Q: How can I restore arousal after a complete hysterectomy?

You asked. Dr. Barb Answered.The loss of hormones (estrogen and testosterone) with a hysterectomy and bilateral salpigoophorectomy (removal of ovaries) is definitely a “hit” to sexual function for women (I assume based on your message that your ovaries were removed). The genitals are, as we say in medicine, abundant with hormone receptors. In other words, hormones play a big role in the health and functionboth urinary and sexualof the genitals. So now, moving on without those hormones, what to do?

For most women, it’s direct stimulation of the clitoris that leads to experiencing orgasm. In the absence of estrogen, there is less blood supply, and, in turn, loss of sensation and ability to arouse or orgasm.

  • A warming lubricant can stimulate circulation and therefore sensation.
  • If your orgasms are weak, you might use the Intensity regularly on your own to build your pelvic floor muscles, which are what enable us to experience orgasm.
  • Probably the most reliable tool to help in achieving an orgasm will be a vibrator. The genitals need more direct and intense stimulation now, and a vibrator is usually a great solution. There are many great options to consider on the website.

This can also be a time to consider treating the genitals with prescription treatments such as localized estrogen or the non-estrogen options, Osphena or Intrarosa. Using testosterone off-label can help women with arousal and orgasm as well.

I’d encourage a conversation with your healthcare provider to see if there are options that may be helpful for you. 

Good luck! I’m glad to hear that your husband is supportive in addressing this frustration for both of you!

 

 

Sex and Your Hysterectomy: Getting Sexy Back

Recently, we’ve been discussing the reasons to have (or not to have) a hysterectomy and the various surgical options—all very important information to have before you decide to have the procedure.

Now let’s talk about what happens after the surgery. Specifically, what might happen to your sex life.

Usually, your doctor will tell you to wait about four to six weeks before having sex, depending on the type of procedure you had. You might want to clarify with your doctor exactly what he or she means by “sex.” Usually, that means vaginal penetration. So ask if oral sex is okay. How about using a vibrator or a hand?

When you’re ready for intercourse, you’ll want to start gently—lots of lube and gentle penetration. If the cervix was removed, it may take time for the top of the vagina (the “vaginal cuff”) to heal. Penetration may feel differently for a while. (Here’s a good metaphor for the process.)   

Sometimes, emotional healing has to happen as well. After all, hysterectomy is the surgical end to childbearing. For some, depending on the reason for the hysterectomy, this is a relief; for others, it’s a significant and sometimes difficult transition. If you are overwhelmed by emotion or even depression, give yourself some time and space to heal. You may also need to seek out a listening ear or professional counselor to regain balance.

If your ovaries were removed, and you haven’t yet gone through menopause, or even if you’re in perimenopause, be prepared for the possibility of significant emotional and physical change. With the removal of your ovaries, hormone production suddenly stops, and you’re now in surgically induced menopause. This requires some preparation ahead of time and some patience and therapy after the procedure.

The good news is that, for most women, sex tends to be unchanged and is sometimes better. The parts necessary for orgasm are still intact, and the issues that may have caused the trouble in the first place (pain or bleeding) are gone. “Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don't have their original problem to interfere with sex,” writes Dr. Paul Indman in this article.

This opinion is supported by several studies confirming that, for most women, sex is the same or better after a hysterectomy. In a small study of 104 women, researchers determined that the best predictor of the quality of sex after a hysterectomy was the quality of sex before the procedure.

Despite the research, some women say that sex just isn’t the same. They report weaker orgasms and less sensation, loss of libido, and difficulty with arousal. Therapies can help—hormone replacement, localized estrogen, lubes and moisturizers—but they can’t replace nature.

Furthermore, although the vast majority of women recover well, a hysterectomy is still a surgical procedure with all the attendant risks and uncertainties. Unexpected outcomes happen—nerves may be damaged; prolapse or fistula may occur. The long-term effect of removing significant abdominal organs is still poorly understood.

With that in mind, some tips for approaching this, or any, surgery might be:

  • Try the most conservative treatments first. Fibroids, heavy bleeding, endometriosis can be treated with less invasive methods. Start there. A hysterectomy isn’t the first line of defense.
  • Opt for the most conservative surgery. If a hysterectomy is the best choice, make sure you understand your options. The least invasive surgical options (vaginal or laparoscopic) simply have better outcomes. If there’s no good reason to remove your ovaries, ask about keeping them.
  • Do your homework and line up your resources. Make sure you and your partner understand what’s happening and be prepared for a time of adjustment afterward.

Several years ago, an acquaintance had a total hysterectomy that included the removal of her ovaries. She was post-menopausal at the time, but sex was still very important to her and her husband. She was worried about the effect her hysterectomy would have on their sex life and discussed it with her doctor.

Recently she told me that there had indeed been a period of transition after her hysterectomy, but that over time, she had regained her former sensation, including the deep, pleasurable orgasms she had been accustomed to.

“I don’t know how it happened,” she told me. “I just worked from the memory of what sex had been before my surgery and focused on regaining that. And I did.”

Everyone’s experience is unique. It’s impossible to predict with utter certainty how an individual will respond to any surgical procedure. With a good medical team, good information, and a supportive partner, you’ve tilted the odds strongly in your favor.

 

Sex and Your Hysterectomy: The Options

As I mentioned in the last post on this topic, even after you’ve decided to have a hysterectomy, a few critical questions remain. Time for a sit-down with your surgeon to hash them out.

First: How will he or she perform the procedure. There are three basic surgical options. The type of procedure your doctor chooses will affect the speed of your recovery, how long you’ll be in the hospital, and how much pain you’ll experience.  

  • Abdominal hysterectomy involves removing the uterus through an incision in the abdomen, usually along the bikini line. This route involves more risk, more pain, and a longer recovery period. Depending on your unique situation, this may be the best (or only) approach, but studies consistently show that, in most cases, the following two options are preferable.
  • Laparoscopic hysterectomy involves using tiny cameras and surgical tools—sometimes operated by a robot—inserted through small abdominal incisions, either to do the hysterectomy entirely or to assist in a vaginal procedure. This is less invasive with good outcomes.
  • Vaginal hysterectomy is just what it sounds like—the uterus is withdrawn through the vagina without requiring an incision. Generally, this procedure was found to involve fewest complications, to take less time to perform, and to offer the best outcome. Some factors, such as the size of the uterus or the shape of the pelvis, might prohibit a vaginal hysterectomy, but overall, this is the best choice.

You should discuss what procedure your surgeon recommends and why. The quality and speed of your recovery rests in his or her hands.

The second topic to thoroughly discuss with your doctor is what, exactly, he or she is taking out. Here are the three umbrella categories of hysterectomy.

Hysterectomy

Hysterectomy is the removal of your uterus and the cervix, which is the organ at the top of the vagina. A lot of discussion and very few facts surrounds the pros and cons of leaving the cervix intact. Unless there’s a problem with the cervix itself, there’s no biological need to take it out—or to leave it in. The preponderance of evidence suggests that the cervix has little to do with sex, and removing it doesn’t seem to change sensation or to affect orgasm.

Removing the cervix, however, can change the vagina: It can become shorter, although rarely enough to compromise sex; some nerves might also be affected, which could make the top of your vagina more sensitive, and not in a good way. But the vagina, as we know, is a very stretchy and forgiving organ, so with the use of dilators (and gentle, consistent sex) the situation can be remedied.

Often, the cervix is removed prophylactically, to avoid a small but real cancer risk. Without a cervix, there’s no longer a risk, ergo, no more pap tests. That’s one point in its favor.

Supracervical Hysterectomy

In the supracervical hysterectomy procedure, only the uterus is removed, leaving the cervix, fallopian tubes, and ovaries intact. In this case, you probably won’t experience much difference in your sexual activity unless you were accustomed to deep-muscle uterine contractions with orgasm. No uterus; no more muscular contractions. You might notice other changes, however, that we’ll discuss in the next post in this series.

Hysterectomy with Bi- (or Uni-) Lateral Salpingo-Oopherectomy

Hysterectomy with bi- (or uni-) lateral salpingo-oopherectomy. Yes, it’s unpronounceable. This is the removal of one or both ovaries and the fallopian tubes along with the uterus. Unless you’re well into menopause, this procedure can put a woman in a hormonal tailspin.

The ovaries are the seat of much of testosterone production (it’s also produced by adrenals) and estrogen production—all the good stuff that keeps the sexual apparatus and our moods humming nicely along. Removing them while they’re still functioning puts a woman into immediate and sometimes intense menopause. It’s called “surgically induced menopause.” For that reason, ovaries are left intact, if possible, especially in younger women.

The decision can be complicated, however. The ovaries themselves can be diseased. Also, some women carry a genetic trait called the BRCA mutation. They are at a much higher risk for breast and ovarian cancer. While breast cancers are often identified at early stages, no screening or early-stage detection exists for ovarian cancer. It’s usually discovered later, when it’s very hard to treat. For women without that genetic trait, the risk of ovarian cancer is low, but not zero.

When menopause is surgically induced, your sex life (among other things) is likely to be seriously impacted just as it is in menopause. You should prepare for low libido, a possible decrease in arousal, dry vagina—all the issues we cover so repeatedly here.

I’d strongly advise you to line up resources ahead of time. Make an appointment with a gynecologist who specializes in menopausal issues. You might be a good candidate for estrogen and/or testosterone therapy. Stock up on lubes and moisturizers. Fire up the vibrator. The hormonal transition could be rocky, but with support and medical oversight, you’ll get through it. Sex (and life) will be good again. Promise.

A lot of issues and options are involved with the decision to have a hysterectomy (beginning with the question of having one at all). Believe me, you want to understand the process, your options, and the possible outcomes. When it comes to this part of your body and your being, you want to know what’s going to happen and to minimize the surprise factor.

 

 

 

Sex and Your Hysterectomy: A Primer

I’m just gonna say it: the best time to get information about sex after a hysterectomy is before the hysterectomy ever happens.

When a patient come to me with sexual issues after having had a hysterectomy, and she is unclear about what kind of hysterectomy she actually received—what organs were removed or whether she had a laparoscopic or a vaginal procedure, for example—this indicates to me that she may not have sought or received the information she needed in order to make an informed decision.

Whether to have a hysterectomy is a loaded topic these days, so let’s just dive in and get the facts out of the way, shall we?

Hysterectomy is the second most common surgical procedure performed on women after caesarian section.  Almost 12 percent of women between 40 and 44 have had one. That number rises to 30 percent by the time you’re 60. About 600,000 procedures are performed every year in the US—the highest rate in the world, although other developed countries also do a lot of hysterectomies.

Most hysterectomies are performed for such benign but bothersome conditions as fibroid growths, endometriosis, heavy bleeding, and vaginal prolapse. Only about 10 percent are done for truly life-threatening conditions such as cancer or a uterine rupture during childbirth.

It’s almost like having a hysterectomy has become a normalized part of growing older as a woman. You get your hair colored, and you have a hysterectomy. That’s just how it goes.

Recently, however, women’s health organizations and other health professionals—as well as women themselves—have been questioning that inevitability and pushing for less radical treatments for benign conditions. These include less invasive treatments, such as having a progestin IUD placed or endometrial ablation for heavy bleeding or uterine artery embolectomy treatments for fibroids. Still, hysterectomy remains the most common go-to for a host of “female troubles.”

Like any surgical procedure, a hysterectomy involves weighing risks and benefits. These are dependent on factors such as age, childbirth history, the size and shape of the uterus, among other considerations.

For example, it might be better for a younger woman with a benign and treatable condition to first try the alternatives to the permanent removal of her uterus because her reproductive organs are still fertile and hormone-producing. Even a woman in perimenopause is still producing hormones with all their good protective benefits to vaginal tissue, heart, and bone.

A post-menopausal woman with an unpleasant uterine prolapse, on the other hand, might be a very good candidate for hysterectomy. This patient’s hormone production has virtually ended and other treatment options aren’t permanent or also involve a surgical procedure.

Sometimes, however, when a woman’s quality of life is so compromised, when she’s in enough pain or bleeding so erratically or profusely, she may be willing to do anything to make it stop. A hysterectomy will make it stop and will often improve both sex and quality of life. But a frank patient/doctor discussion is still critical—so she understands her options and, insofar as possible, what the outcome will be.

So—there are options for treatments of benign conditions such as fibroids or endometriosis. Hysterectomy is invasive and permanent, so it makes sense to explore other options first. But if a hysterectomy seems to be the best approach, you then need to know about the different types of hysterectomy and their outcomes.

This is important, ladies, because how quickly you recover and the effect on your sex life has everything to do with the type of surgery you have and what organs are removed.  

We’ll discuss this in a post next week.

Q: Will I miss my cervix if it's part of a hysterectomy?

Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can't recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I've seen women less fond of progesterone than estrogen.

Whether you're able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it's appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman's health and history.

Glad you're thinking about your continued sexual health, and good luck with your recovery!

Q: Why do I have cramps after a hysterectomy?

You describe cramps, not unlike menstrual cramps, after masturbation. Orgasm includes contraction of pelvic floor muscles, and it sounds like you're experiencing some spasms of those muscles. Radical hysterectomies often require tissue removal or dissection surrounding the uterus and ovaries. It's likely your spasms are caused within nerves and muscles that are still healing.

I suspect this will improve with continued healing, but using an anti-inflammatory medication like ibuprofen may help relieve the pain. If, three months or so after surgery, when most healing has taken place, the spasms and pain persist, a consultation with a pelvic floor physical therapist may be helpful. They can assess the muscles and nerves of the pelvic floor and often remedy persistent pain.

Continue that healing work! I'm hopeful the pain will resolve itself.

Q: Can I revive my sex drive and orgasm after a hysterectomy?

There are a number of pieces to this puzzle--we women are complicated! First, because your hysterectomy was "complete," you no longer have ovaries, which are a major source of testosterone (up to 50 percent) for women. Losing that testosterone can be a major hit to women's desire, arousal, and orgasm. Some women benefit from adding back testosterone, but it's not FDA-approved in the U.S. and not all practitioners are familiar or comfortable with prescribing it for women.

If you're taking oral estrogen, some complicated biochemistry is at play that can further decrease your testosterone. Replacing estrogen by a means other than oral--skin patch, spray, gel--is important.

If you're not taking estrogen, orally or otherwise, that may be a contributing factor, too. Losing estrogen leads to less blood supply to the genitals, which makes arousal and orgasm more difficult.  Localized vaginal estrogen works for many women, and it's not absorbed system-wide.

Beyond the hormonal pieces of this puzzle, I often recommend warming lubricants or arousal oils, which use a stimulant to bring more blood supply to the genitals. Using a vibrator can also help; the more intense stimulation can make a difference. And I encourage women to explore self-stimulation: What you require now may be different from what it was, and the better you understand yourself, the more you can help your partner meet your needs.

Best of luck! It will be worth the time and effort to revive this part of yourself!