Hysterectomy: Post-operative Problems and Concerns
Are Pap smears needed after hysterectomy?
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
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.
Sounds ok. Keep off the lifting.
Does hysterectomy without ovary removal cause bone loss?
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.
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?
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:
- she had naturally become menopausal, i.e., the ovaries
stopped functioning on their own either shortly before or shortly
after surgery.
- 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.
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
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
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.
I don't think so but activity, calorie expenditure is usually decreased.
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!
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!
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.
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.
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.
This is common after hysterectomy. Be sure to include abdominal
muscle exercises in your program.
Weight edging up 8 months after hysterectomy
Did you have the ovaries removed at the time of the hysterectomy?
Did you just become menopausal naturally around the time of the
surgery?
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?
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?
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?
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?
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?
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.
