Common Hysterectomy Questions Answered
While on a birthday trip to Bermuda, Rolonda Wright wasn’t feeling well. VERY not well. Constipation turned to abdominal pain bad enough to send her to the ER for 15 hours.
On her return — after a vacation that wasn’t at all what she’d hoped for — she went to her great OB/GYN for tests and discovered she had a uterine fibroid “the size of a four-and-a-half-month pregnancy” or, as Gennev CMO Dr. Rebecca Dunsmoor-Su translated: about a personal-sized watermelon.
Sitting up high, it was actually visible as a bump when Wright was lying down.
“That’s not at all uncommon,” says Dr. Dunsmoor-Su. “So many women come to me with large fibroids thinking they’ve been eating too much bread. It’s not bread! It’s a big ball of muscle.”
“I thought I had to do more sit ups to get that ab down! A doctor a few years ago suggested a hysterectomy for my fibroids, but I didn’t really have any problems: no pain, no problems with sex,” Wright says. She had heavy periods, but the heavy flow only lasted for a day. “One day I couldn’t leave the house or it would have been a disaster, but the next day it was fine.”
The problem, she says, wasn’t so much the fibroid. It was how little information she had. She came to Gennev to share her journey with us and our readers so that other women would be better informed. You can follow her journey on Facebook, Instagram, TikTok at Rogirll01, or her website.
When you know more, you can act faster, she says. She might have had the fibroid removed when it was much smaller and required less invasive surgery. She might have had a hysterectomy years ago and had a much better time in Bermuda.
Dr. Rebecca Dunsmoor-Su Answers Hysterectomy Questions
Hysterectomy is a big deal, and no one should make the decision to have one without all the information they need and want. So before Wright went in for hers, she came to ask to the questions that should have been answered long ago.
What follows is a very important conversation between Rolonda Wright and OB/GYN and menopause specialist Dr. Rebecca Dunsmoor-Su. Rolonda Wright’s questions are in italics.
How do I prepare for this, both mentally and physically? This housed my child, so it is a little bittersweet. I’m good with it, I’m ready for it, but it’s also a subtle loss.
“It’s a transition,” says Dr. Dunsmoor-Su. “This marks a new stage in your life, and while that’s a good thing, it’s also a loss. You can be happy and sad at the same time.
“I’m glad you’re doing this and sharing this because women put up with a lot: we endure the pain, the bleeding, the discomfort for such a long time. Partly this may be because it increases slowly and gradually over time. If we went from a normal period to a super heavy period in one month, we’d see a doctor. But because it happens incrementally, we feel like it’s a normal part of aging. So I’m glad you’re bringing this to women’s attention.”
That’s part of the reason I came to you. I’m not even sure what questions I should be asking right now. What do I need to know?
“First, there are multiple kinds of hysterectomy. As physicians, we tend to define it by route of hysterectomy: both by how are we going to do the procedure, and also by what we're taking and what we're leaving behind, like ovaries or cervix.
“Fibroids are balls of uterine muscle that grow in the wall of the uterus. They can grow very large. And they are progressive, as they’re estrogen-stimulated. So as long as there's estrogen in the system, they will continue to grow. We tend to see particularly quick growth through perimenopause when women get these really high spikes of estrogen. So a lot of women end up sort of in that perimenopausal stage, coming in to see us because suddenly this thing has grown quickly.”
Why do Black women have more fibroids than white women?
“Unfortunately, this is one of those things we don’t understand. Black and Asian women tend to have more fibroids; there are thoughts about vitamin D lack and other things, but the research just isn’t sufficient to draw conclusions.
“Not only do Black women have more fibroids, they’re more frequently undiagnosed or misdiagnosed and improperly treated because of systemic racism and sexism in medicine. And because Black women are used to being treated poorly by medical professionals, they may not seek treatment as early. Which is so unfortunate, because the sooner fibroids are caught, the more easily they can be treated.”
I’m a few days prior to surgery. What do I need to be thinking about now?
“In the days prior, you should know how your surgeon is going to do the surgery. It matters because different surgeries have different recovery periods. So if you don’t know, be sure to ask. Also, how are you going to recover? How active can you be, and how quickly? Who's going to help you out at home, especially in the first couple of days?
“This is even more important now, in the time of COVID, because you need to take extra precautions. Anyone you come in contact with needs to be wearing a mask and washing their hands frequently, and so do you. If they can be tested for COVID and minimize contact with others, that’s best.”
So why have a complete hysterectomy?
“We do hysterectomies because the surgery is much simpler, and generally the women we see are done having children. It’s possible to preserve the uterus for women who are still planning to bear children, but it is a much more complicated, much more difficult, and much higher blood-loss surgery than just removing the whole uterus. Also, you never have just one fibroid. We usually can see one, but there's always other fibroids in the wall.
“Additionally, fibroids will continue to grow. So we could do the surgery, take the fibroids out, and in two years you could be right back where you are now. If there’s a need to keep the uterus, then we would do the myomectomy, which is the removal fibroid surgery. But if you’re done having children, the hysterectomy is quicker, safer, and has an easier recovery.”
Should I keep my ovaries and fallopian tubes?
“In most women who are having surgery for fibroids, we don't remove the ovaries, because there's no reason to put someone into sudden menopause when really the only problem is the fibroids. We usually take the tubes now because there's some question about whether they contribute to ovarian cancer rates. However, we usually leave at least one or both ovaries because then you drift into a gradual menopause. Your ovaries also have some roles after menopause in terms of making precursor hormones and testosterone. Those are good, so we want to preserve that function if we can.”
Why do some women elect to have their ovaries removed?
“It's always a balance of risk/benefit ratio. When I counsel patients, I ask, ‘Do you have a high risk in your family of ovarian cancer or familial breast cancer?’ Familiar ovarian cancer history could mean you're at higher risk for ovarian cancer, so we might want to consider removing the ovaries.
“Also, if you personally had breast cancer, removing the ovaries can mean reducing the stimulation of the breast tissue with estrogen which can help prevent recurrence.
“But in most women who are just having surgery for something like a fibroid or heavy bleeding, and whose ovaries are not at particularly high risk, there’s a greater benefit to leaving them. Ovarian cancer doesn't happen very often, especially in women with few risk factors. Whereas cardiovascular disease and bone fractures and all those things that come with menopause do happen quite often. And so drifting into a more gentle menopause at a later age is just more beneficial for women.”
What are the different methods of hysterectomy, and how do surgeons and women decide which route to take?
“It really depends on the reason for the hysterectomy and what your provider has been trained to use. It's amazing what we can do without opening your abdomen anymore. Now that we have all these techniques and tricks. Some can be done vaginally, which means we go in through the vagina, grab it, snip it loose and pull it out. In those cases, women don't even have an incision. And that works when the uterus is small, with no large fibroids. But when you have a larger uterus with large fibroids, we use the laparoscopic camera or the robot, depending on training. We make a couple of centimeter-long holes in your abdomen, and we can get that larger uterus out that way. We disconnect the organ with all the fibroids still in it, put it all into a bag to keep it contained, use a device to turn it into one long strip, then pull it all out. The bag is a precaution because rarely the fibroid can contain cancerous cells that we don’t want spreading throughout the body.
“The beauty of this is that the pain of surgery is generally from the incisions. When incisions can be kept really small, or when you don’t have to make them at all, the pain is much less and the recovery is faster. There will likely be a dull aching in the low pelvis, but women won’t have to struggle to recover nearly as much as previous generations.”
How is the uterus anchored inside the body?
“Generally speaking, it is anchored where the uterus and the cervix meet. If you think of the uterus as a fist, the cervix would be the wrist that hangs out into the vagina. It's anchored at the connections or the point where the uterus and cervix are joined by two ligaments that go back to your sacrum or tailbone. There are tubes that come off the top of the uterus and sit around the ovaries, but they're not really connected to the ovaries. There is a little vascular connection between the ovary and the uterus, and that's pretty simple to disconnect. And then it's mostly blood vessels.
“At the bottom of the uterus, we take the cervix and close the top of the vagina. Taking the cervix removes cervical cancer concerns, and there’s really no reason to leave it behind. It doesn’t had to do with sexual pleasure, nor does it provide support for the vagina, as was once thought.”
Will I feel any different without a uterus?
“Because your fibroid is quite large, you may feel the lack of the fibroid, but that’s a good thing! You’ll probably feel a bit thinner and less heavy, you’ll have less constipation, possibly less urinary urgency without that big thing putting pressure on your bladder or making constrictions. In terms of sexual pleasure, there shouldn’t be any difference. The center of women’s sexual pleasure is the clitoris, and we don’t remove that – it’s very important! If your ovaries are not removed, you won’t have a difference in hormones.”
What should I look out for? Are there concerns after the surgery?
“Of course, every surgery carries risks, so let’s talk about them. There are three main things that I counsel about in terms of risks of any surgery and specifically a hysterectomy risk.”
“Number one is bleeding. Because of the fibroid, you have a big uterus; it's got big blood vessels to feed it. So we have to tie those off properly. We’re performing the surgery under visualization, so we can see that nothing's bleeding, but it's not impossible for a blood vessel to be in spasm and not bleeding and then open up later. So if you suddenly feel dizzy or lightheaded or have severe abdominal pain, those are signs of internal bleeding.
“Number two is infection. We give antibiotics before surgery, and it's not a big infection risk, but obviously high fevers, chills, and severe abdominal pain can be a sign of infection.
“The last one's a little more vague. It's damage to structures around the uterus. There's bowel all around the uterus, and the bladder in front. Ureters are tubes that carry urine from the kidneys to the bladder, and they go down the side of the uterus and up and over it to get to the bladder. Experienced surgeons will identify them and make sure they're out of the way and check them at the end, but rarely an unrecognized injury can happen.
“The most common unrecognized injury is actually to the ureter, that tube between the kidney and the bladder. As we're coming down the side of the uterus to seal off the blood vessels, we're usually using cautery because it seals the edge of the blood vessel and then we can divide it.
“If the cautery is just a little bit too close to the ureter, even if it wasn't cut, it could have some localized thermal damage and that can show up a week or two later. That usually ends up presenting as severe abdominal pain, sometimes flank pain. That’s something to look out for as well.
“Again, all of these complications are very rare, but they can happen even to the best surgeon. If there were complications during surgery, your surgeon will let you know about it and tell you what to be on the alert for, but by and large, this is a low-risk surgery.”
What will happen as a result of the surgery? Am I going to gain weight or lose my hair?
“I tell women who are near to the menopause that for about six weeks after a hysterectomy, you may have an upswing in hot flashes. A lot of that's just inflammation and healing; after all, the ovaries took a little hit! But it usually settles out, and you should drift into a natural menopause like you were before the hysterectomy.
“The best way to minimize problems in recovery is to go in healthy and really well nourished. Make sure you've got all the nutrients you need for your body to undertake this big healing process. I am not personally a huge supplement taker. I tend to eat a very balanced diet and that's generally enough, but before my own surgery, I took Gennev’s Vitality product, which is a daily supplement. I used it for the months surrounding my surgery. I knew that I would be barreling through all these nutrients as my body's trying to heal, so I wanted to do everything I could to help my body do that. Vitality is a very focused supplement for women age 40 and above, and it has the things we need more of like vitamin B and vitamin D and so on.
“Before surgery, I talk to my patients about their health goals, their history, and their risks because all of those should inform their surgery.
“Even though you may not go into menopause because of your surgery, you're eventually going to go into menopause. How do you want to handle that? What are your fears about this process of menopausal transition? And, you know, what's most important to you to preserve?
“You know, some women say my biggest fear is weight gain, in which case I say, well, there are a couple of really important things you need to keep in mind: One, you lose muscle mass as you go into menopause. So adding more weight training to your regimen rather than more cardio can help you maintain weight. Two, you need fewer calories as you get older.
“Is fear based around sexual function? In that case, I tell them there are important things they need to do during menopause. One is make sure your relationship and your stressors are under control because probably the most key things in any woman's libido are stress and relationship stress. Number two, make sure vaginal tissues and happy and healthy and take pleasure from intercourse. We can do that by treating vaginal tissues with local estrogen or other moisturizers and using a really good lubricant. Do it right away, because once you start to experience pain down there, you may start to fear sex and it will drive your libido down.
“For some women, fear centers more around longevity in terms of cardiovascular health and bone health. Maybe they have a strong family history of osteoporosis or heart attacks. Then we talk about hormone replacement. Certainly if someone's having significant symptoms around menopause, like significant hot flashes, significant sleep disturbances, HRT can really help them transition comfortably and safely.
“For many or most women, we experience menopause in our fifties, when we're not done at work. We are at the height of our careers. We can't really afford to be having seven hot flashes a day and not sleeping at night. So we take hormone replacement through our fifties and into our sixties and come off it when we retire. I have patients who use hormone replacement for two years. I have patients who use hormone replacement for 10 years. I have patients who use hormone replacement until they die because they love it and it makes them feel good. And all of those are appropriate responses to menopause.”
Rolonda Wright is sharing her journey with us so other women will have an easier — and certainly more informed — journey of their own. While we’re comfortable talking about all kinds of personal things (ask any runner about their digestive system, for example), hysterectomies have long been considered embarrassing and shameful. And that does not help women be healthier.
Our thanks to Rolonda for sharing her experience, asking questions so many women share but are too afraid to ask or have no one to ask. If any of her experience sounds familiar to you, we encourage you to talk to your doctor or ours to learn more. Don’t wait, don’t suffer, don’t be embarrassed. Be healthier and happier instead!
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