to be sure you're not allergic to or excessively irritated by the betadine. Some women can tolerate it on regular skin just fine, but it's too severe for their more delicate vaginal membranes. Burning or itching would be what you'd experience. It's one of those things it's good to figure out before you douche with it—your doctor does not want to look in there ready to do the surgery and find blisters, oh no. And unless you've been instructed differently, do the douche after you have emptied out from the enema and washed up well with regular soap and water. Beyond that, read the directions on the douche (if you haven't been given others on how to do it, how long to hold it in, etc.) and follow them.

What supplements and stuff do I need to stop taking for my surgery?

There's an interesting article from the American Medical Assoc. that succinctly sums up which herbs to stop when, and why. If you have trouble accessing it, just know that "the eight most commonly used herbs that can impact surgery are valerian, echinacea, ephedra, ginko biloba, kava, garlic, ginseng and St. John's wort."

The article also offers "the following guidelines for discontinuing herbal use before surgery:"

Ephedra, ginko and kava - stop using 24 to 36 hours before surgery Garlic, ginseng and St. John's wort - stop using one week before surgery Valerian and Echinacea - start tapering off use two weeks before surgery

The author says "prospective surgery patients should also check the ingredients in vitamin supplements to see what herbs may be included."

Do be sure to include all the herbals and vitamins and otc meds you might be taking when you have that "what are you taking" chat with your surgeon and anesthesiologist. Quite a few really innocent-sounding things will interact with anesthesia (which is really a whole bunch of different drugs, carefully balanced to work together) and pain meds and antibiotics. This just isn't a time to second-guess them: tell all. And if you are taking a combo supplement product, lug the bottle along (or transcribe the ingredient list: there are too many brands and the name won't mean nearly as much as what's really in it). Don't rely on your memory for this, either. Write out a list to give your doctor to put in your chart. And when you're discussing them, do ask your doctor when it will be okay to resume taking them.

I'm not wild about the idea of getting a transfusion. Who would I ask to be very cautious in doing this?

Everyone: your surgeon, their assistant, anesthesia, pre-op nurse who checks you in, circulating nurse in the OR, recovery room; have your spouse or whoever might be "tending" you in the first night after surgery be prepared to mention it to floor nurses as well. You and your surgeon should discuss beforehand and come to an agreement just when he'll transfuse you (just how far your red count will have to drop, what other measures must be employed first, before you'll agree to it). If a blanket permission to transfuse is in your operative permit, be sure to add your stipulations to the permit and have you and your doctor or the witness both initial the addendum. If you have a spouse or other who will be standing by for you, be sure to include them in this discussion, as they may be the ones to advocate for your desires if you are still under anesthesia or too groggy to make a sound judgment.

My mother said that when she had surgery, the preop room was so cold she nearly froze to death. Why do they go out of their way to make you miserable?

Many women have questioned getting colder on their way to the OR or waking up in Recovery shivering. This is actually normal and even desirable. No, not to make you fear things worse, although that certainly happens if you are not expecting it and let it add to your panic.

In fact, you are deliberately chilled down as you go into surgery and even more so during surgery. This lowering of your body temperature helps slow your metabolism down, causing less bleeding, making smaller doses of drugs go further, and generally making the whole procedure less stressful on your body.

Once you reach Recovery, you will be bundled up in warmed blankets, given warmed IV fluids and generally helped to return to your normal body temp again. By the time you get to your room, you should start gradually kicking those blankets off and icewater sips will become very welcome as you try to moisten your dehydrated mouth and body back up (getting oxygen and air is very dehydrating, not to mention the fact that when you aren't conscious, you don't swallow and keep your mouth moistened—also a good reason for doing a super job of brushing your teeth pre-op).

So when you notice that you are getting cold, don't worry and don't fight it. If anything, try to embrace it with a calming mind and a positive vision of a successful surgery and smooth recovery to a new healthier, pain-free you.

What is it like when you are under general anesthesia?

It's not. Like anything, that is—it's like it's not there, that part of time. You simply live on from one moment to the next, and it's only the mangled context that tells you that things have gone on without you.

I had Versed (the amnesia drug) as a pre-op, and while it did help keep me mellow, it never did make me oblivious and I remember a lot of what went on getting settled in the operating room before I was given anesthesia (I recognized the circulating OR nurse's voice through party noises a week and a half later, not to mention remembering talking with her and the anesthesiologist). I respond atypically to drugs, though, so don't go by my experience. Actually, even though its effect was limited, it was just fine and left me with enough wits about me to get myself into a very relaxed, accepting, positive frame of mind (I am very into positive imaging) just as the anesthesiologist said he was ready to start my anesthesia.

And the next thing I know, the very next instant later, I was skunching from the stretcher over onto my bed after surgery. That's it: nothing at all in between, including any sense that time had passed. And once I was that awake, I was drowsy but fully lucid.

And that is how general anesthesia typically feels.

If you have your procedure under a spinal, you may, depending on how you and your surgeon feel about it, be sedated but semi-awake.

I actually wanted to do this (I'm not especially squeamish) but my surgeon said that my uterus was so huge that in order to get it out through a reasonable-sized incision, he needed me fully relaxed, not trying to look around and ask questions (we only met in referral for this surgery, but it didn't take him long to figure me out *grin*). As it turned out, it's probably a good thing, because I swear that in the first few days after surgery, I could see boot tread marks on either side of my incision where someone braced themselves to pull that mess outa there!

I think that everyone has the pre-op fear that they will wake up during surgery. Rest assured that your anesthesiologist is at your head through the entire operation with nothing to do but monitor your anesthesia and how you are doing. "Anesthesia" is actually a group of drugs, and the person administering it is frequently giving you a bit of this and a bit of that to keep you at just the right level of "out" while being as gentle as possible on your system and making for as quick as possible an "awakening" once the surgery is over. Waking up just doesn't happen. While you may remember some of Recovery Room, you aren't around during anesthesia. You aren't.

What are these "pain pumps" I hear about? Do I need one? Will that keep me pain-free?

A "pain pump" is an IV that is administered by a special pump, a blocky machine that's mounted on the pole that holds the bag of IV fluid. It adds a pre-set amount of pain-relieving medication to the general fluid flowing into you when you press a button. In other words, it allows you to control when and how often you get a little boost of pain med. The pump also has a pre-set maximum, so it's not possible to overdose yourself. Pumps generally get favorable reviews from patients because they appreciate that sense of control it gives them.

They are generally set up to dispense one of two different drugs: morphine or demerol. If you are nauseated and are getting demerol, consider that as a potential culprit. If you break out in itches (or find yourself rubbing your nose a lot) you are most likely sensitive to the morphine. Don't hesitate a nanosecond to complain to your nurse and ask that your doctor be notified, whatever the time of day or night, if you feel you are reacting badly to the med or it's not giving you adequate pain relief. There are too many medication choices, so there is no reason to have to put up with unreasonable discomfort.

On the other hand, keep in mind that there are costs to medication. You really need to drink, deep breathe, move your legs and your bowels. Narcotics act against all those. So you can't expect to be totally unconscious and oblivious and 100% discomfort free from your meds.

A good level of comfort in the hospital period is being able to move with caution and discomfort, but not cry-out pain, and you should be fairly comfortable when you are well-positioned and not moving in bed. I've read about some pretty sad events where patients were led to believe they would be pain-free after a surgery, and of course they weren't, and their fear and hysteria made the whole thing quite out of control. Tolerable is the goal, and the word should be discomfort, not pain.

I'm so scared! I'm confused, I'm second-guessing myself. I want to change my mind every five minutes! Please tell me that these emotions are normal.

Emotions are so normal at this time that I'd really worry about someone who didn't feel like a mouse dropped into a sack of hungry cats when contemplating their hyst. This is a major life stage, regardless of our age, on top of a rightly-serious surgery. How could that not unhinge us?

I was so discombobulated by the whole idea that it took me 5 years to admit that I needed the surgery, and those 5 years were no picnic (call me a slow learner). My surgery turned out so much easier and more doable than I had convinced myself it would be, my recovery has been great, and my health so much improved that I have real trouble these days believing I could be such a dodo as to have delayed so long.

There's no rational answer for the pre-op panic, though, because rational isn't what it's about. I suggest sharing it with someone who can be sympathetic but not try to "fix" it for you. Admit what you are doing while indulging in it (do that crying—it's an important part of the coming-to-acceptance part), and trying to use the frenzy part as productively as possible. Many of us joke about alphabetizing the contents of the refrigerator while waiting for our surgical date to finally arrive, but the nesting frenzy is real and you might as well use it to bank housekeeping against recovery, when you will be letting things slide (oh yes you will or you'll be hearing from me about it, missy!). If your state of health permits, this is a good time for walking and exercise—you can use the endorphins as well as the break from your brain, and the stamina you gain will stand you in good stead in recovery.

So just try to go easy on yourself, and accept that this is what the waiting does to you. It does to us all. And yes, if you can focus ahead, think a year down the road to wearing white pants with no fear. There, my friend, is an image to hang onto.

All of this confuses me—if I think positive I'll be fine? Sounds like Pollyanna—or maybe I'm just too cynical.

It seems that a significant part of the "positive attitude" thing is not a Pollyanna rosiness but rather the sense of control of the situation that comes with having as good a grasp as possible of the physiology and pathology underlying your candidacy for a hyst, the available treatment options for that pathology and how they relate to your own situation, and the sense, arrived at after studying the above and trying out various solutions (whether physically or simply exploring them conceptually), that for your own situation the hyst is the best remaining treatment option.

Once you are able to commit wholeheartedly to the hyst as your best option, then you are able to take in stride the stresses, the inevitable failure of the surgery to leave you in "as new" condition, and the possible realization of any negative outcomes that are simply "risks" before the surgery.

Most typically, the women who suffer really crippling regrets later are those who did not successfully achieve this personal sense that this is the only remaining treatment option for regaining some degree of relief from their pathology. For the rest of us, even though we all experience some lingering negative effects (even if only some nerve weirdness around the incision, but up to and including life- threatening complications), we are able to view that balance and remember that at the time, these risks were preferable to the risks of continuing as we were. It's very important to understand, deeply understand, that we are not healthy people and we cannot be made so, ever again. What is within our reach is improvement, not total restoration.

When that commitment is made, then we can embrace the surgery as a positive action we are taking, and throw ourselves wholeheartedly into making it as successful as possible. A body that seeks aid suffers the physical stresses of surgery and recovers more promptly and with fewer complications than one that fights the process. This is demonstrated by research. If you willingly embrace anesthesia, calmly and with positive outlook, you will require fewer drugs and your body will be less stressed and bounce back more strongly and rapidly than if you go under fighting the process in fear. If you get out of bed as soon as possible after surgery, breathe deeply, stand up straight and walk knowing that every step you take moves you towards health and strength, you will have fewer complications and recover more rapidly. If you balance needed rest with the challenges of increasing activity in your recovery, your healing will be stronger and more durable than if you only rest when you collapse recovering from over-exuberance and stress. These are all things that are known about healing, and all things that bring a positive attitude out of the Pollyanna realm and into the hard cold scientific light of Things You Can Do That Really Make A Difference.

The short list, then, becomes:

1. Educate yourself fully about your pathology and about the hyst, both before and after surgery
2. Try all lesser treatments until you can accept that only this extreme and irrevocable treatment offers you relief from a situation you can confidently declare intolerable
3. Research and actively embrace positive measures for a healthy hyst experience and recovery

When you have done all of these, then you have prepared yourself for an experience that should not leave you crippled for the rest of your life with regrets.