Hearing the words "you need a hysterectomy" is scary. It is overwhelming. Things often move very fast, and people faced with this surgical procedure sometimes don't know what questions they can, and indeed should, ask. So here is a list of key questions to discuss with your surgeon.

List of Key Questions to Ask Before (or after) a Hysterectomy:

1. Why do I need this procedure?
2. What is the evidence supporting this procedure for my condition?
3. How do you plan to support the remaining vagina?
4. After the incisions and tissues heal, where will I be referred for post-operative physical therapy?

 What is the rationale for those specific questions?

1. Why do I need this procedure?

“You have cancer, uncontrolled bleeding or pain” are all acceptable responses. 

"Just because you have a prolapse" is not an adequate response.

50-80% of people with pelvic organ prolapse report full resolution of pain, pressure and leakage complaints associated with the prolapse after a course of physical therapy.

If you have symptoms that bother you due to the prolapse (pressure, leaks, pain) that haven’t resolved with a course of Pelvic PT, THEN consider surgery, but I would rarely (if ever) recommend surgery as a first course of action without any attempt at rehab or pre-hab of the tissues. 

Info to back these statements up: (Wiegersma, et al, 2019; Hagen et al, 2014–full citation and links at end of post)

2. What is the evidence supporting this procedure for my condition?

This goes along with #1.

Are you having this procedure due to cancer? Well, then you have no choice. You have to get the cancer out.

Are you having unexplained pelvic pain? Success rates for hysterectomy to address primary pelvic pain have been reported as high as 70%, with pain persisting, at various levels, in 20-40% of individuals. (Hillis, et al, 1995 full reference and link at bottom of blog)

That means that about 3 out of 4 women who undergo this procedure will have a significant reduction in pain. And 1 out of 4 will not.

If there is a choice, have you exhausted all other interventions? More specifically, have you tried pelvic floor physical therapy? As mentioned, Pelvic PT has a high success rate of treating complaints such as incontinence, prolapse pressure, and pelvic pain.

If you can’t find (or afford) full Pelvic PT in person or online, consider an online wellness program from a reputable source (like me!) as a place to start. 

And, if Pelvic PT or the online wellness program doesn’t fully resolve your complaint, and you still end up needing surgery, you will be better connected with your body pre-surgically, and have healthier tissues entering surgery which is a very good thing for long term outcomes.

3. After you remove the uterus, how do you plan to support the remaining vagina?

This is important. The uterus, and its connective tissues, help to stabilize the vagina.

If we remove the uterus, the remaining vagina needs to be stabilized, or you could have a prolapse post-hysterectomy. A recent study indicated a post-hysterectomy vaginal prolpase rate of 12%, or a bit more than 1 in 10 women.

Sacrocolpopexy and Sacrospinous fixation are two options (I discuss them in this post).

Your surgeon may need to make this decision during the surgery, based on the quality of the tissues that will remain, but it is important to have this discussion, so that some type of fixation occurs.
 

4. What is the complication rate post hysterectomy?

 No surgery is without risk of complications. But if we are aware of the possibility of potential complications, then we are not as startled or anxious when they arise, thereby easing some suffering post-procedure.

Potential Complications after a hysterectomy include wound closure issues, urinary tract infection, blood clot, sepsis, death, need for repeat surgery or ICU/ER admission. 

Hillis, et al, 1995 reports a complication rate of 20% of individuals post hysterectomy, and while most complications are mild and short-term, it is still prudent to be aware of them.

In a more recent study, Wallace, et al, in 2016 found the overall complication rate for benign cases to be 7.9%, and malignant cases had a higher rate of complications at 19.4%. Rate of complication was associated with longer surgery times.

5. After my tissues have healed, where will you be referring me for physical therapy?

Would you ever have a knee replaced, or rotator cuff repaired, and not do rehabilitation afterwards? NO!

So why would you literally slice through the definition of someone's core (arthroscopic or open, it's still a slice), remove a key organ, and then just 'stitch them up and send them home' and expect them to recover full function?!?

And you wonder why older physicians and people think it is 'normal' for women to leak and have pelvic pain...it's because we've been neglecting to offer them basic rehabilitative care for centuries.

The studies mentioned above, as well as others, support the use of pre- and post-operative PT in improving patient outcomes as far as pain, improved sexual function, improved continence function of urine and bowels, and overall improved quality of life.

6. What do I do if my surgeon or doctor says I “don’t need PT”?

If your surgeon says "you don't need PT", kindly ask them to document in your chart that you requested the service, and they declined to provide you with a script for it.

It's one thing if they want you to wait 4-6 weeks (although you can start earlier with basic relaxation techniques and breathing techniques to manage pain), but another thing if they deny you a script entirely. The above 'trick' usually results in you obtaining an order.

*Oooh, another fun fact--As a Doctorate Level Profession, PTs are now a "Direct Access" medical service in most states and most insurances do not even 'require' a physical order. The exceptions are Medicare, Medicaid services, and certain Christian Medishare plans. But if you are unsure, call your local PT office, and they will tell you if a script is required.

7. What if there isn't a Pelvic PT near me?

Check out this blog post to help you find a PT near you. There are also PTs that offer online visits, or online programs (like mine!)

I hope this helped you identify the key questions to ask before your hysterectomy.

Thanks for Reading!

With over 600,000 people having hysterectomies in the United States (Simms, et al, 2020) and more than that worldwide, chances are that you, or someone you love, with have a hysterectomy in the future, or has had one in the past.

It is important to recognize the pivotal role that Pelvic Floor PT can play in eliminating pain, regaining full continence, sexual function and confidence post-procedure. Even just ONE visit of PT to connect to your body and your needs, can lead to HUGE gains function and quality of life😃. Here’s how to find a Pelvic PT near you, or here’s my scheduling site if you’d like to work with me.

For those seeking alternative avenues, perhaps you’re not ready to see a Pelvic PT in person, consider a high-quality online course from a trusted professional (like me!). Pelvic Floored offers world-class streamable pelvic wellness programs, that you can work through at your own speed, in the comfort and privacy of your own home, for a fraction of the cost of one:one Pelvic PT. 

And if an online course isn’t in the cards right now, no worries. Consider following me on Instagram, or joining my Newsletter  for free, awesome tips!  My VIPs (Very Important Pelvis) e-Newsletter subscribers also get first notice and best prices on all my programs, so don’t miss out–join today!

xoxo, Dr. Kelly

www.pelvicfloored.com

Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, Frawley H, Galea MP, Logan J, McDonald A, McPherson G, Moore KH, Norrie J, Walker A, Wilson D; POPPY Trial Collaborators. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2014 Mar 1;383(9919):796-806. doi: 10.1016/S0140-6736(13)61977-7. Epub 2013 Nov 28. Erratum in: Lancet. 2014 Jul 5;384(9937):28. PMID: 24290404. 

Hillis SD, Marchbanks PA, Peterson HB. The effectiveness of hysterectomy for chronic pelvic pain. Obstet Gynecol. 1995 Dec;86(6):941-5. doi: 10.1016/0029-7844(95)00304-a. PMID: 7501344. 

Simms KT, Yuill S, Killen J, Smith MA, Kulasingam S, de Kok IMCM, van Ballegooijen M, Burger EA, Regan C, Kim JJ, Canfell K. Historical and projected hysterectomy rates in the USA: Implications for future observed cervical cancer rates and evaluating prevention interventions. Gynecol Oncol. 2020 Sep;158(3):710-718. doi: 10.1016/j.ygyno.2020.05.030. Epub 2020 Jul 26. PMID: 32723676; PMCID: PMC8723888.

Wallace SK, Fazzari MJ, Chen H, Cliby WA, Chalas E. Outcomes and Postoperative Complications After Hysterectomies Performed for Benign Compared With Malignant Indications. Obstet Gynecol. 2016 Sep;128(3):467-475. doi: 10.1097/AOG.0000000000001591. PMID: 27500339. 

Wiegersma M, Panman CMCR, Hesselink LC, Malmberg AGA, Berger MY, Kollen BJ, Dekker JH. Predictors of Success for Pelvic Floor Muscle Training in Pelvic Organ Prolapse. Phys Ther. 2019 Jan 1;99(1):109-117. doi: 10.1093/ptj/pzy114. PMID: 30329105.