"Since my hysterectomy 4 1/2 months ago,
I experience bleeding after intercourse. Is this normal?
It is a small amount of fresh blood, bright red. Is
it possible that I have not healed internally yet?
"
I am age 45. My menstrual history was normal and
the hysterectomy was performed because of a large
rapidly growing fibroid tumor."
S. B.
Complications can occur after hysterectomy ranging
from minor problems such as urinary tract infections
or vaginal spotting to major health concerns such
as wound infections that take 3-4 months to heal or
persistent severe pain with sexual intercourse. It
is difficult for you to know exactly what to expect
since most female friends who have had a hysterectomy
tend to forget the minor difficulties, and sometimes
they may expand out of proportion, any major problems
they have had.
Doctors almost never inform women of all the changes
they will feel during recovery from major surgery
because there are too many possible changes. Most
changes and symptoms go away on their own. The surgeons
also do not cover all of the unusual or rare but recognized
complications of hysterectomy. If you are a person
who develops those problems, they will be totally
unexpected and you will think the surgeon "bungled"
the operation because something happened that you
had never heard of before.
Finally, other procedures such as removing the ovaries
or having cystocele, rectocele, or urinary support
surgery can have their own unique sets of complications
and symptom effects. For example, support surgery
with several incision lines from the vaginal opening
to the end of the vagina is much more likely to result
in painful intercourse than would a plain hysterectomy.
Post operative, decreased sexual libido is a much
greater magnitude when the ovaries are removed than
when surgical menopause does not take place at the
surgery. Then there is another variation in intensity
of libido level when estrogen replacement is adequate
versus being too low or none at all. This article
will focus only on the hysterectomy side effects and
complications and not on the interplay of adding other
procedures.
Is vaginal bleeding after a hysterectomy common and
how long should it last?
Normal post operative bleeding lasts from several
days to several weeks after surgery. After the first
couple of days the bleeding turns into spotting, usually
dark red but sometimes bright red. Then in most instances,
the bleeding stops for good. Sometimes there may be
a burst of bleeding at about 2-3 weeks if there was
a collection of blood clot in the pelvis from right
after the surgery. And occasionally at about 2 - 8
weeks after surgery, there may be some bright red
vaginal spotting due to suture dissolving. The timing
depends upon the type of suture used and how fast
it dissolves. This may be spontaneous bright red spotting
(it is rarely ever heavy) or it may happen after intercourse
or physical activity.
That is the normal course of usual postoperative
vaginal bleeding. Sometimes, however, bleeding can
occur at other times or even much later (up to years).
Causes include:
granulation tissue (healing tissue growing on its
own)
prolapse of a faloppian tube (1)
endometriosis of the end of the vagina (2)
atrophic vaginitis due to low estrogen levels and
traumatic irritation
a cancerous growth at end of the vagina (3)
In the situation you describe of bleeding at 4.5 months,
you will need to have a vaginal speculum exam to look
at the end of the vagina. Most likely you have some
granulation tissue at the end of the vagina. On appearance
it would look like a dark red, beefy friable polypoid
growth at the end of the vagina. It bleeds easily
with touching. The treatment is to biopsy it away
and use vaginal sulfa or other antibiotic cream. There
usually are no pain fibers at all. If it hurts at
all during biopsy, it may represent a prolapsed tube
if only a hysterectomy was performed without removing
the tubes and ovaries. A prolapsed tube more often
causes pain rather than bleeding and it may need to
be removed under anesthesia rather than in the office.
This bleeding is not a serious problem but be sure
to see your doctor.
What are common symptoms I may notice during the
recovery after a hysterectomy?
Several hysterectomy support sites have lists of what
to expect after hysterectomy but they may represent
a mixture of hysterectomy effects as well as symptoms
from having the ovaries removed. The biggest complaint
most women have is fatigue. This persists for 2 or
3 months post op. It seems to last longer when the
return to activity is slower. In other words it pays
to become more active sooner after surgery.
Other immediate (within two weeks) post op symptoms
may include:
urinary tract frequency and urgency
requires being checked for possible urinary tract
infection although there may just be bladder spasms
due to catheter irritation or small pelvic collections
of blood near the bladder.
incisional problems
discharge or weeping of the incision in the first
week or two
itching or burning of the incision at 3-6 weeks
pain that is localized to one side of the incision
or another
swelling underneath or to the side of the incision
but different than the rest of the incision
abdominal wall laxness, pot belly, bloated appearance
gastrointestinal problems
increased "gassiness" immediately after
surgery (treatable with simethicone tablets or liquid)
constipation treatable with stool softeners, flax
seed
loose stools (especially if antibiotics were given)
vaginal problems
bloody or odorous discharge for 1st 1-4 weeks
odor without much discharge (may require topical vaginal
antibiotic cream if persists beyond a week)
vulvar burning or itching (usually just due to dryness
and not a yeast infection)
mood changes
reversion to moods previously ignored due to hecticness
of every day life
fatigue
decreased libido
increased feelings of stress and anxiety
increased depressive symptoms
(Note - any 6 week period of significantly altered
daily activity like postoperative recovery can lead
to a change in mood for better or worse. It is not
very predictable.)
pain
pain and swelling or redness at the site of the intravenous
needles
pelvic cramps and catches somewhat sporadic in occurrence
or related to increased physical activity
general problems
generalized allergic rash or itching to medications
such as antibiotics or pain medicines
Remember that most women will say it takes up to
6 months after surgery before they do not think on
a daily basis about having had surgery.
Are there dangerous symptoms that I need to watch
for after surgery for hysterectomy?
Most of the severe complications of surgery will show
themselves within the first 2-3 weeks after the operation
although sometimes these can manifest even later.
re operation - complications requiring repeat surgery
to repair them (2%)
Vascular thrombosis or hemorrhage causing a stroke
or heart attack (<1%)
Intraoperative or delayed post operative intraperitoneal
bleeding requiring blood transfusion (5%)
a pus type of drainage or extensive redness of the
incision can indicate wound abscess (3-5%)
watery, urine-like vaginal discharge may indicate
ureteral or bladder injury or fistula (1-2%)
leg calf or thigh pain and swelling may indicate a
blood clot (<3%)
sharp chest pains and breathing difficulty can indicate
a blood clot that has broken off to the lung (<1%)
or a pneumonia (<1%) or even a heart condition
(<1%).
pelvic pain with bowel and bladder symptoms may indicate
pelvic infection or abscess or a delayed postoperative
bleed internally.
prolonged bowel laziness (illeus) with bloating and
absent bowel movements may also indicate pelvic infection
or abscess, a delayed postoperative bleed internally,
or ureter or bladder injury.
There can also be major complications that show themselves
later than 3 or 4 weeks after surgery.
ovarian abscess (4-60 weeks) (4)
late pulmonary embolus (up to 6 months after surgery)
small bowel obstruction (6 mos to 10 years) (5)
vaginal vault prolapse (within two years if related
to surgery) (<1%)(6)
persistent pain with intercourse due to adhesions
or abnormal scar formation at the end of the vagina
What are some of the rare or unusual complications
that are possible after hysterectomy?
Many of the complications mentioned above are uncommon.
There are some even rarer problems that may occur.
drug induced blood dyscrasias (anemia, low platelets)
(7)
massive hemorrhage resulting in death
bowel injury requiring colostomy
bladder atony and inability to void urine
liver failure due to anesthetic complications
chronic incisional pain or drainage due to suture
granulomas, endometriosis or foreign body reaction
abdominal compartment syndrome (decreased blood flow
to intraabdominal organs)(8)
kidney shutdown due to renal artery spasm (9)
abdominal or vaginal herniation of the bowels (evisceration)
through the incisions (10)
and many other rare and uncommon events
When can I resume different normal activities after
surgery to remove the uterus?
Doctors will vary significantly in their recommendations
for postoperative activity resumption and there is
a noticeable lack of scientific studies performed
to assess what the recommendations should be. There
are some general principles that should be followed
and practical recommendations that follow from them.
Incisions need to heal at least 48 hours before exposing
them to water which can carry bacteria in
avoid shower or bath until 48 hours after surgery
(longer if the doctor suspects any pelvic infection
or hematoma)
if skin staples are used, they perforate the skin
and leave red marks if water carries in bacteria (avoid
getting incision wet until 48 hours after staples
are removed)
avoid baths or pools until 48 hours after any vaginal
bleeding or discolored drainage ceases
Hernia formation or disruption of the incision has
its groundwork laid in the first two weeks after surgery.
Risk factors include increased blood loss at the time
of surgery and wound infection
In the absence of wound infections or risk factors,
normal activity may be resumed in two weeks except
for those which significantly increase intraabdominal
pressure such as impact exercises or recreation.
Avoid lifting more than 10 lbs with intraabdominal
straining for 6 weeks
Avoid lifting buckets, grocery bags or pushing vacuums
in the first two weeks; after that it depends upon
how you feel
Worsening of pain, especially incisional, is a sign
that activity has been enough and rest should take
place until the pain decreases
After the first 48, hours daily activities should
be resumed in short bursts unless there is excessive
pain. It is better to rest 40 minutes out of every
hour in the first two weeks than to rest several hours
in the AM and several in the PM.
Driving may begin when enough soreness has gone from
the incision so that you can turn your head and upper
body 90 degrees without "guarding" the abdomen
and when you can rapidly slam on the breaks if you
had to. With a vaginal hysterectomy, driving may begin
in one week
Going up and down stairs is permissible as long as
it is done slowly enough so it does not produce excessive
pain. Keeping the up/down trips to 1-2 -per day in
the first several days at home might be advisable
Intravaginal intercourse may significantly increase
intraabdominal pressure and should be avoided for
at least 4 - 6 weeks in the absence of postoperative
pelvic infection
Returning to full preoperative activity still needs
easing into even at 6 weeks because anyone placed
on restricted activity even without having surgery
gets easily fatigued
Returning to non-lifting work occupations is best
done for half days the first week if your employer
will allow.
Returning to strenuous lifting jobs should include
the first two weeks at restricted lifting if possible.
Abdominal exercises may be resumed at 6 weeks but
returning to a preoperative exercise or recreation
level needs to go more gradually as tolerated.
Women who have vaginal hysterectomies or laparoscopic
assisted vaginal hysterectomies recover about 2 weeks
faster than women with larger abdominal incisions
Women with vaginal hysterectomies may return to work
in 4 weeks
Driving may resume in 7-10 days for women after vaginal
hysterectomy
Even with no abdominal incision women should wait
at least 4 weeks to resume vaginal intercourse.
Lifting rules apply equally to women with vaginal
hysterectomy as to women with abdominal incisions
because they are slightly more prone to vaginal vault
prolapse complications.
Please keep in mind, all of the postoperative instructions
are guidelines that need to be modified according
to the person, the procedure and the post operative
problems that may or may not occur. Be sure to check
with your physician if these are reasonable instructions
for you.
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