Hysterectomy: Post-operative Problems and Concerns

From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD
Hysterectomy
and Postoperative Problems

• Are Pap smears needed after hysterectomy?
• Light pink discharge 3 weeks post hysterectomy
• Does hysterectomy without ovary removal cause bone loss?
• Can menopause happen during hysterectomy?
• Weight gain after hysterectomy
• How to get weight off after hysterectomy
• Weight edging up 8 months after hysterectomy
• Does natural menopause cause any weight gain?
• Is orgasm gone after hysterectomy?
• Does PMS go away with hysterectomy and ovary removal?
• Does PMS go away with hysterectomy alone?
• Hysterectomy for prolapse - vaginal or abdominal?

Are Pap smears needed after hysterectomy?

After a hysterectomy, does a woman still need to have annual pap smears?

If you have ever had abnormal Pap smears with dysplasia or HPV changes, I would say yes for about 5 years at least. Then if all of those Paps are negative you could have them every 3 years.

If you've never had an abnormal Pap and you have had 3 recent annual Paps that are all negative, then you probably only need them about every 3 years starting now.

Changes can take place at the end of the vagina (dysplasia, carcinoma in-situ or invasive cancer of the vagina) just as they can on the cervix. Admittedly it is much less frequent but does happen. The only time we see cancer of the vagina (squamous cell) is in women who had a hysterectomy and never got another Pap for many years.

Light pink discharge 3 weeks post hysterectomy

My vaginal hysterectomy was done 3 weeks ago and I feel great! My OB/GYN said I could resume all activities with the exception of intercourse and lifting. I have lost five pounds since surgery and am starting to get back to normal. I clean house, vacuum and have started exercising 30 minutes each day on my air glider machine. I have a very small amount of soreness, very little though. I still have a slight very light pink discharge and only off and on. Is this normal?

Yes. It usually lasts a couple of weeks but it can continue for 6 weeks. There may also be some more spotting out at about 5- 8 weeks when some of the sutures dissolve. After that there shouldn't be any more bleeding.

People I talk to tell me to take it easy and don't overdo but I really do feel fine. When I tire, I lay down. Am I doing anything I shouldn't be?

Sounds ok. Keep off the lifting.

I don't see my doctor for another 3 weeks. Thanks much!

Does hysterectomy without ovary removal cause bone loss?

My question today is does having a hysterectomy while leaving the ovaries intact cause earlier bone mass loss before menopause?

Not that I know of just due to hysterectomy. Bone loss does take place naturally before menopause, however. After about age 35-40, bone loss takes place at about 0.5% a year. When menopause takes place, bone loss is about 1.0-1.5% a year if estrogens are not replaced. For the 1st 20 years after menopause (without ERT), there is a 50% loss of trabecular bone (the spongy, inside bone) and about 30% reduction in cortical (outside, smooth bone). The process is less in blacks but I'm not sure of the exact numbers.

I read something on another site that stated that such loss can occur even with retention of the ovaries. Am I in danger of osteoporosis?

Not from the premenopausal loss of bone, in my opinion

I have seen the Medscape abstract of the 1995 article and its discussion. Women who have hysterectomies have a lower bone density than women who don't. However, I am extremely skeptical that it is the hysterectomy that causes it. You have to remember WHY younger women (who don't have their ovaries removed) get hysterectomies: chronic pain (decreased physical activity), chronic dysfunctional bleeding (low estrogens for years preceding the surgery), endometriosis (received medications to suppress the ovaries), etc. None of the studies matched on weight at the time of the surgery or smoking at the time of the surgery, only years later postmenopausally.

Finally, it makes no physiologic sense other than two things: having a hysterectomy puts you at bed rest and decreased activity for about 6 weeks and not quite normal physical activity during the next 6 months; secondly there is some question that surgery (of any type) around the perimenopausal time may stimulate an earlier menopause by one or two years. The bone loss from those two factors could explain the small differences found in the study.

Can menopause happen during hysterectomy?

I was reading the message board one day and a comment was made a person could have started menopause during the hysterectomy. How would one know if this happened?

If the ovaries are removed at the time of hysterectomy, a woman ALWAYS goes thru menopause. This is the cause of menopause, ovarian failure or removal of the ovaries.

In a woman who is NOT having the ovaries removed at the time of hysterectomy, let's say age 35, you would not normally expect her to have symptoms of menopause after the surgery. The exception would be because:

1. she had naturally become menopausal, i.e., the ovaries stopped functioning on their own either shortly before or shortly after surgery.
2. Sometimes is a ovary has only a small number or eggs (follicles) left, i.e., it is on its "last legs", the stress of surgery can actually cause menopause a few months to perhaps a few years (just a guess, not scientific) earlier than it would normally have occurred.

I was very warm off and on after surgery while in the hospital and had 1 or 2 night sweats, woke up soaking wet. I caught bronchitis while at the hospital so it could have also been fever, I don't know. My doctor said they injected me with alot of hormones at the hospital and I started the estrogen pills three days after the surgery so time will tell.

Either your doctor removed your ovaries at the time of the surgery (surgical menopause) or they thought you had already undergone menopause at an earlier time and now they are just replacing the estrogen by mouth that your ovaries were once making.

Weight gain after hysterectomy

I had my hysterectomy last month and all went well during the surgery. My doctor said the one fibroid was so large it was like delivering the head of a baby. I also had my ovaries removed. Now at home, recovery is a piece of cake with no real pain to speak of. I am trying to walk to build strength. The part that amazes me is how tired you get!

I read about gaining weight with hysterectomy. I sure hope not. At 43 I have been struggling already! I am taking Premarin. The doctor said most side effects are caused by the hormone progesterone. Please let me know about the weight gain and taking hormones.

Unfortunately, weight gain takes place after hysterectomy just like it does after most elective, uncomplicated surgeries that don't involve the bowel. During recovery, which averages 6 weeks but really isn't normal until 6 months, most people expend much less calories than when they are not recovering from surgery. With the exception of the first week in which they may lose weight, there is a net weight gain tendency since most people eat at the same rate they were used to before surgery. If you are expending only 350 calories a day less than you were before surgery, you will put on a pound every 10 days -- permanent weight. If this keeps up for 90 days (because you are being careful not to strain much) that is almost 10 lbs.

Hormones can play a small role. Estrogen by mouth can cause salt retention which in turn causes fluid retention and thus weight gain. It shouldn't be more than 3 lbs., however. Progestins can stimulate appetite but after a hysterectomy most women don't need to take progestin after the uterus is gone.

How to get weight off after hysterectomy

In response to the other woman's dilemma about weight gain after hysterectomy, I too had a hysterectomy 2 years ago at age 40. I had large fibroids, soaking periods, was anemic, cold all the time, and incontinent from the pressure on my bladder. My uterus was also prolapsed. I was not menopausal and I have my ovaries which are functioning normally.

I too, have gained 20 pounds since surgery. I exercise, eat light, and do strength training and have not been able to lose this weight. I've had my hormone levels checked including thyroid function; every thing is normal. Is weight gain normal after hysterectomy even with the ovaries left intact?

Yes. Many women put on weight even though the ovaries are left intact. Most lose the weight, some do not. Just as after pregnancy some women don't lose what they gained. There's no known metabolic reason I know of other than the decreased activity that follows surgery for several months.

Has our metabolism permanently slowed down?

I don't think so but activity, calorie expenditure is usually decreased.

Is this normal and what can we do about it?

There has to be permanent change in eating habits (less calorie intake) or increased exercise levels or both. I wish I knew a secret to do this!

How much dieting and exercising will bring about weight loss?

Each pound of fat permanently lost is 3500-4000 cal. Daily fluid shifts can be several pounds one way or the other. So you MAY have to be over 20000 calories in deficit to see a change on the scale. That gets discouraging for many and the exercise is skipped or the calories don't get as restricted as much as they were. If you can decrease calories by 300 per day (no snacks or splurges allowed) and increase activity by 200 calories per day, You should not only quit gaining weight, but also lose weight. Remember this is permanent change and you may only lose about a pound or 2 a MONTH!

I ride my bike nearly 12 miles 6 days/week and walk 6 miles 6 days/week. Is there something else we can do?

That sounds like alot. Sometimes when you start a very vigorous exercise program there is some weight gain due to increased muscle mass. It negates calorie restriction and takes awhile before there is a net, continuous weight loss. Exercise also stimulates appetite so you need to be careful. If you keep it up and eliminate the even occasional calorie splurges, YOU WILL LOSE WEIGHT.

Thank you, for your quick response! I have hope that I can lose weight (I have lost a pound since last week!) even if it takes a while. By the way, should I eliminate the strength training just for the summer? All it does is give me bigger muscles (my shirt sleeves are tight and I've had to buy larger dress sizes), and greatly increase my appetite.

Yes, if weight loss is your primary goal. If muscle fitness or strength is the goal, no. Remember, keep up the aerobics for the calorie expenditure.

Also, should I be worried about my weight? I am 5'4" and weigh 162 lbs and am in very good health. I always weighed 142 lbs since college until 2 years ago. My doctor isn't worried; she says I have good muscle mass.

Ideal body weight formula for women is 100 + (4x(height_in_inches minus 60)). For you that is 100 + (4 x (64 - 60)) = 116. Very few women or men weigh their ideal weight so there is a range around that that is "normal". Your body mass index is 27 (average is 25). If you were at mass of 28, that would warrant medical concern. Basically, the tables say you are overweight (weight of 140 would get you out of that category) but not obese and not at medical risk for weight related diseases. That's probably why your doctor was not concerned.

But I feel fat mostly in my stomach area since the hysterectomy. Thanks again for your help.

This is common after hysterectomy. Be sure to include abdominal muscle exercises in your program.

Weight edging up 8 months after hysterectomy

I had a hysterectomy 8 months ago. Previously I was very slim and fit, though I always watched my weight. I have found in the last few months that my weight has increased by around 16-20 pounds. Although I have returned to the gym and work out regularly and am following a low fat diet, the weight seems to be edging up rather than down. I cannot accept this is a permanent situation. Any suggestions as to whether progesterone cream, kelp or any other supplement may help?

Did you have the ovaries removed at the time of the hysterectomy? Did you just become menopausal naturally around the time of the surgery?

I didn't have my ovaries removed, I was 39 at the time of surgery and not menopausal. Is there any hope for me losing this weight over a period of time - especially if I continue a healthy eating and fitness regimen?

Yes. The only way to lose weight is over a period of time is by establishing permanent eating habits that result in less calories in than out. Most women actually have eating habits that would result in weight loss if it weren't for the once-in-a-while splurges. For example, if you have an extra 700 calories a week over what you expend, you will gain a pound every 6 weeks (at about 4000 cal/lb) or about 9 lbs a year. As you know, many people have at least one 700 calorie splurge weekly. I'm not familiar that progesterone cream or kelp will actually help with weight loss.

One of the best pieces of advice I ever heard was by a physician who was a diabetic himself. He said the ideal diet was to calculate approximately how many calories you consume on an average, daily basis and eat 100 calories less than that for the rest of your life. (I wish I had the discipline to do this myself.)

Does natural menopause cause any weight gain?

Can menopause itself, not hysterectomy or removal of ovaries, cause any weight gain.

I must admit, I thought menopause itself would explain some of the weight gain that women experience. Apparently it doesn't. See the abstract from the Framingham study that follows.

*****

Hjortland MC, McNamara PM, Kannel WB
Some atherogenic concomitants of menopause: The Framingham Study.
Am J Epidemiol 1976 Mar;103(3):304-311

Longitudinal assessment of the effect of change in menopausal status on seven biologic concomitants was made in 40- to 51-year- old women from the cohort of 1686 women premenopausal at the initial Framingham examination and subsequently followed for nine biennial examinations. Within this age range, women of any specific age undergoing natural menopause were leaner at the exam prior to menopause than their controls; while women undergoing surgical menopause with bilateral oophorectomy were heavier. Hemoglobin levels rose after menopause. There was a rise in serum cholesterol levels between the premenopausal and menopausal examinations in natural menopause and in surgical menopause with bilateral oophorectomy. This rise was not seen in surgical menopause without bilateral oophorectomy. No significant changes in weight, blood pressure, blood glucose or vital capacity were found to accompany the menopause.

Is orgasm gone after hysterectomy?

The Board Certified gynecologist that I went to says a hysterectomy is the answer. I have all my children and I am 39 years old. I would love not to have anymore pain and constant bleeding but I keep hearing about total hysterectomies causing orgasm problems and decreased desire. Also, bladder problems and they call it being castrated. I am scared and don't know what is true! I have a wonderful sex life now when I am not in pain which is about 2 weeks out of every month! I also have powerful and fulfilling orgasms and I am scared that this will change after hearing and reading about Hysterectomies. Please help me as I am really scared. Some say, you will be so glad you did it and others say, DON'T DO IT NO MATTER WHAT! What is the truth??

There is no truth and no answer that applies to all situations. For every woman it is a trade-off of symptoms (i.e., pain in your case) versus possible change in orgasmic response.

The physiology of female orgasm is comprised of two events basically: release of blood vessel engorgement (which accumulated during arousal phase) and uterine, vaginal and some say, clitoral contractions. After hysterectomy there are no more uterine contractions with orgasm. There are still vaginal and possibly clitoral contractions. Some women perceive all of these while many only perceive some, it varies. As far as the vascular response there probably are less blood vessels to get engorged over time because they are not having to supply the uterus any more.

The most common thing physicians hear from women concerning orgasm after hysterectomy is that it is different but still present and pleasurable. There are some women, however, who say that orgasm is gone. I suspect those women were very sensitive to the uterine contractions part of orgasm. Other women will also admit to problems with sex but it is really because of decreased libido (desire) or decreased arousal.

Removal of the ovaries can affect decreased desire but if estrogen is replaced and sometimes testosterone, that can account for most but, not all of the decrease.

Everything you hear is correct but the proportion is not equal, at least from a physician's view. The majority (let's say 75-85%) of women having a hysterectomy have a substantial net improvement in their daily lives. The rest don't and some feel worse off than before.

Does PMS go away with hysterectomy and ovary removal?

I was scheduled for a hysterectomy when I found out that the doctor I had doing it was not respected in the field. I have a new doctor that is doing a vaginal hysterectomy on Monday and I have only one ovary left in me now. I am curious how, if you keep your ovary does PMS go away? My PMS is directly associated with ovulation for me and it is severe. I am high risk for ovarian cancer but at this point I only have cysts once in a while on my remaining ovary. The doctor is leaving the decision to me as to whether I leave it or not (as long as it looks healthy when she gets in there) I am very confused and don't know what to do! I do not want PMS any longer and I am 40 years old. I worry constantly about ovarian cancer but I also don't want to do the wrong thing. Can you tell me how PMS and leaving the ovary correlate if they do at all?? Pro's and con's please. I only have a few days left and I just have to make a decision/I hear so many different things that I am just so confused.

Although the symptoms of PMS are closely associated with the luteal (last half) of the menstrual cycle, most studies have not shown any consistent differences in levels of estrogen or progesterone between women with PMS and those without. It has been demonstrated, however, that permanent reduction of estrogen and progesterone with oophorectomy (removing ovaries) results in reduction of PMS symptoms even if estrogens are given back as hormone replacement after the surgery. See the two abstracts that follow.

If indeed you are at high risk for ovarian cancer, e.g. family history, bilateral oophorectomy substantially reduces but does not eliminate the risk of ovarian cancer. However, following their removal, your risk of heart disease, osteoporosis (bone thinning), pelvic floor relaxation problems, atrophic vaginitis (to name only a few) is substantially increased over your lifetime IF you are not committed to hormone replacement therapy (HRT). The problem is that most women, 10 years after surgery or menopause, are not taking their HRT. So if you do decide to proceed with removal of your remaining ovary because of your severe PMS and your high ovarian cancer risk, please remember to take your estrogen!

*****

Am J Obstet Gynecol 1990 Jan;162(1):105-109
The effect of hysterectomy and bilateral oophorectomy in women with severe premenstrual syndrome.
Casper RF, Hearn MT
Department of Obstetrics and Gynecology, University of Western Ontario, Toronto, Canada.

The etiology of premenstrual syndrome is unknown, although this syndrome is linked to the menstrual cycle. Fourteen women with severe, debilitating premenstrual syndrome volunteered for a study of therapy by hysterectomy, oophorectomy, and continuous estrogen replacement. All had completed their families and had failed to benefit from previous medical treatment. The diagnosis and severity of premenstrual syndrome were assessed by means of prospective charting and psychological evaluation. All patients had clearly cyclic symptoms and psychological scores consistent with a major disruption of their lives before surgery. Six months after surgery, premenstrual syndrome symptom charting revealed complete disappearance of a cyclic pattern with scores equivalent to those of a normal population. Psychological measures 6 months after operation showed dramatic improvement in mood, general affect, well-being, life satisfaction, and overall quality of life. Surgical therapy, involving oophorectomy, hysterectomy, and continuous estrogen replacement, is effective in relieving the symptoms of premenstrual syndrome and is indicated for a small, selected group of women.

*****

Am J Obstet Gynecol 1990 Jan;162(1):99-105
Lasting response to ovariectomy in severe intractable premenstrual syndrome.
Casson P, Hahn PM, Van Vugt DA, Reid RL
Department of Obstetrics and Gynaecology, Queen's University, Kingston, Ontario, Canada.

A total of 14 women with severe premenstrual syndrome unresponsive to conservative medical therapy were treated with danazol in doses sufficient to suppress cyclic ovarian steroidogenesis. In each case medical ovarian suppression resulted in complete relief from symptoms. For ongoing symptom relief, each woman elected to undergo bilateral ovariectomy and concomitant hysterectomy. Both medical ovarian suppression and ovariectomy with low-dose conjugated estrogen therapy afforded lasting relief from cyclic symptoms of premenstrual syndrome and a corresponding improvement in overall quality of life. We conclude that cyclic ovarian steroidogenesis is a powerful determinant for the expression of premenstrual symptomatology.

Ovariectomy with low-dose estrogen replacement is an effective alternative for the woman with debilitating premenstrual syndrome who does not respond to conventional interventions.

Does PMS go away after just hysterectomy alone?

I am 26 and I am considering a hysterectomy. I have very bad periods and major mood swings to the point of being so depressed I don't want to see or talk to anyone. I have a lot of pain 2 weeks before and during. I also gain about 5 pounds.I have had my children and I don't see a need for the plumbing if it is giving me problems. Is this a good idea for me or should I wait till I'm older?

It sounds as if you are considering a hysterectomy basically because of severe PMS symptoms. It is possible, however, that there are other causes of your symptoms such as menstrual cramps due to endometriosis or adenomyosis, or chronic pelvic pain due to varicosities, etc. I guess the first question I would ask is whether you have had a diagnostic laparoscopy to look at the pelvis and have you had any hormone therapy to suppress ovulation and menses? These things should be done before considering hysterectomy. Secondly, if you think the main problem is PMS, has your doctor had you fill out a prospective symptom calendar to confirm that the mood changes are not present more than the two weeks premenstrual? If we had an interactive, internet educational consultation we could better pin down whether hysterectomy is the next step for you. It really is essential to know exactly what we are treating in order to fully understand the risks and benefits of the treatment.

Let us assume for the sake of this writing that the diagnosis of PMS, and only that, has been confirmed. The question then becomes as to how successful hysterectomy is in curing PMS symptoms. Also, because you are still quite young, removal of the ovaries would be very undesirable, so the question is refined to "would hysterectomy without ovary removal cure the fluid retention, mood swings, depression, and 2 weeks of pelvic pain that follow ovulation of the egg from the ovaries?"

Women who fail lifestyle changes and medical therapy for PMS often inquire about hysterectomy for PMS. They are cautioned that if the ovaries, which cause the cyclical hormonal changes, are not removed, it is very possible that the symptoms will not go away. Some women continue to have PMS symptoms even after hysterectomy; on the other hand many women having hysterectomy note that their PMS symptoms disappear.

In some of the few studies which have evaluated hysterectomy in PMS patients, the accuracy of the PMS diagnosis suffers from a lack of prospective calendar symptom charting. Nevertheless, hysterectomy without ovary removal seems to cure about 75% of women who have PMS (1). With well documented, refractory-to-medical-therapy PMS, removal of the ovaries along with the uterus cures close to 100% of women (2).

In other studies that look at PMS symptoms in those women who have had a hysterectomy without removing the ovaries, there seems to be a question of whether there is not some other diagnosis than PMS which is causing the symptoms.

In one study of 36 women (3) who felt they still had PMS after a hysterectomy in which the ovaries were not removed, prospective symptom charting along with hormonal assessment to detect ovulation found that:

• 25% had no PMS
• 61% had sporadic symptoms not occurring each cycle
• 14% had true PMS

This probably reflects the lack of consistent criteria to diagnose PMS but it also indicates that many times, hysterectomy without ovary removal is curative of PMS. The bottom line is that about 25% of the time, a woman will undergo hysterectomy for what she thinks is PMS but symptoms of some sort will still persist; 75% of the time she will feel better. As long as you understand this, you can make some choices. In general, I would suggest making sure of the accuracy of the diagnosis for which you are considering surgical therapy.

PMS disease profile

Hysterectomy for prolapse - vaginal or abdominal?

My doctor says I need a vaginal hysterectomy for prolapse of the uterus. I've heard that this type of surgery has better success if done abdominally. Also, is other surgery needed at the time?

Exactly which components of surgery are needed in addition to the hysterectomy depend upon how bad the prolapse is and what other associated support defects are present on pelvic exam. It is extremely uncommon today to do JUST a hysterectomy for uterine prolapse. Most of the time there are additional procedures such as culdoplasty (support of the vagina at the end and obliteration of a possible bowel hernia space), paravaginal repair (unilateral or bilateral) to reduce bladder dropping), retropubic urethropexy to support the neck of the bladder so there is no induced stress incontinence of urine from repairing the other defects and occasionally posterior colporraphy (rectocele repair) if there is a weakness along the line of old episiotomies or obstetric tears from past deliveries.

These procedures may be done with an abdominal incision or only a vaginal incision depending upon the surgeon's preference and training and skills. Recently there is some evidence that abdominal approaches may last longer but then again there are many experienced vaginal surgeons that do just as well long-term with a vaginal approach.