Our Bodies, Ourselves (135 page)

Although the death rate from hysterectomy is low (under 1 percent), surgical complications include the following:

•
Infection
. Most infections can be treated successfully with antibiotics, but some can be severe or even uncontrollable.

•
Hemorrhage
at the time of surgery or afterward (a transfusion or second operation may be necessary).

•
Damage
to your internal organs, most frequently the urinary tract and sometimes the bowel. Sometimes there is damage to the ureter (tube connecting the kidney to the bladder) or the bladder.

Less common surgical complications include blood clots, complications from the anesthesia, and intestinal obstruction from postsurgical scarring.

For those of us who are in our early forties or younger, removal of the uterus and ovaries may increase the risk of heart attack. Even if our ovaries are not removed, there is an increased chance of an earlier menopause. This is usually due to the decreased supply of blood to the ovaries, so that they lose their ability to produce hormones, either immediately or over time. Many physicians assure us that we can avoid these risks by taking estrogen, but estrogen therapy does not substitute for functioning ovaries (see
Chapter 20
, “Perimenopause and Menopause”).

Hormonal effects of hysterectomy with oophorectomy vary from one woman to the next. Some women suffer severe hot flashes and lack of lubrication. Some women use hormone therapy for a while, then gradually taper off. Long-term symptoms sometimes associated with hysterectomy and/or oophorectomy include constipation, urinary incontinence, bone and joint pain, pelvic pain, and depression.

Many women are concerned about the effect that hysterectomy, with or without oophorectomy, will have on sexual response. Some physicians and popular literature suggest that any sexual difficulties we may experience are “all in our head.” In fact, there is some physiological basis for these problems. For women who experience orgasm primarily when a partner's penis or fingers push against the cervix and uterus (causing uterine contractions and increased stimulation of the abdominal lining), that kind of sensation may be lost if the uterus and cervix are removed. This is probably an individual response and has not been proved in studies. In addition, if the ovaries are removed, hormone levels drop sharply, and that can affect sexual feelings:

I had a hysterectomy two years ago at the age of 45. I went from being fully aroused and fully orgasmic to having a complete loss of libido, sexual enjoyment, and orgasms immediately after the surgery. I went to doctors, all of whom denied ever having seen a woman with this problem before and told me it was psychological. Before surgery, my husband and I were having intercourse approximately three to five times a week, simply because we have an open and loving relationship. Now I find that I have to work at becoming at all interested in intercourse. And I no longer have the orgasm that comes from pressure on the cervix, although I still have a feeble orgasm from clitoral stimulation
.

Testosterone, a hormone that contributes to muscle strength, appetite, and sex drive, can increase sexual desire in women whose ovaries have been removed, but it may have masculinizing side effects, such as a lowered voice, acne,
and facial hair. Side effects can be limited by using low-dose testosterone cream or gel. However, even in low doses, these products have not been adequately tested for long-term safety.

Local effects of surgery may occasionally cause problems. Vaginal lubrication tends to lessen after hysterectomy and oophorectomy, and intercourse may be uncomfortable if your vagina has been shortened by the operation, or if there is scar tissue in the pelvis or at the top of the vagina. In order to minimize scarring, preserve nerve function and ligament support, and avoid shortening the vagina, some physicians recommend leaving the cervix in if no cancer was involved.

However, for many women, sex is unchanged or even more enjoyable after hysterectomy, since painful symptoms are gone. In the words of a woman who had a hysterectomy because of huge fibroids:

I had terrible cramps all my life and genuine feelings of utter depression during my periods. My ovaries were not removed, and my libido was not affected. My sexual response, if anything, improved. I also had for the first time no fear of unwanted pregnancy and more general good health
.

Consider the benefits of surgery against the possibility of changes in sexual desire or response that can't be predicted in advance. Treatments less drastic than a hysterectomy can usually reduce pain and bleeding from benign uterine conditions and improve overall wellbeing.

Total hysterectomy, sometimes called complete hysterectomy:
The surgeon removes the uterus and cervix, leaving the fallopian tubes and ovaries. You may continue to ovulate but will no longer have menstrual periods; instead, the egg will be absorbed by the body into the pelvic cavity.

Total hysterectomy with bilateral salpingooophorectomy:
The surgeon removes the uterus, cervix, fallopian tubes, and ovaries. One ovary may be left in, if it is not diseased. In rare cases (usually to treat widespread cancer), the surgeon will remove the upper part of the vagina and perhaps the lymph nodes in the pelvic area. The latter is called radical hysterectomy.

Supracervical (or subtotal) hysterectomy:
This procedure leaves in the cervix, to limit the effect of surgery on the function and anatomy of the vagina. It's also less likely to interfere with nerves and arteries as well as ligaments that support the vagina. If the cervix is left in, you still need Pap tests.

The uterus can be removed either through an abdominal incision or through the vagina. Surgeons sometimes prefer an abdominal approach because it enables them to see the pelvic cavity more completely. The incision is made either horizontally, across the top pubic hairline, where the scar hardly shows afterward, or vertically, between the navel and the pubic hairline. Vertical incisions tend to heal more slowly.

Vaginal hysterectomy has the advantage of a shorter recovery period and faster healing. Because the incision is inside the vagina, you won't have a visible scar. Laparoscopically assisted vaginal hysterectomy (LAVH) enables the surgeon to see an image of the pelvic cavity without the downside of a large incision. Vaginal hysterectomies are performed increasingly frequently and require greater skill, so it's important to find a surgeon who does them regularly. Mistakes during surgery can result in permanent urinary tract difficulties. Other disadvantages include a possible shortening of the vagina, which can
result in painful intercourse afterward and temporary (but severe) back pain.

Minimally invasive loparoscopic techniques (where the pelvic organs are visualized through a small scope placed through the belly button) are used more frequently now to avoid the long recovery and large scar associated with the abdominal approach. Because only small incisions are required, the recovery is dramatically better. Just be sure to find a surgeon experienced in these relatively new techniques.

After a hysterectomy, you may be in the hospital for as few as one or as long as several days, depending on the kind of procedure, the amount of anesthesia, and your general health. For the first day, you will probably have an IV and a catheter inserted in your bladder. You will usually be given medication for pain and nausea. Within a day, you can expect to be on your feet and encouraged to do exercises to get your circulation and breathing back to normal. You may also be told to cough frequently to clear your lungs. (Holding a pillow over an abdominal incision, or crossing your legs if you had a vaginal incision, will help reduce pain from coughing.) You may also have gas pains to contend with. A self-help technique to dispel abdominal gas uses heat applied to an acupressure point beneath the navel. Walking, holding on to a pillow and rolling from side to side in bed, and slow deep-breathing exercises may help, too. You can begin to have light solid foods, as well as fluids, when you feel able to keep them down. Hospital stays are growing shorter and shorter. This can be scary, but once your IV is out and you can keep down oral pain medications, being at home with good help may provide many comforts and avoids the risk of catching an infection in the hospital. Plan ahead to make sure you have the support you need (family, friends, or community support services).

After you go home, you may have light vaginal bleeding or oozing that gradually tapers off. You may also have hot flashes caused by estrogen loss, even if your ovaries were not removed. You will probably continue to have some pain, despite taking pain medication. Consult your medical practitioner if you have fever, nausea and vomiting, or foul vaginal discharge, as this may signal an infection.

Try to arrange for someone to take care of you for the first few days. You can expect to feel tired, so ask family and friends for help with household chores and children for at least the first few weeks. Your health care provider may tell you to avoid tub baths, douches, driving, climbing, or lifting heavy things for several weeks. If you have to drive or need to carry small children, ask for suggestions about how and when you can do these tasks safely.

Full recovery generally takes four to six weeks, but some women feel tired for as long as six months or even a year after surgery. Most medical practitioners also recommend waiting six to eight weeks before resuming sex and/or active sports, but some women return to them earlier. Start with light exercise, such as walking, and gradually build up to your old routines.

Some women feel only relief following hysterectomy, especially when the operation eliminates a serious health problem or chronic, disabling pain. But even if you were prepared for it and did not expect to feel depressed, you might cry frequently and unexpectedly during the first few days or weeks after surgery. This may be due to sudden hormonal changes. Many of us are also upset by losing any part of ourselves, especially a
part that is so uniquely female. Acknowledging feelings of anger and grief after losing a part of yourself or some of your sexual responsiveness is an important part of the recovery process.

Some gynecologists recommend psychiatric help and prescribe antidepressants or tranquilizers (or other habit-forming drugs) while ignoring treatment of underlying physical or sexual conditions caused by the surgery. Often, talk therapy alone—or conversations with friends and family—enables us to cope with any posthysterectomy depression. Some women have started their own postsurgery support groups by networking in their community. Visit HERS Foundation (hersfoundation.org) for more resources.

Vulvitis, or inflammation of the vulva, may be caused by one of several medical conditions, medicated creams, or external irritants. It can also be caused by an injury; oral sex; a bacterial, viral, or fungal infection; sitting in a hot tub; allergies to common commercial products such as body soaps, powders, and deodorants; or irritation from sanitary napkins, synthetic underwear, or panty hose. Vulvitis often accompanies vaginal infections. Stress, inadequate diet, and poor hygiene can increase the likelihood of vaginal infections. Women with diabetes may develop vulvitis because the sugar content of their cells is higher, increasing susceptibility to infection. Postmenopausal women often develop vulvitis because as hormone levels drop, the vulvar tissues become thinner, drier, and less elastic and therefore more prone to irritation and infection.

Symptoms of vulvitis include itching, redness, swelling, burning, and pain. Sometimes fluid-filled blisters form that break open, ooze, and crust over (these could also be herpes). Scratching can cause further irritation, pus formation, and scaling, as well as secondary infection. Sometimes, as a result of scratching, the skin whitens and thickens.

Women with this problem tend to overclean the vulva, contributing to further irritation. Wash once a day with warm water only.

The first step in treating vulvitis medically is to make a diagnosis. Depending on the cause, your health care provider may prescribe antifungal creams or antibacterial treatment. Cortisone cream or other soothing lotions can relieve severe itching. (Low-dose cortisone creams are good for a short time; fluorinated ones can cause thinning and atrophy of the skin if used for a long time, though these may be required for some conditions.) Postmenopausal women may be given a form of local estrogen. If you have a vaginal infection or herpes, treating these problems will usually clear up the vulvitis as well.

If the vulvitis persists or worsens, you may need a vulvar biopsy to rule out the possibility of cancer or chronic vulvar conditions such as lichen sclerosus, a skin disease that can produce itching, bruising, pain, and scarring. This biopsy can be done in the practitioner's office with local anesthetic.

Discontinue using any substances that might be a cause of vulvitis. All commercial preparations may be irritating, including antifungal agents and lubricants containing propylene glycol. Keep your vulva clean, cool, and dry—and remember to wipe from front to back. Hot boric acid compresses and hot sitz baths with comfrey tea are soothing. Use unscented white toilet paper (as perfumes and dyes may be aggravating)
and soft cotton or linen towels, and wear cotton underwear to prevent chafing. Aveeno colloidal oatmeal bath and cold compresses made of plain, unsweetened, live-culture yogurt or cottage cheese also help relieve itching and soothe irritation. Calamine lotion can be used to address itching. Use a sterile, nonirritating lubricant such as K-Y jelly or Astroglide during intercourse and other genital sex.