Abdominal surgery. Operations involving open abdominal incisions will require several weeks for healing, and several months for return of your full energy.
Vaginal operations. Healing after vaginal surgery involves surprisingly little pain in most cases, and the return to activity is usually quite rapid. However, pain and tenderness around the perineum may last for weeks or even months, to some degree.
Laparoscopic procedures. These Band-Aid operations are known for allowing a quick recovery. However, unlike abdominal and vaginal procedures, upper abdominal and shoulder discomfort are common during the first few days after laparoscopy, due to small amounts of gas left behind in the abdomen. One fairly consistent benefit of recovering from laparoscopy: you should feel progressively better with each passing day. If you notice that your recovery starts to move in reverse, call the doctor.
CONCERN #5: “SEX ISN’T WORKING RIGHT”
Though you’ll need time to heal, you should always be able to return to a satisfying sex life after pelvic surgery. For women who have been uncomfortable or inhibited due to vaginal relaxation or incontinence, correction of these problems may improve sexual function for a few reasons: first, directly through relief of the physical problem. For instance, women who have had a hysterectomy for prolapse may notice an improvement in sexual pleasure, as the cervix is no longer bumped during penetration. Second, sexual function may be enhanced indirectly—for example, due to the elimination of anxiety and inhibition that once accompanied fear of accidents during intercourse. That’s right—surgery might even enhance your sex life!
On the other hand, new sexual problems can sometimes arise after surgery, and they need to be specifically addressed. Changes in vaginal anatomy, postoperative scarring or pain, decreased libido: which of these should you worry about? A better understanding of how surgery will affect the various areas down there might help to clarify the issues.
THE OUTER GENITALS
The clitoris, most directly responsible for female sexual pleasure, is almost never directly affected by surgery for incontinence or prolapse.
THE OVARIES
No matter how extensive your pelvic operation, if you’re premenopausal and the ovaries are left intact, their production of sex-related hormones should remain unchanged. With removal of the ovaries (oopherectomy) in premenopausal women, hormonal changes may lead to vaginal dryness, hot flashes, and even mood swings. All of these low-estrogen changes can affect sexual desire and function. You should discuss with your doctor starting hormone replacement, or dealing with menopausal symptoms via nonhormonal strategies.
THE UTERUS
A great deal of interest has been focused on sexual function following hysterectomy. Are there reasons to be concerned? During arousal, the uterus normally elevates and congests with blood; during orgasm, small uterine contractions occur. Some women are aware of these physical events and others are not, and the importance of them to each woman’s sense of pleasure is highly variable. Though some women might notice the absence of uterine contractions and other secondary sexual sensations after hysterectomy, very few perceive it as a negative change.
One report from the Maryland Women’s Health Study, published in The Journal of the American Medical Association, suggested that women after hysterectomy often experience an increase in their sexual pleasure, desire, and function. In this study, both the frequency of sex and overall libido were increased after hysterectomy, and the rate of painful intercourse declined from 40 to 15 percent.
Interestingly, a Scandinavian study of more than a hundred women found that after removal of the uterus, partners with a good relationship before surgery had a 61 percent chance of enjoying improved sexuality afterward. Those with a poor presurgery relationship had improved sexuality only 17 percent of the time. Perhaps, in the end, true love really does conquer all!
THE VAGINA AND PERINEUM
The perineum is a highly sensitive area, critical to sexual function. If you had a perineal incision for the repair of a rectocele or a lax vaginal opening, try following the same basic tips outlined in chapter 7 for episiotomy healing, starting with ice packs on your bottom. The vagina itself is an amazingly forgiving part of the body—quick to heal and almost always left with no visible scars. The majority of stitches used for pelvic reconstruction are absorbable and disappear on their own. However, as mentioned earlier, a graft of synthetic mesh, or permanent stitches, may be used in some cases. Rarely, these materials may poke through an adjacent area of vaginal skin that hasn’t fully healed, causing an erosion; pain during intercourse (for either partner) or a heavy discharge with spotting are the most common signs. For some, part or all of the permanent surgical material must be removed for proper healing to occur.
YOUR NEW SIZE AND SHAPE
By definition, the anatomy of the vagina after surgery will always be different than before, and these differences will be most pronounced after the repair of advanced pelvic prolapse. Pelvic surgeons take great care to avoid any changes that might make intercourse difficult or painful. A goal of surgery is to improve sexual function by normalizing the vaginal anatomy and perineal tone. Nevertheless, occasionally the width or depth of the vagina may be left too narrow or short to allow for comfortable intercourse. Don’t worry—this can almost always be effectively addressed. The first task is localizing the problem. Narrowing can occur at the perineum, along the vaginal walls, or up at the vaginal apex. Your doctor can make this assessment during a simple examination once you have fully healed. Treatment involves stretching the tissues, slowly but surely, back to the desired size and shape. The dilation can be performed by self-massage or gentle and well-lubricated intercourse; alternatively, silicone dilators can be used to gradually stretch the vaginal tissues. Estrogen creams are sometimes useful during this process, to keep the vaginal skin well lubricated and pliable. As evidenced by the physical changes of childbirth, when the vagina stretches more than ten centimeters wide and later shrinks to a fraction of that size, these tissues are among the most malleable in the whole body.
POOR LUBRICATION
Dryness is the enemy of lovemaking, and it must be ruthlessly combated. After surgery, you’ll need plenty of lubrication to avoid friction against healing areas that can remain hypersensitive for many months. Try copious quantities of plain water-based lubricants such as K-Y, Slippery Stuff, Astroglide, or Liquid Silk. Also, as we’ve discussed, the use of vaginal estrogen for postmenopausal women—in the form of tablets, creams, or an insertable ring—is often the best way to improve lubrication and skin tone.
As with healing after childbirth, the return to comfortable sex after vaginal surgery may occur sooner or later than you had expected. Intercourse should be avoided for six to twelve weeks, as determined by your doctor, while the incisions heal and stitches dissolve. When you finally give it a try, choose positions that put you in control of the angle and depth of penetration.
The Cutting Edge: Will New Procedures Make Surgery Obsolete?
Wide open, phenomenal, meteoric. There aren’t enough adjectives to describe the growth that’s taking place within this niche of women’s health. The number of innovations under development is astounding, including a number of fascinating minimally invasive alternatives to major surgery. As you keep abreast of all that’s new, temper your enthusiasm with a healthy dose of skepticism. After all, over the past several decades, a number of procedures have looked very appealing in the short term but have revealed limitations a few years down the road. Only through careful research will we find the needles within this haystack of medical innovation. Among the many emerging therapies are:
Radio-frequency therapy. This outpatient technique uses painless microwave rays to actually tighten up, or shrink-wrap, the fascia in the vaginal walls. This restores strength to the vaginal walls and support to a floppy urethra, and early results have shown some effectiveness in curing stress incontinence. The long-term benefits and risks will need to be assessed over time.
Implantable
gizmos. Tests are under way for injectable micro-stimulator devices (such as the RF Bion), designed to stimulate the pelvic nerves and muscles. A tiny chip is injected beneath the vaginal skin using local anesthesia, requiring no incision. Can you imagine?
Botox. Yes, the same injectable antidote for the common wrinkle is also being tested for various bladder problems. Stay tuned.
Acupuncture. Speaking of needles, can acupuncture be used to improve incontinence and bladder overactivity? The answer is not so clear. Some people feel that actual sites and meridians located around the back of the lower leg, or on the lower back, can directly soothe the sacral bundle of nerves surrounding the bladder; others feel that a general release of endorphins and brain chemicals may improve urinary control. One study demonstrated improvements in overactive-bladder symptoms within a group of women; others since then have been unable to confirm a beneficial effect. Acupuncture and traditional Chinese medical treatments—including moxabustion, hot cups placed over the skin—are being studied at some centers.
Percutaneous tibial nerve stimulation (SANS). This novel therapy is a loose variation of acupuncture, focused on a site near the foot. A thin needle is inserted just above the ankle, right next to a chain of nerves leading up to the pelvic-nerve circuit. Once or twice weekly, electrical stimulation is delivered through the wire. Amazingly, it can work, at least for overactive-bladder symptoms. Short-term improvements have been seen, but unless treatments continue, the effects disappear. An even more futuristic variation is currently being tested: it involves the use of a laser light pen to stimulate the same suspected acupuncture point without any needles at all. Whether it will cure symptoms remains to be seen.
AFTERWORD
The Stage Is All Yours
NAVIGATING THE POLITICS, ECONOMICS, CULTURE, AND ETHICS OF CHILDBIRTH
Disease varies from place to place, less because of climate or geography than because of the way work and reproduction are organized and carried out in those places.
—Jurshen, 1996
Medical and social prejudices against women sidestepping their biblical sentence to painful childbirth are still with us.
—Feminist professor of English, British Medical Journal, 1999
Want to make some mischief? Try logging on to your computer, finding a women’s-health chat room on the Internet, and typing these words: “A woman should have the right to choose how she delivers her own baby!” Give it a day, or maybe two, and then check back in.
You won’t believe the number of responses you receive.
Voices from both sides of the debate will claim with equal conviction that they represent the true interest of women. One side maintains that cesarean delivery is an artificial disruption of a natural event, and that offering this choice is meddling with a female body that knows how to give birth. The other side believes that not offering women free choice in the labor room is a denial of personal autonomy, an intrusion into one of life’s most intimate medical decisions. Political correctness is an elusive target when it involves such an emotionally and politically charged subject.
As doctor, my goal has been to provide you, the patient, with enough information to establish your own voice in the debate, and to understand how this handful of often overlooked female problems can be caused, treated, and hopefully prevented. Our understanding of these topics is by no means complete. Even the best research study will often introduce more questions than answers. Nevertheless, new and exciting answers have been emerging, and I’d argue that the woman who is truly informed based on our best existing knowledge, and is exposed to all sides of the debate, has had her autonomy and intelligence respected in the highest regard. She is able to speak for herself rather than depending on others, and she is more fully in control of her own body. According to at least one recent survey, the overwhelming majority of women are ready to have their own voice. Eighty-three percent expressed a desire for information regarding the postnatal risk of prolapse and incontinence; 94 percent wanted to be more actively involved in making decisions regarding forceps, cesarean section, and other obstetrical interventions. I hope these chapters have achieved their goal of informing at least some of you among that silent majority.
But however vital the role of medical information and scientific research may be in determining the best approach to childbirth, our understanding of these topics would be incomplete without one inescapable and elemental fact: reproductive choices will never be made on the basis of science and medicine alone. It’s impossible to fully understand your childbirth experience and postreproductive body without at least some appreciation of the economics, politics, personalities, and even ethics behind the baby business. So in these last few pages, let’s step back from the microscope we’ve used to understand the nerves, muscles, and inner workings of your pelvic anatomy and take a telescopic view of factors that lie beyond the realm of science. Although these players on the stage of childbirth may remain unseen, their influence on your reproductive choices, and the physical effects that sometimes follow, can be potent.
The Ethics of Childbearing and Informed Consent
“Why wasn’t I told about all this stuff before I had my baby?”
Whether facing a food label or surgical-consent form, today’s consumer wants to know everything pertaining to risks, benefits, and side effects—all the ingredients of decisions, big and small. Informed consent is the ethical and legal principle that safeguards each person’s right to know and choose in the medical world. It’s a standard that requires a particular form of communication between doctor and patient: the disclosure of basic risks and benefits of any procedure that’s about to be performed, and a discussion of the alternatives that are reasonably foreseeable at the time of consent.
For millennia, giving birth required few decisions, big or small. No ovulation kit, ultrasound, amniocentesis, or epidural, and only one reasonably foreseeable way out for the newborn: one that too often proved itself to end tragically for baby, Mom, or sometimes both. Along with the last few ticks of the historical clock, the miracles of antibiotics, blood transfusions, and safe surgery began to quickly erase the fear of death from the labor room. Today fewer than four hundred women die from childbirth-related complications each year in the United States. The new era of childbirth is no longer one of fear, but one of decisions, technological options, and ultimately, ethics. Suddenly, there are more ways for a mother to give birth, more factors entering into her physician’s medical judgment, and more attitudes and beliefs behind each woman’s image of the ideal childbirth. And we, as patients and doctors living in this privileged era, enjoy the luxury of debating the most appropriate role for a constant stream of technological innovations.
With all of childbirth’s many choices, are the standards of informed consent being met? Without question, over the past few decades, women and their partners have become informed and active participants in many key areas—for instance, choices surrounding contraception and fertility, pain control, and fetal testing. Yet arguably, when it comes to the effects of childbirth on each woman’s body and the problems that can follow, truly informed participation is often lacking. Though episiotomy may arise as an issue before or during labor, other issues more important to the pelvic floor generally do not. What about all of those muscles, nerves, and supports of the deeper pelvic floor? What about the effect of obstetrical choices on a woman’s future risk of incontinence, prolapse, or sexual dysfunction? What about the potential effects of forceps, fetal size or position, the length of labor and pushing, the decision over vaginal birth after cesarean, or elective cesarean birth? These and other factors, as you’ve learned, may have reasonably foreseeable consequences to a woman’s health. In the future, our discussions and disclosures during pregnancy and childbirth probably will weigh more carefully these basic connections between childbirth and female function afterward, between obstetrics and gynecology.
The emergence of postobstetrical problems into the spotlight of women’s health raises other e
thical issues that are no less challenging. Consider one in particular: the right to choose between vaginal and cesarean birth. Should cesarean delivery be considered an elective procedure—a luxury, like cosmetic surgery, to freely choose—or a matter of medical necessity? If a healthy, low-risk woman is allowed to choose a cesarean, has her obstetrician abdicated his or her own responsibilities and been reduced to the role of technician?
On what basis can women be denied the right to choose? Is it the view that vaginal childbirth, and all that may follow in its aftermath, is inherently more natural than a surgical birth? Or is it because cesareans are simply too expensive to offer on demand?
What about the woman who refuses vaginal delivery to eliminate the small but serious risk of a previous cesarean scar rupturing, versus one determined to prevent the incontinence or prolapse that her mother endured, or yet another who simply wants to avoid the physical or emotional effort of a vaginal birth?
What is the proper role of an elective cesarean birth in preventing later problems that are not ones of life and death but rather of quality of life?
To what degree women will be permitted free choice in these matters will remain a subject of debate for years to come, and it’s wrong to start drawing blanket conclusions until we have more definitive answers. In the meantime, it’s not wrong to start talking. Each woman is entitled to balance the pros and cons of medical decisions involving her body, including the route of delivery, the management of labor, even forceps and episiotomy, considering their possible aftereffects. The female body surely does know how to give birth, and it should always be encouraged to do so. But informing a woman what to expect while she’s expecting is not enough—she should also know what to expect afterward, not only days but years later. In this age of free-flowing information between patients and doctors, the maternal repercussions of childbirth should be freely disclosed and no longer overlooked.
Ever Since I Had My Baby Page 32