Treatment

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The steps you will take while preparing for any type of surgery are typically the same. Below, a number of practical issues are discussed, as well as information on surgeries that are common for women, primarily those related to your reproductive system.

What to bring to the hospital

• Ask the hospital for a list of the items they provide, such as toiletries (toothbrush, toothpaste, shampoo, etc.). If you prefer certain brands of toiletries, bring your own. Leave cash and jewelry at home (remove your rings). Bring an inexpensive watch, clock or clock/radio to help keep you oriented after surgery.

• Favorite magazines, books, crossword puzzles, etc., to spend relaxed time while your body resumes normal functioning. Bring eyeglasses, if required.

• Flowers, family photos, cards, etc., to make your room warmer and more cheerful.

• Music, audio books, and humorous or inspiring tapes or CDs because reading after surgery may at first be tiring or difficult with certain medications.

• Spiritual or religious art, medallions, beads, etc.

• Favorite foods and snacks, if allowed.

• List of phone numbers you might need.

• Notepad and pencil to have by your bed to jot down questions for your doctors or nurses.

• Your own pillow, quilt and/or pajamas, although these are optional.

• Something nice to smell, like mild fragrances to counteract the hospital atmosphere, can be very uplifting—for example, lavender, which is often used for relaxation, and Melissa, the "gladdening" herb, which has a fresh lemony scent. Putting a few drops of a high-quality essential oil on a cotton ball inside a small paper cup can be very pleasant when placed by your bedside, without bothering a roommate.

• Consider bringing a pair of earplugs or eye-mask to promote restful sleep.

The Pre-surgical Visit

The presurgical visit is generally scheduled the day before surgery. An anesthesiologist will examine you and review your medical history to determine what type of anesthesia is safe for you. You will be given an exam and questions will be asked regarding your health. Blood and urine tests will be given and perhaps an electrocardiogram, or EKG, which provides an electrical recording of the heart. If you have had a blood or urine test or EKG in the past 30 days, let your physician know—this may eliminate the need for these tests during the presurgical visit.

Preoperative Preparation

Just before surgery, preoperative preparation—or preop prep—takes place. The steps vary, but this is what you can expect:

• An identity bracelet will be placed around your wrist.

• A health care professional will review your medical history and will perform a brief physical exam.

• The area of your body undergoing the operation will be cleaned and may be shaved.

• You may be given a laxative or an enema to empty your bowels. You may be asked to douche or to empty your bladder.

• You'll be asked to remove any dentures, hearing aids, contact lenses or eyeglasses, nail polish, wigs, hairpins, combs and jewelry.

• You'll be asked to remove all your clothes and will be given a hospital gown and perhaps a cap.

• You may be given medication to help you relax. You may also be given other medications that your doctor has ordered.

• A needle may be placed into a vein in your arm or wrist. This needle is attached to a tube that will supply your body with fluids, medication or blood during and after the surgery. This is called an intravenous (IV) line.

• A tube called a catheter may be placed in your bladder to drain urine. This is often done after you have been given anesthesia. This way it is not felt.

Common Surgical Procedures

There are several reasons why gynecologic surgery may be recommended. Examples include symptoms caused by abnormal uterine bleeding, fibroids, pelvic pain from endometriosis (a disorder that occurs when some of the tissue that forms the lining of the uterus grows in other parts of the body) or other conditions, and uterine prolapse (when the uterus is no longer supported by muscles and ligaments, and drops into the vagina). All are common reasons why women seek surgical treatment from their health care professional.

If you have one of these conditions, here are some of the procedures your health care professional may recommend:

• Laparoscopy and hysteroscopy. These minimally invasive techniques are used to diagnose and treat many conditions. The laparoscope is inserted through a small incision just below the navel so the surgeon can view and treat conditions in the pelvis. Sometimes other small incisions may be needed. General anesthesia is often used during laparoscopy. The hysteroscope is inserted through the vagina and cervix giving the surgeon access to the uterus.

  Both procedures are performed with long, thin telescope-like instruments equipped with a light and camera so the surgeon can view the area being treated on a video monitor. Complications are not common but may include bleeding, injury to other organs or reactions to the anesthesia. You may also feel bloated and gassy the next day because often the abdomen has to be inflated with gas to make it easier to more easily maneuver the tools. In the hands of a skilled surgeon, minimally invasive surgeries offer several advantages to abdominal surgery: smaller incisions, less pain, smaller risk of bleeding, shorter recovery and less visible scars.

  Laparoscopy may be used for diagnosing endometriosis, pelvic pain and infertility. It can also be used for surgery on the fallopian tubes and to treat adhesions (painful scar tissue that may develop internally as a result of prior surgery).

  Hysteroscopy can be done in a health care professional's office or operating room under local, regional or general anesthesia depending on whether other procedures, including laparoscopy, are done at the same time. Hysteroscopy may be used, among other reasons, to identify causes of abnormal bleeding or repeated miscarriages, to take a biopsy or to diagnose infertility.

• Fibroid vaporization. This procedure vaporizes and destroys fibroids with electrical energy from a small electrode inserted through a hysteroscope into the uterus through the vagina and cervix. It is performed under either local or general anesthesia. Fertility is not affected by this procedure, but fibroids may grow back eventually. Bleeding, infection and damage to other structures are risks associated with this procedure.

• Myomectomy. This surgical alternative to hysterectomy treats fibroids by cutting the growths out of the uterus and removing them through an incision in the abdomen. The surgery may also be done through the vagina with the use of a hysteroscope, or laparoscopically through a small incision in the lower abdomen. General anesthesia is usually used. The benefit of a myomectomy is that fertility is preserved because the uterus and cervix are left intact.

  This procedure is frequently more complicated than hysterectomy, and the risks of a myomectomy should not be underplayed. Myomectomy takes as long and often longer than a hysterectomy, and it may involve greater blood loss and a greater need for transfusion than hysterectomy.

  Myomectomy may also involve a more difficult postoperative course than hysterectomy, and there is the risk of damage to ureters and other structures, as with hysterectomy. Scarring of the uterus following myomectomy may also affect fertility. And the procedure doesn't prevent further fibroids from growing. In fact, they often grow back and may require more surgery.

• D & C. This common surgical procedure, also known as dilatation and curettage, involves scraping the internal lining of the uterus to diagnose and treat abnormal uterine bleeding. It can also be performed to determine the cause of severe menstrual pain or gain information about why you are unable to get pregnant. This elective procedure is also commonly performed after a miscarriage to empty the uterus of remaining tissue associated with the pregnancy. D&C is sometimes done to remedy a condition called endometrial hyperplasia, in which the uterine lining has become too thick. Occasionally, a woman may experience bleeding after menopause; if vaginal bleeding occurs after a cessation of at least six months, then a D&C may be recommended.

  The procedure can be done on an inpatient or outpatient basis and involves dilating the cervix and inserting a thin, spoon-shaped instrument (a curette) to remove a sample of the internal lining of the uterus for testing or to remove the portion of the lining that is causing excessive bleeding. Following the D&C, you will be given oral medication for any postoperative pain, such as severe cramps. Most pain disappears within 24 hours. You may also be given an antibiotic to prevent infection.

• Endometrial ablation. During this procedure, the uterine lining is removed. There are several different techniques used during endometrial ablation, including the following:

  • Electrocautery: The endometrial lining is removed by way of a roller ball, through which electric current travels to cauterize the tissue.

  • Hydrothermal: The lining is destroyed by heated fluid that is pumped into the uterus.

  • Laser: A beam of light radiation destroys the endometrial lining.

  • Balloon therapy: A balloon at the end of a catheter is inserted into the uterus, filled with fluid, and heated to the point that it erodes the endometrial tissue.

  • Electrode ablation: A mesh electrode expands to fill the uterine cavity and delivers an electrical current to destroy the lining.

  • Cryoablation (freezing): A probe introduces extremely low temperatures into the uterus to freeze and destroy endometrial tissues.

  • Microwave ablation: A slender probe that delivers microwave energy is inserted into the uterus to destroy the endometrial lining.

  Some of the above endometrial ablation procedures are performed with the help of a hysteroscope or a resectoscope, a device similar to a hysteroscope that has a built-in wire to deliver electrical current to remove endometrial tissue. And some endometrial ablation procedures use ultrasound to guide the instrument into the uterus.

  Depending on the type of endometrial ablation performed, it may be done as an outpatient surgery or as part of a hospital stay, and it may be performed under local or general anesthesia. The length of surgery and recovery time will vary depending on the type of ablation used.

  Following endometrial ablation, most women will still menstruate, but there is a chance that some will stop altogether. Although some women will remain fertile, this procedure is not recommended for those who plan to have children.

• Hysterectomy. This common procedure removes the uterus and possibly other parts of the reproductive tract, such as the cervix, fallopian tubes and ovaries. If your ovaries are removed during the surgery, the procedure is called a bilateral salpingo-oophorectomy. A hysterectomy may be performed through the abdomen (abdominal hysterectomy), through the vagina (vaginal hysterectomy) or through the vagina with assistance from viewing instruments placed in the abdominal cavity (laparoscopically assisted vaginal hysterectomy [LAVH]). The most common complications are infection, injury to the bladder or bowel and bleeding.

  The setting and type of anesthesia used for hysterectomy can depend on the type of hysterectomy that is recommended. Typically there is a one- to two-day stay in the hospital and a two- to six-week recovery period. Side effects from hysterectomy include: difficulty emptying the bladder or bowels, urinary tract infections, abdominal pain and fatigue.

How Anesthesia Works

One of the most common fears people have about any type of surgery concerns anesthesia. Anesthesia refers to the drugs and gases used during an operation to relieve pain. These drugs work by artificially putting you to sleep and by blocking messages to the brain. As a result, all or part of the body becomes insensitive to pain and feeling for as long a time as needed.

Anesthesia can be given by either an anesthesiologist (a doctor who specializes in anesthesia) or by a nurse anesthetist working under the supervision of a physician. For minor surgeries done in a health care provider's office, local anesthesia can also be given by the health care professional performing the procedure.

During surgery requiring anesthesia, the anesthesiologist adjusts the level of the drugs to heighten or lessen their effect. He or she also continually monitors a patient's breathing, heart rate, blood pressure, temperature and other vital signs, and performs blood transfusions, if necessary.

Before any operation, you should ask who will be administering and monitoring the anesthesia. Because it is difficult for a surgeon to operate and monitor a person's anesthetic at the same time, it is best if another person monitors the anesthetic. Minor procedures must be carefully monitored as well, because even sedatives can depress breathing.

The type of anesthesia used during surgery depends on a woman's age and physical condition; on the nature and length of the procedure; and on any personal history or family history of adverse reactions to drugs. Some operations can be done with more than one type of anesthesia. In some cases, a health care professional may steer you toward one type of anesthesia based on your medical history and the type of surgery.

The four types are: conscious sedation, local anesthesia, regional anesthesia and general anesthesia. Their effects range from a short-lived numbness to temporary paralysis or unconsciousness, depending on the blend of products used and how they are administered.

• Conscious sedation puts you to sleep using sleeping pills, but not deeply enough to cause unconsciousness. It is often used in office-based gynecological procedures, such as new methods of sterilization, and may be used during colonoscopies.

• Local anesthesia is injected directly into a tissue to numb it. It is used for minor surgeries and may be coupled with a mild sedative. There are few, if any, side effects.

• Regional anesthesia blocks sensation in a region of the body, such as from the waist down. The two main types are spinal and epidural. Both are injected near the spinal cord. An epidural is administered through a thin plastic tube or catheter and can be given continuously during surgery. After surgery the catheter can be left in to provide postoperative pain relief. Spinal anesthesia acts faster and produces more numbness than an epidural, but cannot be given continuously. Spinal anesthesia is often associated with headaches as it wears off.

• General anesthesia includes a group of agents that block pain, relax the muscles and produce unconsciousness. It can also shut down memory function. Typically, general anesthesia agents are given via inhalation or intravenously. In some cases, the anesthesiologist may also give a pre-medication orally or through an injection anywhere from a few minutes to a few hours before the surgery to induce relaxation and drowsiness. Temporary side effects of general anesthesia may include nausea, vomiting, muscle pain or shivering.

Many gynecologic surgeries are performed using an epidural injection—the type of anesthesia commonly used during childbirth. Epidurals are becoming increasingly popular because they can keep a person comfortable without causing grogginess or affecting a person's consciousness.

An epidural works by putting anesthetic drugs in the epidural space just outside the spinal cord, which affects the large nerves entering and leaving the spinal cord. These nerves are responsible for transmitting information to the spinal cord and brain about touch, temperature and pain. If too large a dose of the medications is given or if the needle is inadvertently placed inside the spinal sac, the anesthetic could affect nerves higher up in the chest that control breathing and heart rate. An epidural can also cause blood pressure to fall. The administration of an epidural requires a skilled anesthesiologist.

Some procedures demand a particular method of anesthesia, leaving you without a real choice. You may, however, be able to request that the smallest possible amount of a drug be administered, which may reduce side effects. Before receiving any anesthesia, you should discuss the procedure with your surgeon or anesthesiologist to learn about the options.

The anesthesiologist typically will discuss your surgical procedure and anesthesia-related issues before your scheduled surgery. Use this meeting to express any fears or concerns you have about anesthesia. You should also ask the following questions:

• What types of anesthesia are appropriate for this type of surgery?

• What effects can I expect after the operation?

For safer surgery, it's important to share as much information as possible about yourself and your health history with the anesthesiologist including:

• previous adverse reactions to anesthesia in yourself and in other family members

• any allergies you have

• if you smoke

• which medications, including herbal supplements, you've recently taken

• if you think you might be pregnant