Understanding Hysterectomy

Knowledge of this surgical procedure can help you take charge of your health. If you have problems coping with the need for your surgery, talk to your doctor or seek counseling. It is not unusual to experience loss and fear before a hysterectomy and by dealing with those feelings before surgery, you will be better prepared for a more comfortable recovery -- and probably a quicker one.

You and your doctor have decided that hysterectomy -- the surgical removal of the uterus -- is the best way to treat your condition. As with any major surgical procedure, hysterectomy has many benefits, as well as some risks. It is important to recognize both.

Your surgery may involve removing only your uterus (hysterectomy) or it may include the removal of your ovaries and fallopian tubes as well (salpingo-oophorectomy). If your surgery is in relation to a cancer treatment or another serious condition, your surgery may be more extensive. Discuss your surgical procedure thoroughly with your doctor.

The Female Anatomy

The ovaries are a pair of hormone-producing, walnut-sized organs that contain unfertilized eggs. The ovaries release estrogen, which helps protect you from osteoporosis and heart disease. An egg is released every month until menopause.

In the pelvis, the uterus is a pear-shaped, muscular organ held in place by several ligaments, or bands, that attach to the pelvic wall. Your bladder and bowels are nearby and will be gently moved out of the way during your surgery.

The uterus houses the fetus during pregnancy and sheds its lining (called the endometrium) each month when conception does not occur. After menopause the uterus no longer sheds its lining, and menstrual periods stop.

The fallopian tubes connect your ovaries to the uterus. Your fallopian tubes are about four inches long.

The cervix is the lowest part of the uterus, opening into the vagina. It is the part of the uterus that thins and opens during childbirth. The cervix produces hormones and contains nerve endings that are stimulated during intercourse.

The vagina is a three- to four-inch long canal connecting the cervix to the outside of your body. Padded with a layer of fat under a mucous membrane, the vagina secretes a mucous-like lubricant during sexual arousal.

Facts about Hysterectomies

In an abdominal hysterectomy, an incision is made either horizontally or vertically, right above the pubic hair line in the abdomen.

In a vaginal hysterectomy, there is no visible incision, because the surgery is accomplished through the vagina. A thin tube called a laparoscope is sometimes used to help the surgeon see inside the abdomen and perform the surgery. This is called a laparoscopically assisted vaginal hysterectomy.

After a hysterectomy, your menstrual periods stop. You can no longer become pregnant. If your ovaries have not been removed, they will continue to produce hormones, and you will continue to ovulate every month. During ovulation, the egg will be released, and it will be absorbed into the abdomen.

If you had monthly mood swings before your hysterectomy they will continue, but there will be no bleeding, because there is no uterus.

If your ovaries are removed and you are not menopausal, you will immediately enter menopause. Symptoms may include hot flashes, mood swings, vaginal dryness, anxiety or depression. If you and your doctor have decided to use hormone replacement treatment after your hysterectomy, you may not experience menopause symptoms. Estrogen replacement offers you the bone and circulatory protection that your natural estrogen production provided before surgery.

Why Have a Hysterectomy?

The reasons for performing a hysterectomy are as individual as each woman. Some common reasons include:

  • Severe endometriosis
  • Fibroids that are unresponsive to other medical therapies
  • Damage from pelvic inflammatory disease
  • Uterine prolapse or pelvic relaxation
  • Cancer or malignant tumors in the uterus, ovaries or cervix
  • Severe pelvic pain
  • Menstrual disorders that are not relieved by other treatments
  • Ovarian cysts (if a woman has completed childbearing)

Possible Risks with Hysterectomy:

  • Side effects from anesthesia
  • Infection
  • Bleeding
  • Need for a blood transfusion
  • Damage to nearby organs
  • Bowel blockage
  • Injury to the urinary tract
  • Blood clots in the veins or lungs

The Day Before Surgery

Because your bowels are close to the uterus, your doctor may want you to have some type of bowel preparation -- either a series of antibiotics and prescribed laxatives, or a liquid laxative followed by an enema. This is more commonly done if cancer or severe endometriosis is suspected. Your doctor may ask you to limit your diet to clear liquids for one to three days before surgery.

Do not drink or eat anything after midnight the night before your surgery. When you are given anesthesia, your muscles relax to the extent that you may vomit, so it is extremely important that your stomach is empty.

Getting Ready for Surgery

Tests you may have before surgery include:

  • Blood
  • Urine
  • Chest X-ray
  • Electrocardiogram (EKG)
  • Barium enema
  • CT scan

Your doctor's office should make an appointment for your preadmission workup and any testing required. If you need additional help with scheduling, please discuss this with your doctor's office. A nurse from your doctor's office can answer your questions about tests that have been ordered.

Packing for the Hospital

You should bring only essential items to the hospital: a toothbrush and toothpaste, hair brush, lip balm (to help ease dry mouth and lips after surgery), nonskid slippers and a robe that ties in front. BJC HealthCare provides a gown. If possible, leave your suitcase locked in your car until you are assigned a room.

DO NOT bring credit cards, jewelry, money or other valuables to the hospital. Hearing aides, eyeglasses, dentures and partial plates should be left with your family or a friend when you go into the surgery area. This will keep them from being lost or misplaced. If this is not possible, ask the nurse in charge to mark your things with your name and put them in a safe place. If you bring a storage case for such items, put your name on the case, and give it to the nurse during your admission process.

The Day of Surgery

When you arrive at the hospital at your assigned time, use valet parking or park in the hospital parking garage. Go to the admitting office to complete admission papers and get your identification bracelet. From here, you will be escorted either to the hospital's gynecological division or the surgical waiting area. A nurse will ask you questions about your current health, and the names and doses of any medications you currently are taking. It may be helpful to bring a list of your medications to the hospital, along with notes on allergies and previous hospitalizations or surgeries. The accuracy of this information is important for your treatment during your hospital stay.

The nurse will check your blood pressure, pulse, temperature and breathing as part of a short physical examination. You will be asked to change into a hospital gown that ties in the back. You may have an enema at this time, depending upon your doctor's orders. Our staff will make every effort to help you get to surgery on schedule. If at any time you are uncomfortable or have questions, stop a member of your health care team and be sure to get your questions answered. We are there for you.

In the gynecological division, your family can be with you while you wait to be taken to the surgery waiting area. If you go directly to the surgery waiting area, only one person can accompany you. Other family members or friends can stay in the surgery waiting area, where your doctor will come to tell them about your condition after surgery.

Pre-surgery Waiting Area

The pre-surgery waiting area is close to the operating room. One family member or friend may stay with you until you go into surgery. The room is sterile looking, and the people who work there are wearing operating room scrubs. To keep the area as sterile as possible, you will be given a cap to cover your hair. The room may be chilly. If you are cold, be sure to request an additional blanket.

Several people will ask you the same questions. By asking you the same questions more than once, we are verifying information that helps ensure your safety, and we are making certain everyone caring for you has accurate information.

In this waiting area, you will see your surgeon, perhaps a resident physician (a doctor-in-training in obstetrics and gynecology) and an anesthesiologist, who will administer or supervise your anesthesia during surgery. You'll be asked about previous surgeries or allergies, and you'll have a chance to ask any other questions you may have. You may be asked to sign a consent form for surgery and a consent form to receive blood if needed, unless you signed these forms earlier in your doctor's office.

You may be given a sedative to help you relax. An intravenous (IV) line will be started so you can receive fluids during surgery. If you have questions, it's important to ask them before the sedative is given.

When it is time to go to the operating room, your visitor will be asked to go to the surgery waiting room, where other family members may be.

The Surgery

In the operating room, members of the staff wear green scrubs. Do not be alarmed by the large number of instruments, monitors and machines in the room. Many procedures are performed in the operating rooms, and only those instruments needed for your hysterectomy are used for your particular surgery. You will be helped to slide onto the operating table. Your doctor, anesthesiologist, resident physicians, operating room nurses and support staff will all be present, preparing for your surgery. Monitor wires will be placed on your chest, and the anesthesiologist will give you medication to relax.

If you are given a general anesthesia, the room will fade away as the anesthesia takes effect, and you will be completely unconscious and closely monitored the entire time. Or, you may receive regional anesthesia (a spinal or epidural block). Your surgery will last from two to six hours.

After Surgery: The Recovery Room

When you are brought into the recovery room, you will be asleep or groggy. If you feel nauseated, tell a nurse. Medications can relieve the nausea. Your blood pressure and pulse will be taken often. Pain medication is available. Ask for it as you need it.

You will feel a big bandage on your stomach if you've had an abdominal hysterectomy, or packing in your vagina if you've had a vaginal hysterectomy. You also may have a small tube in your nose to keep your stomach empty and your intestines at rest.

There will be another small tube (catheter), in your bladder. This is to keep your bladder empty during surgery and recovery. You may feel a third small tube just above your pubic hair line, placed there during surgery if bladder repair work was done. These catheters are temporary and usually removed within 24 hours to one week. Ask your doctor what to expect in your specific case.

You may have small tubes on your abdomen with bulb-like collection containers, or drains, attached. These drains collect the fluids produced in your abdominal region as your body heals.

You may be given oxygen. This may make you nose dry. You also may have several wires attached to machines that monitor your well-being in the recovery room. You will be moved into your hospital room after the health care team confirms that you are in stable condition and your pain is under control. This may take from one to five hours.

Your Hospital Room

When you are moved from recovery into your hospital room, you probably will still be sleepy from the anesthesia. You will still have tubes in place from the recovery room. You may be wearing air-filled stockings that help with your circulation and prevent blood clots.

Your blood pressure, pulse, respiration and temperature will be taken frequently. To encourage you to keep your lungs clear, nurses will help you turn from side to side and ask you to cough and breathe deeply. Sometimes a device that encourages deep breathing -- called an incentive spirometer -- will be used. The routine may be uncomfortable, but it is necessary to decrease the risks of pneumonia and blood clots.

Pain medication is given either by injection or through your intravenous (IV) catheter. Most patients use a patient-controlled analgesia (PCA) for pain after surgery. The PCA allows you to press a button to release pain medication through your IV. Some patients who received epidural anesthesia may use their epidural catheter to receive pain medicine for the first 24 hours following surgery. This is a safe, quick method that puts you in control of your pain relief. The PCA has safeguards against overdosing on pain medication. Your nurse will give you instructions on how to use the PCA. After a few days or as soon as your bowels are functioning normally, you will take pain medication by mouth.

If you have an abdominal hysterectomy, you may have some bloody discharge from your vagina, and you will wear a sanitary pad. If you have a vaginal hysterectomy, a heavier bloody discharge will occur, and vaginal packing may be in place when you wake up from surgery. This packing usually will be removed within the first 24 hours.

If you have not been nauseated, your doctor will order ice chips for you. The ice chips and lip balm will help soothe your dry mouth and tender nostrils if you have oxygen. You will continue to sleep or doze after recovery. When awake, remember to keep coughing and deep breathing to help prevent complications. Using your PCA will make this important routine easier.

Encourage your family and friends to give you some quiet time after surgery. Ask them to come in shifts until you are feeling stronger. If you have a private room, one person can stay with you through the night.

The First Day After Surgery

Doctors and staff make rounds early in the morning. This is the time to have your questions ready. Make a list of questions as they occur to you or your family members. This will help you remember to ask everything during these early morning visits. Doctors also often make evening visits to patients.

If you have an abdominal hysterectomy, you will not be given anything to eat or drink (except ice chips) until some gas is moving in your bowels.

The bowels are near the uterus, and during surgery they are gently moved aside and out of the way. After surgery, eating must wait until the bowels start to push gas along in order to handle food. It may be difficult for you to pass gas without feeling embarrassed. This is not the time to be polite. Passing gas is a normal, healthy function, and following abdominal hysterectomy, it is a sign that you can drink fluids and eat, and are on your way to returning home.

If you have a vaginal hysterectomy, you will probably have clear liquids within the first 24 hours after surgery. If the liquids are tolerated without nausea, your diet is advanced to regular food. In a vaginal hysterectomy, the bowels begin functioning more quickly.

Make sure to balance activity and rest, overdoing neither. If you need more time to sleep, limit your phone and visitor time. It is important to walk and move about to prevent complications. Walking stimulates the return of bowel function and reduces the risk of pneumonia, and blood clots in the legs and lungs. Try combining visiting and walking so there is enough time for rest.

Your health care team will measure all the fluids that go in and out of your body. We will ask you to urinate into a collection container that fits into the toilet so we can make sure your bladder and kidneys are working at full capacity.

If you have a vaginal hysterectomy, you may be drinking clear liquids, such as apple juice, lemon lime soda, fruit punch or lemonade. You will need to keep a record of how much you drink every eight hours.

Walking, turning, coughing and deep breathing will help you pass gas. Remember that there is a difference between incisional pain and gas pain. The relief for gas pain is walking, and the relief for incisional pain is pain medication.

Until you are up and walking regularly, you may still wear inflatable stockings to keep the blood circulating in your legs.

The Rest of Your Stay

The second day after surgery is very similar to the first. You will start doing more for yourself, but remember that every individual is different. Your recovery will be uniquely yours. Do not compare your progress to your neighbor, friend, sister or mother. You know when you are making progress. Listen to your body: rest, walk, laugh, cough, deep breathe, use the pain medication when you need it -- and think wellness.

During your entire stay, you will be assessed by the health care team many times during the day, evening and at night. Your IV will probably be left in place during most of your stay, although you will receive less fluid through the IV as you begin drinking again. Once you pass gas, pills will be substituted for pain injections or your PCA device.

Vaginal hysterectomy patients typically go home one to three days after surgery. Your vaginal discharge will be similar to menstrual bleeding in amount and color, and will taper off after a few days. Before leaving the hospital, you must be able to urinate without discomfort, bleeding or urgency. Because the bladder is so close to the uterus, the health care team wants to ensure that your bladder is functioning normally before you are discharged. If you also had bladder surgery to correct incontinence, you may go home with the catheter in place, since voiding will return to normal more slowly.

Abdominal hysterectomy patients have longer hospital stays. Your stay depends a great deal on when your bowels begin to function normally. The abdominal bandage is removed on the first or second day after surgery, and the drains from the abdomen, if there are any, will remain in place until there is very little or no drainage.

You will have some vaginal drainage for a few days after surgery. It will decrease in amount with each day. You will sleep wearing compression stockings, and you may wear them during the day if you are not walking at least six times daily in the hospital hallway.

Your incision should be clean and dry. The staples will be in place for a few days. The routine for your hospital stay will be much the same after the third day as you are gradually weaned from various tubes and catheters. The average stay is from four to seven days.

Your Discharge Day

Once your bowels are working normally, preparations will begin for your discharge from the hospital. Your IV line and drains will be removed. If your stay has been brief, your incision staples will be left in place and will be removed during your first follow-up visit. If you staples have already been removed, small see-through bandages may be left to cover the incision area. These bandages will come off in the shower a few days after you return home. The stitches that hold your incision together are deeper and do not need to be removed. Your vaginal bleeding should have stopped or tapered off to a pink discharge.

About 10 to 14 days after surgery, you may notice a small increase in pink or brownish discharge. This is normal for a day or two. It is part of the healing stages of your internal vaginal incision.

On discharge day and for several weeks to follow, you will tire easily. Keep your expectations modest, and avoid any lifting or strenuous activity. Before you leave the hospital, a member of your health care team will discuss your discharge plan, pain medications and any other prescriptions or treatments ordered by your doctor.

What to Watch for at Home

Before you go home, you will be given a list of things to watch for. Call your doctor if you have:

  • Increased vaginal drainage or bright red blood
  • Temperature of 101 degrees or higher
  • Any urinary incontinence, leaking or dripping; painful or burning urination
  • No urination at all
  • Severe pain
  • Wound draining, opening, inflammation or swelling
  • Nausea, vomiting
  • Increase in the size of your abdomen or if you are no longer passing gas

Remember that your surgery required both internal and external incisions, and it will take time to heal. Be gentle on yourself.

Hormonal Changes

If your ovaries are removed -- and if you are not already in menopause -- you will start to feel the lack of hormones about three days after surgery. In menopause, there is a slow shutdown in hormone production, but when the ovaries are removed surgically, hormone levels drop suddenly.

Your doctor may recommend hormone replacement therapy to ease the symptoms of hormone withdrawal. You may have only a few symptoms or you may experience them all. The symptoms are not life-threatening and can be tolerated without hormone replacement. The most common symptoms include: hot flashes, night sweats, anxiety, depression, insomnia, emotional swings, moodiness and decreased sex drive. Later, symptoms may include bladder irritability and vaginal dryness.

For some, estrogen replacement therapy works very well. Estrogen replacement can help replace natural hormonal secretion, protecting women from heart disease and osteoporosis.

Hormones can be prescribed in several forms: pills, patches or injections. They can be synthetic or natural. Dosages may be adjusted to fit individual needs. If symptoms persist, talk with your doctor. A dosage change may be all that is needed. Your are unique in your hormonal needs.

For women who cannot or choose not to take synthetic or natural estrogen, there are other ways to deal with hormone withdrawal. Some alternatives include herbs, teas, vitamins, soy products, changes in diet, exercise, yoga, meditation and tai chi. Many books outline alternative therapies to help prevent the side effects of decreased hormone production. If you are interested in pursuing this area, do some reading and discuss different approaches with your doctor.

At Home

Once you are home, continue to take care of yourself proactively and participate in your recovery process. Do not overexert yourself. It will take about six to eight weeks to recover. During that time, you can do a great deal to make sure that you regain your health and energy. Some of the care-giving that you do for others will have to be put on hold until you have healed.

Remember, the more you build your tolerance and use your muscles, the stronger you will become. At the same time, expect daily variations in your energy level and mood, and allow yourself to adapt to changing daily needs.

Your doctor may instruct you to shower instead of bathe, since getting in and out of the tub may strain your abdominal incision. You may shower as often as you like. If you have an abdominal incision, just pat dry the incision after showering.

Use sanitary pads for the light vaginal bleeding that may last up to a week after surgery, as well as for the brownish discharge that may last another five weeks. Regardless of the type of hysterectomy you have, there will be an incision internally at the tip of the vagina where the cervix was removed along with the uterus. Trauma to this area could cause infection or bleeding.

Since your bowels may be slow to move due to decreased activity after surgery, your diet should include fruit, vegetables, whole grain foods and eight glasses of water or fluids daily. This diet and slow but frequent 10-minute walks will help avoid constipation during your recovery.

Recovery Guidelines

First two weeks:

  • Lift nothing heavier than five to 10 pounds
  • No strenuous physical activity
  • No intercourse
  • No tampons
  • No douches
  • No lubricants, foams or jellies
  • No driving
  • Tub baths may resume after incision heals

Weeks three and four:

  • Gradually increase activity
  • Begin driving
  • Do short, light errands according to tolerance level
  • No intercourse, tampons, douches or lubricants

At six weeks:

  • Resume normal activities
  • Work up to tolerance level at your own pace

Hysterectomy and Sex

Some women may notice a change in their sexual response after a hysterectomy. Because the uterus has been removed, the uterine contractions sometimes felt during orgasm will no longer occur. However, the clitoris is the source of most of the sensations of arousal and orgasm, and this will not be affected by your hysterectomy. Some women have heightened response, because they no longer have to worry about getting pregnant, or because they are relieved from the discomfort of heavy bleeding that preceded surgery.

If your ovaries were removed before natural menopause, you may notice that the vaginal walls become thinner and drier. Estrogen replacement and vaginal lubrication gels and creams made specifically for vaginal lubrication will help with dryness and add comfort. The vaginal lubrication can be part of foreplay during lovemaking.

Good communication with your partner is essential. It is best to achieve maximum arousal before penetration, since this will help lubricate your vagina naturally. You lose some of the fatty padding in the pubic area, which can make some positions uncomfortable. You and your partner may wish to experiment with different positions until you find several comfortable ones. If your ovaries have not been removed, there will be no decrease in vaginal lubrication or fatty tissue.

If your surgical procedure required making the vagina shorter, deep thrusting during sex may be uncomfortable or even painful. Being on top and controlling the penetration during intercourse may help, or you can try bringing your legs together a bit. This may make sex more comfortable and satisfying.

Your body will adjust to the changes it has undergone if you give it time. In the meantime, communicate with your partner and your health care professional. Some women have reported a loss of sex drive, vaginal lubrication and orgasmic capacity; this is much more common if the ovaries are removed and estrogen is not replaced. But others have actually found a more fulfilling sexual life. Many women can change their approach to their sexuality and enjoy lovemaking more, if they become more familiar with their bodies and communicate with their partners.

Adjusting to the Change

Your physical changes can be dealt with through good communication with your doctor and your partner. Your mental outlook contributes greatly to your ability to adjust to this life change. Grieving is a normal part of the process. Some sense of loss is to be expected. A long-term depression needs more help.

Talk with your partner, your doctor or a trusted friend as needed. Join a support group. If depression continues, consider professional counseling. Getting counseling early when problems begin can make coping easier for you.

Keep the lines of communication open with your health care team. Your happiness is an important part of who you are and what you contribute to the world. Sometimes it takes counseling sessions, a change in dosages of estrogen, the addition of vitamins or minerals, or an adjustment in your diet. Be proactive in your own care. Read, talk, learn and be involved in your wellness.

Open communication between you and your health care team is essential at all steps along the way. Ask questions and share your concerns. Making your hospitalization and recovery time a positive experience will get you on the road to living life to the fullest.