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Before You Undergo a Hysterectomy it is Vital You Know the Pros and Cons

Hysterectomy

Types of Hysterectomy Biology of the Reproductive System Reason for Hysterectomy Talking With Your Doctor about Hysterectomy Complication Associated with Hysterectomy Recovery from a Hysterectomy New Options for Hormonal Replacement Therapy after Hysterectomy Do I have to take Estrogen after a Hysterectomy? How long do I take Estrogen after a Hysterectomy What are the Nonoral Estrogen Products? Sex after a Hysterectomy

The Different Types of Hysterectomy
Women who undergo abdominal hysterectomy have their uterus removed through an incision in the lower abdomen. Usually a doctor will also remove one or both ovaries and the fallopian tubes during this procedure.

There are other types of hysterectomies that a doctor may use including laparoscopic assisted vaginal hysterectomy and vaginal hysterectomy.

Like an abdominal hysterectomy, a vaginal hysterectomy involves removal of the uterus. With vaginal hysterectomy the uterus is removed from the vagina instead of the abdomen. During a vaginal hysterectomy your doctor may decide to remove the ovaries and fallopian tubes as well as the uterus depending on your specific health condition.

Vaginal hysterectomy is usually a choice for women whose uterus is not enlarged or if any problems associated with the uterus are limited to the uterus and not the surrounding organs.

Vaginal hysterectomy has many advantages over abdominal hysterectomy including:

• Shorter hospital stay
• Fewer complications
• Faster recovery time
• No abdominal skin incision
• Less pain and discomfort

Laparoscopic assisted vaginal hysterectomy (LAVH) offers some patients an alternative to abdominal hysterectomy. It is possible to accomplish a vaginal hysterectomy with the assistance of the laparoscope when vaginal hysterectomy may have been contraindicated secondary to pelvic adhesions, thus avoiding the risks and pain of an abdominal incision. The laparoscopy can help your doctor remove any scar tissue that may exist on reproductive organs, facilitating removing the uterus through the vagina.

Sometimes while performing a laparoscopic assisted vaginal hysterectomy your doctor may find scar tissue that spans many areas. If this is the case, your doctor may decide that an abdominal hysterectomy makes more sense than a vaginal one. Your doctor may discover this after surgery has begun.

Before discussing the hysterectomy, it is important you understand how the female reproductive system works.

Biology of the Reproductive System
The most well-known organ of the reproductive system is the uterus. Often referred to as `pear shaped` the uterus resides in the pelvis or lower abdomen. The uterus is connected with the fallopian tubes toward the top of the uterus and to the ovaries by ligaments on the sides of the uterus. The cervix lives at the base of the uterus and protrudes into the top portion of the vagina.

During your reproductive years your ovaries release an egg every month. This egg passes through the fallopian tube and will fertilize if sperm is available. If the egg is fertilized it implants in the uterine lining and pregnancy results. If the egg is not fertilized however, the lining sheds and you start your menstrual period. The menstrual period is nothing more than blood and tissue that collects inside your uterus as your body prepares for fertilization and pregnancy.

The ovaries are not just egg laying machines. They also produce hormones including estrogen and progesterone, which help keep the body efficiently functioning during the reproductive years. During menopause, the ovaries stop producing hormones and eggs. Eventually your monthly menstrual period stops.

Reasons for Hysterectomy
Fibroids:  Many women have fibroids, a condition where tumors form in the uterus. These tumors are not cancerous but can cause pain and dysfunctional uterine bleeding. Large fibroids can put pressure on your back, and give you a chronic lower back pain. Pressure on your bladder from large fibroids can give you a feeling of urgency and that you have to urinate all the time. Fibroids may cause pain with intercourse, called dyspareunia. Many hysterectomies are performed when chronic symptoms associated with fibroids become a problem.

Uterine bleeding: Some women have irregular and abnormal uterine bleeding that calls for a hysterectomy. Abnormal uterine bleeding or dysfunctional uterine bleeding is associated with irregular, heavy, or severe bleeding from the uterus. It can be caused by fibroids or changes in your hormonal production. Cancer of the uterus and an infection of the uterus can also cause abnormal uterine bleeding. Hysterectomy is an option for abnormal uterine bleeding if conservative measures do not help.

Pelvic relaxation: For some women the pelvic muscles and ligaments weaken over time resulting in prolapse of the pelvic organs, such as the bladder, uterus, rectum and intestines. The ligaments that support these structures become weakened with age, chronic cough, obesity or after childbirth. In severe cases you may see your uterus sticking out through the opening of the vagina. The symptoms of pelvic relaxation include a bearing down feeling, a pressure sensation or pelvic pain and problems with controlling your urine. A hysterectomy may be needed to correct the symptoms you are experiencing from pelvic support problems. At the time of hysterectomy many other surgical procedures can be performed to help improve your symptoms cause by pelvic relaxation.

Cervical abnormalities: Changes of the cervix that may lead to cancer found by a pap test can be treated successfully without a hysterectomy, but when the cervical changes become more serious such as invasive cancer a hysterectomy as well as radiation may be needed to control the disease. Hysterectomy may be the only way to stop the cancer from spreading into other organs.

Adnexal mass: This is a condition where a mass or tumor grows in the ovaries or fallopian tubes. If the tumor is just in the ovary a hysterectomy is not needed, but if the tumor involves endometriosis or adhesions as well as the ovary a hysterectomy may be necessary for definitive therapy.

Cancer: Cancer affecting the uterus or ovaries may call for a hysterectomy.

Chronic pain: Some women experience chronic pain in the uterus and pelvis. This may result from endometriosis,  or scarring of pelvic organs. A hysterectomy may be performed to help relieve this pain.

Talking With Your Doctor about Hysterectomy
If you decide to undergo an abdominal hysterectomy it is vital you discuss the pros and cons with your doctor. You want to be clear about the risks and advantages of removing all or portions of the reproductive organs.

Oophorectomy: An oophorectomy is removal of both ovaries through surgery. Many women have this performed along with a hysterectomy. Your doctor may ask you if you want your ovaries intact or if you want them removed with your uterus. If you keep your ovaries, your body will still be able to produce natural estrogen and progesterone. Thus you may not need hormonal replacement therapy after the hysterectomy. If you have additional problems however that affect the ovaries, you may need to remove your ovaries regardless.

Most women have the ovaries removed if they are post menopausal, as the ovaries do not produce significant amounts of hormones anyway at this age.

Supracervical Hysterectomy: This procedure, sometimes called a subtotal hysterectomy allows a partial removal of the uterus. In this case the uterus but not the cervix is removed. There are many different reasons your doctor may leave the cervix. Some women feel that the cervix contributes to sexual satisfaction, thus prefer to leave it.

This procedure is also done sometimes when a hysterectomy is performed as an emergency to save a mother who is having a severe postpartum hemorrhage. It is important that women realize if the cervix remains intact their risk for cervical cancer remains higher than in a woman who has a complete hysterectomy.

Complications Associated With Hysterectomy
There are some complications with hysterectomy as there are with any surgery. The most common complications include:

• Excessive bleeding or hemorrhage: this occurs rarely and may result in a blood transfusion
• Infection: many women develop a fever after a hysterectomy. Sometimes this results from an infection that must be treated. Serious infections are a rare complication.
• Damage to surrounding organs: the organs surrounding the uterus may be damaged during a procedure. This includes the bladder or ureters.
• Urinary retention: some women are not able to pass urine after this procedure. Usually if this happens your doctor can insert a catheter to alleviate the problem. This problem is usually short-lived.
• Thromboembolism: this involves formation of a clot in a blood vessel. This is a risk with many surgeries. Usually this risk can be minimized with early ambulation after surgery or the use of low dose heparin.

Recovery from a Hysterectomy
Most women will stay in the hospital two to three days after a hysterectomy. It usually takes several weeks to fully recover from the surgery.

Your doctor may provide fluids and food shortly after surgery, though many women experience nausea or vomiting the first day after surgery. If this happens your doctor may recommend intravenous fluids to be continued until the nausea passes. There are many antiemetic medications that help with post operative vomiting.

Once you are discharged you can usually resume normal activities as soon as you are comfortable doing so. Your doctor will prescribe pain medications to help relieve pain you may experience at home.

If you are taking narcotic pain medications your doctor will recommend you avoid driving until you discontinue use of them. Walking and stair climbing in moderation are perfectly fine after surgery. Taking a showering is preferred to a bath until the vaginal tissue is well healed. Most women usually return to work in 4 to 6 weeks or as soon as they feel ready after a hysterectomy.

New Options in Hormonal Replacement Therapy after Hysterectomy
Nonoral estrogen products are safer than the traditional oral estrogen pills. Nonoral estrogen products approved for use in the United States are the transdermal patch, skin gels, vaginal creams, a vaginal ring and the vaginal tablet. Nonoral estrogen avoids going through the liver, which means lower doses are needed for effective treatment with fewer side effects.

After the findings of the WOMEN'S HEALTH INITIATIVE study that demonstrated oral estrogen therapy (0.625 mg/day) when used in women who had undergone hysterectomy (and therefore did not require a progestin) showed a small increase in stroke risk, it is recommended that you take the lowest dose possible of estrogen.

The study also showed an increase in cardiovascular disease, breast cancer risk as well as increase in stroke risk with the combination hormonal replacement therapy, progesterone/estrogen oral pills, used in women that still have a uterus.

The safest estrogen products that should be used after seeing the results of the Women`s Health Initiative study are the nonoral estrogen products.

Why do I have to take estrogen replacement after removal of my ovaries at the time of hysterectomy?
Menopausal symptoms: Estrogen is the most effective treatment available for symptoms such as hot flashes, urinary symptoms, and vaginal atrophy after removal of the ovaries at the time of hysterectomy. Vaginal atrophy (atrophic vaginitis), is a condition in which the vagina can become dry, resulting in pain with intercourse.

Quality of life: After hysterectomy with removal of the ovaries some women may have severe menopausal symptoms. A dramatic improvement in their quality of life is seen when they are treated with estrogen. This is due to relief of hot flushes and restoration of normal sleep.

Urinary tract infection: Estrogen has been found to decrease the frequency of urinary tract infections after hysterectomy with removal of ovaries. It does not help the symptoms of urinary incontinence.

Depression: Estrogen may improve mood and decrease depression in some women after hysterectomy with removal of ovaries.

Osteoporosis: Estrogen may be used for prevention of osteoporosis in women with a high risk for fracture in which alternative therapies are inappropriate.

How long will I need to take Hormonal replacement therapy after Hysterectomy?
While the hot flashes generally subside a few years after your hysterectomy, the symptoms of vaginal atrophy such as itching, discomfort and pain with intercourse persists and worsens over time. For long term treatment of vaginal atrophy the nonoral estrogen products will provide sufficient symptom relief. When your hot flashes, night sweats and insomnia subside you want to discontinue therapy.

What are the nonoral estrogen products?
Transdermal Patch:  The low-dose transdermal estrogen patches relieve moderate to severe hot flashes as early as the second week of use. They provide rapid symptom relief and maintain steady levels of hormonal therapy. Patches may be applied to various body parts. They occasionally will cause skin irritation and adhesion problems.

Esclim, Estraderm, and Vivelle are brand names for the generic estradiol biweekly transdermal patch.

The patch is replaced twice a week, about every 3 to 4 days. Apply the patch to a clean, dry, hairless area on your skin. Press the patch firmly against the skin for about 10 seconds to make sure the patch stays on. Do not place the patch in an area exposed to sunlight and do not place the patch on the breast. Tight clothing may rub the patch off as well as areas of the skin that bends. When it is time to remove the patch, fold it in half and place the sticky sides together. Discard in the trash away from children. Apply a new patch in a different area of the skin to avoid irritation. If a patch falls off, reapply it or apply a new patch and wear it for the rest of the scheduled period of time.

The newest option in estradiol transdermal patches is Menostar. This transparent, small in size patch is a convenient once-a-week transdermal delivery of estradiol. It provides low estradiol blood levels which are affective in preventing bone loss and preventing hot flashes.

Transdermal Gel:  Estrasorb Lotion is the first and only estrogen therapy in a lotion like emulsion that provides rapid and sustained relief from moderate-to-severe hot flashes. Estrasorb lotion is a unique delivery system, micellar nanoparticle (MNO) technology, which deposits estrogen in submicron-sized nanoemulsions, using the skin as a drug depot. In other words, apply the lotion once daily to your skin on both thighs and calves. Rub the medicine into the skin for three minutes or until absorbed. Any extra medicine left on your hands should be applied to your buttocks. It is recommended to use the lotion at the same time each day. Do not apply sunscreen with Estrasorb lotion, it may affect the amount of medicine you absorb. To prevent transfer of the lotion to other people through contact, allow the drug to dry completely and cover with clothing. Wash your hands with soap and water after you have finished applying Estrasorb lotion.

Vaginal Tablets:  Vaginal tablets, such as Vagifem provides locally administered estrogens that provide sufficient estrogen to the vaginal tissue to treat vaginal atrophy. Vaginal atrophy is due to the lack of estrogen after removing the ovaries. Atrophic vaginitis is associated with vaginal dryness, soreness, and itching. Vagifem tablets provide relief from atrophic vaginitis when used regularly. The usual dosage is 1 tablet a day for the first 2 weeks, then 1 tablet twice weekly. You can discontinue the use of Vagifem tablets after about 3 to 6 months, or when your symptoms disappear.

Vaginal ring:  Estring vaginal ring is an estrogen replacement system for the relief of vaginal problems such as itching, vaginal dryness, burning and difficult or painful intercourse after your ovaries are removed. Estring ring is left in the vagina for 3 months. Insert the estring in the vagina by bending the estring into an oval shape and inserting it as deeply as possible into the upper third of the vagina. If the ring slips out, rinse it in warm water and reinsert it. When you want to replace the ring, simply hook a finger through it and pull it out. You must replace the ring after 90 days, or your symptoms will return.

Hysterectomy and Sex
Hysterectomy may affect a woman sexually in varying ways. Many women who undergo a hysterectomy will lead a completely normal sex life. Still others will experience increasing sexual responsiveness and feeling. Unfortunately other women do report they are not as easily aroused following their hysterectomy. This may result from a variety of factors that can usually be identified and overcome.

Some women may notice a change in their sexual response after the uterus has been removed, uterine contractions that may have been associated with orgasm will no longer be perceived. Other women may experience a heightened response. This may be due to the fact that they no longer have to worry about getting pregnant and no longer have tremendous pain or dysfunctional bleeding.

Some women notice they no longer associate uterine contractions with orgasm after their uterus is removed. This is perfectly normal. Many women however report increased sexual responsiveness, in part because they feel more liberated and no longer have to worry about reproductive disorders commonly associated with the uterus and other organs.

During hysterectomy vaginal tissue is removed and may make the vagina shorter. Deep thrusting during intercourse may be painful. Changing positions during intercourse may help, such as being on top or bringing your legs closer together.

If a woman’s ovaries are removed after a hysterectomy, she may experience vaginal dryness. Fortunately estrogen cream and use of over the counter lubricants can help alleviate this problem. Deep thrusting may also cause some concern, as some vaginal tissue needs to be removed during a hysterectomy. This makes the vagina slightly shorter, thus less penetration may feel better than more during intercourse. A woman may find riding on top more comfortable if this is an issue after a hysterectomy.

Some researchers originally believed that supracervical hysterectomies might lessen sexual side effects. During this procedure a woman’s cervix is left intact. However more recent studies suggest no difference in sexual enjoyment between women who have this procedure performed vs. those who have an abdominal hysterectomy.

One complication of hysterectomy is depression. Women who undergo a hysterectomy are susceptible to depression, and this in turn may interfere with their ability to enjoy sexual relationships. Some women fall into depression because they sense they have lost some vital portion of their femininity. Others linked their femininity with their ability to reproduce; an ability that is lost once the uterus is removed. Fortunately there are many steps a woman can take to restore her self-image and sense of femininity. If you feel depressed after a hysterectomy, talk to your doctor who can recommend appropriate treatments.

Whenever you consider any medical procedure that is life changing, including a hysterectomy you should be sure to consult with your doctor. Together the two of you can decide what if any procedures you need and what steps you can take to overcome any adverse side effects associated with the procedures. Planning ahead of time and making an informed decision will help you recover more quickly and feel empowered to take charge of your sexuality and life after surgery.