New Research on the Myths Regarding Instructions Doctors Give Following Surgery
A recent study from National Institutes of Health recommends that doctors change many of the current restrictions on activities following gynecologic surgery. After reviewing information from medical journals, medical textbooks in obstetrics, gynecology, and general surgery, the American College of Obstetricians and Gynecologists Practice Bulletins and Committee Opinions and clinical guidelines of Royal College of Obstetricians and Gynecologists of the United Kingdom, they found that the available studies do not support many of the recommendations currently provided by doctors. Resumption of usual activities after gynecologic surgery helps integrate women back into normal life and, although more study is needed, they suggested the following after abdominal surgery (restrictions are less after laparoscopic surgery):
Resumption of Normal Activity: Prolonged bed rest increases the risk of pneumonia and blood clots in the legs. A quick return to normal activity after gynecologic surgery should decrease the likelihood of these problems. For most women, normal activity includes walking, lifting, and climbing stairs. Many of the previous restrictions were intended to avoid straining the abdominal incision in a way that might cause it to open. But, as seen below, these fears are not justified.
Lifting: Patients have usually been instructed to not lift more than 10 pounds. However, normal events like forceful coughing (which we often encourage you to do) , or getting up from a lying down position (which you have to do to get out of bed every morning) place more stress on the incision than lifting. In fact, the force needed to tear open a surgical incision is much greater than the force generated by any kind of daily activity.
Poor nutrition, infection, obesity, anemia, and diabetes, as well as the type of suture material and the surgeon’s technique are more likely causes of the incision opening after surgery.
Climbing Stairs: Climbing stairs is a common and normal activity. There is no evidence that climbing stairs increases the risk of the incision opening.
Bathing and Swimming: Baths have usually not been permitted for 2 to 6 weeks after surgery in order to prevent wound infection. However, if the incision is closed and not already infected, there is no evidence that a tub bath is harmful once the bandage has been removed.
Driving a Car: The concerns have been that the physical activity associated with driving might cause the wound to open or that post-operative pain might cause you to hesitate to step on the brakes quickly in an emergency. However, there is no evidence that these things are true. It is a good idea to first try the pedals and hand controls in a stationery car. If this feels comfortable, then take the car for a short ride accompanied by another adult who could drive the car if you feel unable to continue driving.
More important is the possibility that narcotic pain medication may cause drowsiness or slow your reflexes while driving. Therefore, you should not drive until you no longer need narcotic pain medication.
Sex Following Hysterectomy: Sex can probably be initiated once you are comfortable and both partners are ready. If your cervix has been removed with the uterus (total hysterectomy), there is a small risk of infection around the sutures left in the vagina and a small risk of these sutures coming undone during intercourse. If you are menopausal, had prior pelvic radiation therapy, or have diabetes your risk is higher.
The cervix is a major source of normal lubrication, so if your cervix has been removed it is best to use vaginal lubricants during sex and try sexual positions with the woman on top so penetration can be controlled. This puts less pressure on the sutures at the top of the vagina.
If your cervix was left in place (supracervical hysterectomy) the risk of infection is even less and there are no sutures at the top of the vagina to worry about coming apart.
Returning to Work After Gynecologic Surgery: Advice on when to return to work varies greatly. In the United Kingdom, a survey found that doctors recommended returning to work anywhere from 1 to 10 weeks after surgery. It appears that a gradual return to work is better than an abrupt return to full-time work.
Recovery at Home After Major Gynecologic Surgery
Authors: Evenson M, Payne D, Nygaard I.
Source: Obstetrics and Gynecology, 2012;119:780-4
Study from: University of Utah School of Medicine
Problem: Women’s recovery and pain control during the first 6 weeks following gynecologic surgery has not been well studied.
Study: Women having either abdominal or vaginal surgery were asked to determine their pain and pain medication use after surgery.
Results: 80 women had vaginal surgery; some women had a hysterectomy and others had bladder repair surgery. 47 women had abdominal surgery; some women had a hysterectomy and others had removal of fibroids (myomectomy) or ovarian cysts.
On recovery day 3, inadequate pain control was reported by about 50% of women in both groups and at the end of one week 25% of women had inadequate pain control. By day 14, most women who had vaginal surgery had minimal pain, but 20% of women still had pain after abdominal surgery. Two weeks after discharge, narcotic pain medication was still being used by 10% of women after vaginal surgery and 32% of women after abdominal surgery. By 6 weeks, half of the women in each group felt recovered and two-thirds felt “back to normal.”
Authors’ Conclusions: Pain control after hospital discharge is inadequate for many women after both vaginal and abdominal surgery. The time to full recovery is longer than 6 weeks for half of women.
Dr. Parker’s Comments: Recovery from surgery varies from woman to woman, but it usually takes a bit longer than either the doctor or patient hopes will be the case. In the past 10 years, doctors have been better educated about helping patients manage pain, but some doctors still discourage use of pain medicines and many patients stop using pain medicine before they should. Laparoscopic surgery has been proven to cause less pain and have a faster recovery than abdominal or vaginal surgery. But, even following laparoscopic surgery, patients often try to return to normal activity faster than they should.
I always tell patients that there is no advantage to being a martyr and that they will sleep better and feel better if they take some pain medication for the first few weeks after surgery. Also, patients are not aware of the level of fatigue that they will feel after surgery. And, the fatigue can last for weeks after the pain has gone away. Fatigue is due to a number of things: the effects of anesthesia and narcotic pain medication; the stress of surgery on the body; tissue injury and release of proteins (cytokines) into the bloodstream that are sedating (nature’s way to force you to rest); and, injured tissues need for energy to heal, leaving little reserve for the rest of your body.
So, some form of pain medication allows you to rest more and sleep better. Also understand that recovery and return of energy may take longer than you wish.
These new recommendations need to be fully tested by scientific study, but since this is unlikely to happen soon (or ever), it is best to discuss the new recommendations with your doctor.
By William H. Parker, MD
Clinical Professor, Obstetrics and Gynecology, UCLA School of Medicine
Director of Minimally Invasive Gynecologic Surgery, UCLA Medical Center, Santa Monica
Page last updated: January 19, 2014