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  • Vaginal hysterectomy is just what it sounds like—the uterus is withdrawn through the vagina without requiring an incision.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.

 

 

 

Real Women, Real Answers: Live Webcast on Sex after Menopause

We women deal with many physical and emotional changes during and after menopause. Both in my medical practice and as part of the MiddlesexMD team, I'm alert for "kindred spirits" who understand the transition—and are willing to talk about what changes in hormones mean for real women leading real lives. The people at Vibrant Nation, the leading online community for women 45 and older, have been among those kindred spirits. I published articles on the VibrantNation.com site for almost five years and had some of our liveliest online discussions there. (They have recently changed their platform and, unfortunately our content is no longer available on their site.)

Among the things we've talked about is how hormonal changes—and the painful or less pleasurable sex that can come with them—can take a real toll on our relationships. And I know from the women I see in my office and the emails I get from around the world (literally!) that we're not talking enough about how sex changes and what we can do about it. We're not talking enough to our doctors, to our partners, not even with our girlfriends.

VN-BSB-ad-15_01-v7-300x250And for many of us, it's hard to find straightforward, trustworthy information about how to deal with issues like pain during intercourse, diminished orgasm, and changes in libido.

That’s about to change. I'm excited to have been asked by Vibrant Nation to lead a panel of women who will share their stories and advice for getting that spark back in the bedroom. Vibrant Nation is having its first-ever live webcast discussion, Sex After Menopause, on March 31, 2015, at 1:00 p.m. EST. We'll have real women telling their stories, with experts providing perspective and solutions. And you can participate! Pre-register by following this link (Online Form - Pfizer Attendees List - Pre-event - Barb Depree) and you'll have the opportunity to submit your own question or story and to win a $100 Amazon gift card.

Join us. Let's stop the silence and extend the conversation. Let's support each other by sharing our questions, our successes, our struggles. Let's build the community of kindred spirits!

Disclosure: This post is part of a Vibrant Influencer Network campaign. MiddlesexMD is receiving a fee for posting; however, the opinions expressed in this post are Dr. DePree's. Neither MiddlesexMD nor Dr. DePree is in any way affiliated with Pfizer and does not earn a commission or percent of sales.

Q: How would I work with a menopause care provider?

Your primary care provider will continue to be your health resource for the spectrum of things that can happen at any age and especially at midlife: hypertension, sinus infections, asthma, joint injuries, and so on. A menopause care provider is a specialist; gynecology is typically also supported through health insurance (but individual plans vary). Some insurance plans require that your primary care provider provide a referral for "menopause care," which I recommend begin as soon as women are aware of symptoms of perimenopause.

When you're reviewing options for menopause care, look for certification by The North American Menopause Society (and get help from the NAMS website to find a practitioner with the NCMP credential). Certification means a health care provider has completed extra training to gain competency in menopause. (Those who are "members" of NAMS have access to the specialized information the organization provides but are not certified.)

Needle in a Haystack: Looking for a Health Care Provider

We’ve discussed when you might want to look for a new health care provider. MiddlesexMD advisor Dr. Sheryl Kingsberg minces no words on that point: If your health care provider isn’t addressing your sexual health concerns, find a new one. If your current physician isn’t listening or is talking down to you, find a new one. If you are uncomfortable and can’t communicate with your provider—you guessed it—find another.

Gulp.

Changing physicians is a daunting task. The process is fuzzy, and credible information is hard to come by. Maybe that’s why we put up with less-than-ideal situations for so long.

But the relationship with your doctor is too important to settle for an uneasy status quo. Trisha Torrey, who writes extensively about the issue, says it’s like choosing a spouse, except that you may be more intimate with your provider.

If you’ve been dissatisfied with your provider or are just putting up with a situation because you’ve been avoiding the task of finding a new one, here’s a plan of attack.

If possible, out of fairness to your current physician, try to address with him or her the reason for your dissatisfaction. If you aren’t a good “fit” with her personality or style of practice, a heart-to-heart might not be very productive. It’s unlikely that he can change such basic traits. But if you have a problem with her staff or have health care issues (such as sexual complaints) that haven’t been addressed, you should give your doctor an opportunity to discuss the causes of your dissatisfaction.

Also, as Torrey points out, “nice” doesn’t necessarily equal “competent.” A good bedside manner is pleasant and soothing, but for my money, I’d rather have competency.

If you’re convinced that you need a different provider, don’t leave your old provider until you’re sure you have a new one. You don’t want to come down with a cough or find a lump without a regular physician. According to a 2008 article in the New York Times, “Studies have found that it is hard to get an appointment at short notice when cold-calling, and that patients with a regular source of care get better care, even when they are uninsured.”

Then, as you begin your search, consider these issues:

  • Insurance and hospital affiliation. Finding out what providers are covered by your insurance is probably your first order of business, unless you’re okay with paying for medical service out-of-pocket. Call your company for a list. Does the hospital a physician is affiliated with make a difference to you? That could also factor into your search.
  • Age. Do you want an older person with more experience but who may or may not be as familiar with the latest treatment options? Or do you want a younger provider, who may be around for your golden years, but who lacks long-term experience (at this point).
  • Language-gender-culture. Are any of these variables important to you? Would you prefer a provider of the same gender? Do you have religious or cultural preferences or prohibitions? Do you have a hard time understanding accents?
  • Special health concerns. If you have diabetes or allergies, do you want your primary care provider to have more expertise in that area? Some general practitioners have extra training in various subspecialties.
  • Location and hours. Do you want a provider near at hand, or are you willing to travel to someone you’re comfy with? Would evening hours be a bonus so you don’t have to take time off work?

Once you’ve mulled over these parameters, your next challenge is to find solid, trustworthy information about the providers on your short list. The bad news is that it may be easier to get information about a washing machine you want to buy than about a doctor you’re considering. Websites that provide information and ratings on physicians are in their infancy, and sites that feature patient reviews have to be carefully vetted for objectivity.

“The truth of the matter is that people are hard pressed to make well-informed decisions when they choose a doctor, and they’re doing it blind,” said Joyce Dubow, a senior adviser in the office of policy and strategy at AARP in an article in the New York Times.

When you call your insurance company for participating providers, ask if they have a review system or an “honor roll” of providers. Some companies are starting to do this.

Some online sites rate physicians, but they vary in quality and credibility. You wouldn’t trust a review of a washing machine from the company that sells it; neither should you find a doctor on a site hosted by a pharmaceutical company. Pay attention to who created the website, who funds it, who makes money from it, how complete it is, and how current it is. Check out healthgrades.com for basic information and some reviews or healthline.com.

Doctors must be licensed to practice in a state, but board certification indicates a higher level of competency. Most providers are board-certified, and yours should be as well, either with the American Board of Medical Specialties for MDs, the American Osteopathic Organization for DOs, or the American Board of Physician Specialties, which accepts both disciplines. A doctor may be certified with other boards as well, but these three are widely recognized and demand a certain level of competency and achievement. To find a health care provider with specific menopause-care knowledge, you might start with the North American Menopause Society's website at menopause.org; there's a practitioner search you might find helpful.

Word of mouth is still a common and effective way to get information about local providers, especially if the word comes from someone in health care. I found a terrific dentist from a hygienist who taught at a dental school. Another woman found her internist from a trusted pharmacist. Ask family and friends who they see and how they like the person.

Check social media sites and search engines like Google. It’s easy and worth a shot, just make sure you’re getting information about the right person.

Finally, schedule consultations with the providers on your short list. You’ll probably have to pay for the appointment, but you’ll be able to assess the provider’s attitude and personality, the office environment, and, very importantly, the attitude of the staff.

Bring a list of questions, such as whether she schedules same-day appointments for illness, how he handles emergencies, whether you’ll see the doctor or members of the staff (physician’s assistants or nurse practitioners), how she handles prescriptions, where he went to medical school, how long she’s been in practice (if you haven’t ferreted this out already). Ask about board certification and any special training. And tell him or her you want to feel free to discuss matters of sexual health.

Finding a provider is a challenge, but it’s a critical and long-term relationship, so it’s worth putting in the effort upfront in order to avoid ongoing dissatisfaction down the road. And take heart from Dr. Sheryl: “If a women is smart enough to have found the MiddlesexMD website, she’s savvy enough to ask friends and other health care providers and to do some basic research to find someone she’s comfortable with.”