Post-Hysterectomy: What To Expect After Your Surgery
What to Expect after Hysterectomy
Frederick R. Jelovsek MD, MS
"Since my hysterectomy 4 1/2 months ago, I experience bleeding after intercourse. Is this normal? It is a small amount of fresh blood, bright red. Is it possible that I have not healed internally yet? "
I am age 45. My menstrual history was normal and the hysterectomy was performed because of a large rapidly growing fibroid tumor." S. B.
Complications can occur after hysterectomy ranging from minor problems such as urinary tract infections or vaginal spotting to major health concerns such as wound infections that take 3-4 months to heal or persistent severe pain with sexual intercourse. It is difficult for you to know exactly what to expect since most female friends who have had a hysterectomy tend to forget the minor difficulties, and sometimes they may expand out of proportion, any major problems they have had.
Doctors almost never inform women of all the changes they will feel during recovery from major surgery because there are too many possible changes. Most changes and symptoms go away on their own. The surgeons also do not cover all of the unusual or rare but recognized complications of hysterectomy. If you are a person who develops those problems, they will be totally unexpected and you will think the surgeon "bungled" the operation because something happened that you had never heard of before.
Finally, other procedures such as removing the ovaries or having cystocele, rectocele, or urinary support surgery can have their own unique sets of complications and symptom effects. For example, support surgery with several incision lines from the vaginal opening to the end of the vagina is much more likely to result in painful intercourse than would a plain hysterectomy. Post operative, decreased sexual libido is a much greater magnitude when the ovaries are removed than when surgical menopause does not take place at the surgery. Then there is another variation in intensity of libido level when estrogen replacement is adequate versus being too low or none at all. This article will focus only on the hysterectomy side effects and complications and not on the interplay of adding other procedures.
Is vaginal bleeding after a hysterectomy common and how long should it last?
Normal post operative bleeding lasts from several days to several weeks after surgery. After the first couple of days the bleeding turns into spotting, usually dark red but sometimes bright red. Then in most instances, the bleeding stops for good. Sometimes there may be a burst of bleeding at about 2-3 weeks if there was a collection of blood clot in the pelvis from right after the surgery. And occasionally at about 2 - 8 weeks after surgery, there may be some bright red vaginal spotting due to suture dissolving. The timing depends upon the type of suture used and how fast it dissolves. This may be spontaneous bright red spotting (it is rarely ever heavy) or it may happen after intercourse or physical activity.
That is the normal course of usual postoperative vaginal bleeding. Sometimes, however, bleeding can occur at other times or even much later (up to years). Causes include:
- granulation tissue (healing tissue growing on its own)
- prolapse of a faloppian tube (1)
- endometriosis of the end of the vagina (2)
- atrophic vaginitis due to low estrogen levels and traumatic irritation
- a cancerous growth at end of the vagina (3)
In the situation you describe of bleeding at 4.5 months, you will need to have a vaginal speculum exam to look at the end of the vagina. Most likely you have some granulation tissue at the end of the vagina. On appearance it would look like a dark red, beefy friable polypoid growth at the end of the vagina. It bleeds easily with touching. The treatment is to biopsy it away and use vaginal sulfa or other antibiotic cream. There usually are no pain fibers at all. If it hurts at all during biopsy, it may represent a prolapsed tube if only a hysterectomy was performed without removing the tubes and ovaries. A prolapsed tube more often causes pain rather than bleeding and it may need to be removed under anesthesia rather than in the office.
This bleeding is not a serious problem but be sure to see your doctor.
What are common symptoms I may notice during the recovery after a hysterectomy?
Several hysterectomy support sites have lists of what to expect after hysterectomy but they may represent a mixture of hysterectomy effects as well as symptoms from having the ovaries removed. The biggest complaint most women have is fatigue. This persists for 2 or 3 months post op. It seems to last longer when the return to activity is slower. In other words it pays to become more active sooner after surgery.
Other immediate (within two weeks) post op symptoms may include:
- urinary tract frequency and urgency
- requires being checked for possible urinary tract infection although there may just be bladder spasms due to catheter irritation or small pelvic collections of blood near the bladder.
- incisional problems
- discharge or weeping of the incision in the first week or two
- itching or burning of the incision at 3-6 weeks
- pain that is localized to one side of the incision or another
- swelling underneath or to the side of the incision but different than the rest of the incision
- abdominal wall laxness, pot belly, bloated appearance
- gastrointestinal problems
- increased "gassiness" immediately after surgery (treatable with simethicone tablets or liquid)
- constipation treatable with stool softeners, flax seed
- loose stools (especially if antibiotics were given)
- vaginal problems
- bloody or odorous discharge for 1st 1-4 weeks
- odor without much discharge (may require topical vaginal antibiotic cream if persists beyond a week)
- vulvar burning or itching (usually just due to dryness and not a yeast infection)
- mood changes
- reversion to moods previously ignored due to hecticness of every day life
- decreased libido
- increased feelings of stress and anxiety
- increased depressive symptoms
(Note - any 6 week period of significantly altered daily activity like postoperative recovery can lead to a change in mood for better or worse. It is not very predictable.)
- pain and swelling or redness at the site of the intravenous needles
- pelvic cramps and catches somewhat sporadic in occurrence or related to increased physical activity
- general problems
- generalized allergic rash or itching to medications such as antibiotics or pain medicines
Remember that most women will say it takes up to 6 months after surgery before they do not think on a daily basis about having had surgery.
Are there dangerous symptoms that I need to watch for after surgery for hysterectomy?
Most of the severe complications of surgery will show themselves within the first 2-3 weeks after the operation although sometimes these can manifest even later.
- re operation - complications requiring repeat surgery to repair them (2%)
- Vascular thrombosis or hemorrhage causing a stroke or heart attack (<1%)
- Intraoperative or delayed post operative intraperitoneal bleeding requiring blood transfusion (5%)
- a pus type of drainage or extensive redness of the incision can indicate wound abscess (3-5%)
- watery, urine-like vaginal discharge may indicate ureteral or bladder injury or fistula (1-2%)
- leg calf or thigh pain and swelling may indicate a blood clot (<3%)
- sharp chest pains and breathing difficulty can indicate a blood clot that has broken off to the lung (<1%) or a pneumonia (<1%) or even a heart condition (<1%).
- pelvic pain with bowel and bladder symptoms may indicate pelvic infection or abscess or a delayed postoperative bleed internally.
- prolonged bowel laziness (illeus) with bloating and absent bowel movements may also indicate pelvic infection or abscess, a delayed postoperative bleed internally, or ureter or bladder injury.
There can also be major complications that show themselves later than 3 or 4 weeks after surgery.
- ovarian abscess (4-60 weeks) (4)
- late pulmonary embolus (up to 6 months after surgery)
- small bowel obstruction (6 mos to 10 years) (5)
- vaginal vault prolapse (within two years if related to surgery) (<1%)(6)
- persistent pain with intercourse due to adhesions or abnormal scar formation at the end of the vagina
What are some of the rare or unusual complications that are possible after hysterectomy?
Many of the complications mentioned above are uncommon. There are some even rarer problems that may occur.
- drug induced blood dyscrasias (anemia, low platelets) (7)
- massive hemorrhage resulting in death
- bowel injury requiring colostomy
- bladder atony and inability to void urine
- liver failure due to anesthetic complications
- chronic incisional pain or drainage due to suture granulomas, endometriosis or foreign body reaction
- abdominal compartment syndrome (decreased blood flow to intraabdominal organs)(8)
- kidney shutdown due to renal artery spasm (9)
- abdominal or vaginal herniation of the bowels (evisceration) through the incisions (10)
- and many other rare and uncommon events
When can I resume different normal activities after surgery to remove the uterus?
Doctors will vary significantly in their recommendations for postoperative activity resumption and there is a noticeable lack of scientific studies performed to assess what the recommendations should be. There are some general principles that should be followed and practical recommendations that follow from them.
Incisions need to heal at least 48 hours before exposing them to water which can carry bacteria in
- avoid shower or bath until 48 hours after surgery (longer if the doctor suspects any pelvic infection or hematoma)
- if skin staples are used, they perforate the skin and leave red marks if water carries in bacteria (avoid getting incision wet until 48 hours after staples are removed)
- avoid baths or pools until 48 hours after any vaginal bleeding or discolored drainage ceases
Hernia formation or disruption of the incision has its groundwork laid in the first two weeks after surgery. Risk factors include increased blood loss at the time of surgery and wound infection
- In the absence of wound infections or risk factors, normal activity may be resumed in two weeks except for those which significantly increase intraabdominal pressure such as impact exercises or recreation.
- Avoid lifting more than 10 lbs with intraabdominal straining for 6 weeks
- Avoid lifting buckets, grocery bags or pushing vacuums in the first two weeks; after that it depends upon how you feel
Worsening of pain, especially incisional, is a sign that activity has been enough and rest should take place until the pain decreases
- After the first 48, hours daily activities should be resumed in short bursts unless there is excessive pain. It is better to rest 40 minutes out of every hour in the first two weeks than to rest several hours in the AM and several in the PM.
- Driving may begin when enough soreness has gone from the incision so that you can turn your head and upper body 90 degrees without "guarding" the abdomen and when you can rapidly slam on the breaks if you had to. With a vaginal hysterectomy, driving may begin in one week
- Going up and down stairs is permissible as long as it is done slowly enough so it does not produce excessive pain. Keeping the up/down trips to 1-2 -per day in the first several days at home might be advisable
- Intravaginal intercourse may significantly increase intraabdominal pressure and should be avoided for at least 4 - 6 weeks in the absence of postoperative pelvic infection
Returning to full preoperative activity still needs easing into even at 6 weeks because anyone placed on restricted activity even without having surgery gets easily fatigued
- Returning to non-lifting work occupations is best done for half days the first week if your employer will allow.
- Returning to strenuous lifting jobs should include the first two weeks at restricted lifting if possible.
- Abdominal exercises may be resumed at 6 weeks but returning to a preoperative exercise or recreation level needs to go more gradually as tolerated.
Women who have vaginal hysterectomies or laparoscopic assisted vaginal hysterectomies recover about 2 weeks faster than women with larger abdominal incisions
- Women with vaginal hysterectomies may return to work in 4 weeks
- Driving may resume in 7-10 days for women after vaginal hysterectomy
- Even with no abdominal incision women should wait at least 4 weeks to resume vaginal intercourse.
- Lifting rules apply equally to women with vaginal hysterectomy as to women with abdominal incisions because they are slightly more prone to vaginal vault prolapse complications.
Please keep in mind, all of the postoperative instructions are guidelines that need to be modified according to the person, the procedure and the post operative problems that may or may not occur. Be sure to check with your physician if these are reasonable instructions for you.