Chapter List

• Introduction to Total Health for Women
• Acne
• Alcoholism
• Allergies
• Anemia
• Angina
• Appendicitis
• Arthritis
• Asthma
• Back Pain
• Bladder Infections
• Breast Cancer
• Breast Implant Complications
• Breast Lumpiness
• Bronchitis
• Cervical Cancer
• Cesarean Section
• Chronic Fatigue
• Colds and Flu
• Cold Sores
• Colorectal Cancer
• Constipation
• Depression
• Dermatitis
• Diabetes
• Diarrhea
• Eating Disorders
• Eczema
• Endometrial Cancer
• Endometriosis
• Fatigue
• Fibroids
• Fibromyalgia
• Food Allergies
• Foot Pain
• Gallstones
• Gender Discrimination
• Gum Disease
• Hair Loss
• Headache
• Hearing Loss
• Heartburn
• Heart Disease
• Heart Palpitations
• Hemorrhoids
• Hepatitis
• High Blood Pressure
• High Cholesterol
• Hiv and Aids
• Hysterectomy
• Incontinence
• Infertility
• Inflammatory Bowel Disease
• Inhibited Sexual Desire
• Insomnia
• Irritable Bowel Syndrome
• Lactose Intolerance
• Laryngitis
• Lung Cancer
• Lupus
• Menopausal Changes
• Menstrual Problems
• Motion Sickness
• Muscle Cramps
• Neck and Shoulder Pain
• Oral Cancer
• Osteoporosis
• Ovarian Cancer
• Overweight
• Painful Intercourse
• Panic Attacks
• Pelvic Inflammatory Disease
• Phlebitis
• Physical and Emotional Abuse
• Pneumonia
• Post-Pregnancy Problems
• Post-Traumatic Stress Disorder
• Premenstrual Syndrome
• Psoriasis
• Raynauds Disease
• Repetitive Strain Injury
• Rosacea
• Sexually Transmitted Diseases
• Sinusitis
• Skin Cancer
• Smoking
• Stress
• Stroke
• Temporomandibular Disorder
• Tendinitis and Bursitis
• Thyroid Disease
• Ulcers
• Unwanted Hair
• Vaginal Infections
• Varicose Veins
• Vision Problems
• Water Retention
• Yeast Infections

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Hysterectomy

Hysterectomy

Get the Facts First

You know what a hysterectomy is.

It's a surgical procedure in which a woman's uterus, and sometimes her ovaries, are removed. And you probably know that a lot of women have the operation and that the surgery has a reputation for being performed unnecessarily.

But you may not know what you would do if your doctor said, "You need a hysterectomy."

Controversy and Confusion

Hysterectomies are the second most common operations performed in the United States, behind cesarean sections. From 1988 through 1991, an average of 564,000 hysterectomies a year were done. The surgery is performed most often on women in their early forties.

Controversy surrounds hysterectomy: Experts say about 25 percent of the operations are unnecessary. Gary Lipscomb, M.D., assistant professor in the Department of Gynecology at the University of Tennessee in Memphis, concedes that hysterectomies are sometimes performed when they're not medically warranted. In these cases, he says, doctors may err on the side of surgery instead of other approaches for a number of reasons.

"Part of it is the way we are trained. We are trained to be aggressive in managing disease," says Dr. Lipscomb. "Most of us, including myself, have surgical personalities. And doing surgery is an active approach to problems, instead of a more passive approach. There's an old adage among surgeons in general that a chance to cut is chance to cure."

Another reason some hysterectomies are done is that women who have heavy bleeding ask for the procedure as a way to stop it, says Dr. Lipscomb. Such hysterectomies may be medically unnecessary, but they may be appropriate as far as the woman is concerned, he says.

And some patients want treatment that will give them immediate results, so even when they are offered less invasive treatments that may take a while to be effective, they choose hysterectomy, he says.

Still another factor in the hysterectomy equation is money. "If you're in private practice, and you do surgery, it generates income," says Dr. Lipscomb--more income, in some cases, than less invasive treatments or more conservative surgeries.

Finally, some doctors may not offer alternative reproductive surgeries if they can't perform them as well, says Philip Brooks, M.D., clinical professor of obstetrics and gynecology at the University of California School of Medicine at Los Angeles. "Not all doctors are competent in all procedures," he says. So if a doctor is better at removing the uterus than he is at removing fibroids or the pelvic adhesions of endometriosis, he may offer hysterectomy alone.

A Big Decision

Deciding about hysterectomy is not easy. It's major surgery that involves incisions, a stay in the hospital, anesthesia and painful days afterward. It can also trigger physical, psychological and sexual changes, many of which doctors can't predict. If the ovaries are also removed, the surgery will cause a woman to have sudden, early menopause. And then there's the one definite consequence that's irreversible--the loss of the ability to bear children.

So women may wonder "Do I really need this procedure? Am I doing the right thing?" It's often hard to decide. And some women don't--they leave it up to their physician. "For some women who are having a lot of problems, they just want to get it over," says Linda Bernhard, R.N., Ph.D., associate professor of nursing and women's studies at Ohio State University in Columbus. "It's like 'I just want to be done with it, I don't want to deal with this anymore, I'm so sick of it.' That puts women in a very vulnerable position to have some nice physician say, 'Well, we can fix you all up. We'll just take it all out, and then everything will be better.' "

But women can get involved, take control and make the decision that's right for them.

All about the Procedure

Hysterectomy is most clearly warranted when a woman has cancer or serious, life-threatening complications during childbirth.

Other conditions for which doctors might recommend or perform hysterectomies include fibroids, heavy bleeding, endometriosis, prolapsed uterus, pelvic pain and pelvic inflammatory disease, although when the surgery is necessary for these conditions is less clearly defined.

There are different types of hysterectomies. A total hysterectomy, for instance, removes the uterus and the cervix, while a partial hysterectomy removes only the uterus.

There are also different methods of doing a hysterectomy. In an abdominal hysterectomy, the uterus is removed through an incision in the abdomen. In a vaginal hysterectomy, the uterus is removed through an incision in the vagina. The surgery is less invasive, and recovery is easier than with the abdominal procedure.

In the 1990s, new techniques have been developed using laparoscopy. During the procedure, a laparoscope, a surgical microscope at the end of a viewing tube, is inserted through an incision in the navel, allowing physicians to view the woman's reproductive area, says Dr. Lipscomb. They can then determine whether a vaginal procedure would be likely to be effective.

In cases where a traditional vaginal hysterectomy might prove difficult to do, miniature operating instruments can be inserted through other small openings in the abdomen and the uterus removed vaginally under laparoscopic guidance. This is known as a laparoscopic-assisted hysterectomy.

In any of these procedures, doctors may recommend the removal of one or both ovaries in a procedure called an oophorectomy. Some doctors advocate removing the ovaries in women who have finished bearing children in order to prevent ovarian cancer, even though a woman's risk of getting the disease over her entire life span is only 1 in 80.

Other medical professionals recommend leaving the ovaries in as long as possible because they supply estrogen, which plays a role in preventing osteoporosis and heart disease, as well as androgen, which influences a woman's sex drive.

You Have a Choice

The thing to remember about hysterectomy is that a lot of times it's not the only possible treatment, says Paula Bernstein, M.D., Ph.D., attending physician at Cedars-Sinai Medical Center in Los Angeles. There are usually other treatment alternatives for fibroids, heavy bleeding, pelvic pain, endometriosis, prolapsed uterus and pelvic inflammatory disease.

Fibroids are the reason for about 30 percent of hysterectomies. Alternatives include leaving fibroids alone or removing them through myomectomy, which leaves the uterus in place.

Heavy bleeding, the problem that leads to 20 percent of hysterectomies, can often be treated with medication or a procedure called endometrial ablation, in which the lining of the uterus is removed but the organ is left intact. Endometriosis can be treated with drugs as well, or the diseased tissue alone can be removed through laparoscopy.

Fifteen percent of hysterectomies are performed for prolapsed uterus, in which the uterus literally starts to fall. It's believed that having a lot of children may contribute to prolapse because childbirth distends the birth canal and stretches and weakens the muscles and ligaments supporting the uterus, says Dr. Lipscomb. Aging can also play a role. As women grow older, the connective tissue that supports the uterus becomes weaker, says Dr. Lipscomb. Estrogen helps maintain the muscles and ligaments that support the uterus, so after menopause women who do not go on hormone replacement therapy may be at increased risk for prolapsed uterus, he says.

Women who develop a prolapsed uterus can ask their doctors about exercises called Kegels, which help to strengthen the uterine muscle. They can also ask about a pessary, a device that is inserted in the vagina--much like a diaphragm--and holds the uterus in place. An advantage of the pessary is that it is a nonsurgical way to relieve the symptoms--pelvic pressure, urinary incontinence and rectal discomfort--that can arise when a woman has a prolapsed uterus. The disadvantages are that sometimes it is uncomfortable and can cause an unpleasant odor and discharge.

Obstetrical complications, such as hemorrhaging during childbirth and gynecologic cancer, are the reasons for about 11 percent of hysterectomies. For these conditions, there's usually no alternative. "Those are the life-threatening reasons," says Susan Haas, M.D., assistant professor of obstetrics and gynecology at Harvard Medical School.

In other cases, though, whether a woman has a hysterectomy is ultimately up to her. "In my opinion, since the woman lives with all the risks and all the benefits, she's the one who makes the decision," says Dr. Haas. "We should term this 'elective hysterectomy.' That reinforces the concept that it's an option or a choice and that the final decision-making power lies with the woman. It also implies that she can make that decision at any point," she says.

Even in the case of cancer, if a woman feels she's not quite ready for the surgery, it probably can wait a day or two, says Marvel Williamson, R.N., Ph.D., professor of nursing and director of the School of Nursing at Park College in Parkville, Missouri. Meanwhile, women need to take the time to find out their options, adds Dr. Bernhard.

What You Need to Know

Hysterectomy may cause a woman to have an early menopause even if she does not have her ovaries removed. If you're a candidate for surgery and you're still in your childbearing years, consider the fact that you will no longer be able to have children. While this may seem obvious, Dr. Bernhard says that some women don't take it into account. "Most women seem to have all the negative symptoms and that's what got them into the surgery in the first place. And they want to get rid of the symptoms," she says. "In the process, feelings or thoughts about childbearing may get lost." Hot flashes and vaginal dryness, two other side effects of menopause, may also occur.

A study of 10,598 women, ages 39 to 60, in the Netherlands showed that the 986 women who underwent hysterectomy but kept their ovaries--especially those between the ages of 39 and 41--experienced more hot flashes and vaginal dryness than 5,636 menopausal women who had not had a hysterectomy. Women ages 39 to 41 who'd had the operation reported menopausal complaints one to three times more often than menopausal women who hadn't had a hysterectomy.

Women who undergo hysterectomy can also experience urinary tract symptoms such as frequent urination and urinary incontinence, as well as deepening of the voice and weight gain. These physical changes are the result of declining estrogen levels. In the Netherlands study, women ages 39 to 41 who'd had a hysterectomy but kept their ovaries reported about twice as many problems not exclusive to menopause--such as irritability, dizziness, tiredness, depression, forgetfulness, headache and muscle and joint pain--as did menopausal women who hadn't had the surgery.

Some studies indicate that women feel depressed after a hysterectomy, but whether the operation itself causes depression is unclear. "Our society still has this negative perception that hysterectomy is going to make you something less. If women internalize that, then they may feel depressed," says Dr. Bernhard.

Other studies show that depression after a hysterectomy may be no more typical than depression about bodily changes that can occur after other types of surgery. And some studies reveal that women are less depressed after hysterectomy than they were before, when they had to deal with problems such as heavy bleeding and pain.

Women may also experience a sense of loss after hysterectomy, says Dr. Bernhard.

Some women say they've experienced positive physical changes, reporting restored vigor because they're no longer bleeding heavily and having pain. The operation can often end anemia as well. "I've heard women say they just feel so much better. The physical improvement in their health is often the greatest reward," says Dr. Bernhard. The women are pain-free, are no longer hemorrhaging and no longer have to plan their life around their bleeding, she says.

While studies indicate that women have these positive responses in the short term, more study is needed on the long-term effects, says Dr. Bernhard.

Women may experience sexual changes after hysterectomy because they feel different about their bodies and have anxiety about resuming sex. For some women, the orgasm experience changes.

"The uterus elevates and contracts at the time of orgasm. Most women couldn't say, 'I know what that feels like,' but when the uterus is gone, it feels different," says Dr. Bernhard. "It's not that they don't have orgasms, they just are different."

What to Consider

If you are a candidate for hysterectomy, weigh your decision carefully. Here's some help.

Find a doctor you like. Look for a doctor you can talk to, who understands what you're going through, answers your questions and will do what you want, says Nancy Petersen, R.N., director of the Endometriosis Treatment Center at St. Charles Medical Center in Bend, Oregon. If your doctor tells you that you need a hysterectomy but it doesn't seem right to you, see another doctor. Hysterectomy is often overkill for endometriosis, she says.

Ask about your options. There are usually alternatives to hysterectomy, experts say. Ask your doctor what they are, says Dr. Williamson.

Questions to Ask the Doctor Deciding whether or not to have a hysterectomy is difficult. Explore all your options by asking questions. Here are some to begin with. * Why are you recommending a hysterectomy? * Is there an option other than hysterectomy? * What are the pros and cons of a hysterectomy for my problem? * Do you recommend removal of my ovaries? If so, why? What are the risks and benefits of keeping them? The risks and benefits of removing them? * Why are you recommending an abdominal (or vaginal) hysterectomy? * Are you planning to use a laparoscope? If so, how much of the surgery will you do with the laparoscope? * How many procedures like mine have you done with a laparoscope? * When you do the procedure, will there be another surgeon present who is experienced in using a laparoscope for hysterectomy?

Get other opinions. Get a second, third, even a fourth opinion. "Don't let any one physician tell you this is what you should do," says Dr. Bernhard.

Learn about the procedure. Ask your doctor which particular procedure will be done and why, says Dr. Brooks. Find out how much experience your doctor has with the procedure she is suggesting.

Decide what's most important. Set your priorities, says Dr. Bernstein. Ask yourself "How debilitating is the pain? How much is it interfering with my lifestyle? Do I want to have children? Would I feel comfortable about adopting?"

Don't rush. Take time to make your decision, says Dr. Bernhard. "There's probably no rush," she says.

If You Go for It

If you decide to have a hysterectomy, ask your doctor whether the less invasive vaginal surgery is right for you. "If there is a choice, a vaginal is always the safer, more comfortable way to go," says Dr. Williamson.

Find out whether your doctor has experience using the laparoscope, since its use in hysterectomy is fairly new.

Keep in mind, though, that if you have ovarian cancer, an abdominal hysterectomy is usually the only option, says Dr. Lipscomb.

Here are some things you can do to make the surgery easier.

Involve your mate. Studies show that men often view their partners differently after hysterectomy, so "we need to help him understand," says Dr. Williamson. "Don't be afraid to ask him 'What fears do you have about my hysterectomy? How do you think my surgery will affect our sex life?' " she says. You can start by expressing your own fears and see how he responds, Dr. Bernhard says.

Get some female support. Talk to your friends or join a support group. "Sometimes women find talking about it with other women helps more than talking with just their partner," says Dr. Williamson. Ask your doctor or call a local hospital for support groups near you.

Grieve your loss. "As for any loss, the grief process needs to be expressed verbally and emotionally. If women can't talk about it or cry about it, the feelings of grief will come out in some other way," says Dr. Williamson. "Give yourself permission to talk about it." Find someone, such as a friend or therapist, who will go through it with you, she says.

Expect a change. Women often feel different after hysterectomy, experts say. It's hard to know how you will respond, but be ready for something.

Resume sex ASAP. Try to have sex as soon as you can after the surgery, says Dr. Williamson. She recommends that women wait 10 to 14 days for the incision to heal. Part of the healing process after surgery is the development of scar tissue, and if women wait too long, the scar tissue in the pelvic cavity and around the vaginal incision can become very tough, making sex more uncomfortable, she says. Having sex can minimize the scar tissue toughness, because the area gets increased circulation and expands during engorgement.

"We would like women to resume intercourse, gentle intercourse, between the two- and four-week period, if possible," she says. Women should try to have sex at least twice a week until the healing process is complete, she says, which can take as long as three months.

Take time alone before sex. After surgery, women should start by "having their first orgasm alone," says Dr. Williamson. They should masturbate the first time so they can get used to any new sensations, she says. "It lets them know that everything still works and that it doesn't hurt to get turned on and have an orgasm."

Start all over. With your partner, that is. When women who've had a hysterectomy are ready to start intercourse again, the couple needs to pretend it's their very first time having sex, says Dr. Williamson. "They need to allow her to be in control, to have as long a foreplay session as possible," she says. Many women are concerned that sex will be painful, so taking it slow can help, she says. And don't be afraid to use artificial lubricating jellies, she says. Products to consider for vaginal dryness include K-Y Lubricating Jelly and Replens, which are available in pharmacies.

Vary your sexual routine. Before the surgery, get in the habit of varying your sexual techniques, like the positions you and your partner use, because you probably will have to do so after the surgery, at least at first, says Dr. Williamson.

Try Kegels. Many women say the pleasurable feeling of needing to be filled that they experienced during sex is no longer there after hysterectomy, says Dr. Williamson. This may be due to vaginal scar tissue that does not engorge and stretch as well as other genital tissue. Or it could be because the woman's cervix has been removed, leaving her vagina shorter than before. Performing Kegels during sex can help women achieve that feeling, she says, because they help to lengthen and lift the vagina.

Normally Kegels can be done anywhere; you simply tighten your vagina as if you are trying to keep from urinating, hold it from two to five seconds, then release. After hysterectomy, do Kegels during sex. Besides strengthening the vaginal muscles, they will enhance the feeling of pressure on the penis, Dr. Williamson says. "What people describe to me is that the best feelings come when the muscles are contracted or tightened, and that it's held as long as possible," she says.