It was a sweltering summer day in 2015, and I was standing in line to register my then eight-year-old daughter for figure skating lessons. I hadn’t been there more than 10 minutes when I felt that unwanted sensation that every woman knows too well: I was leaking.
How was it even possible? Before leaving the house, I’d armed myself with a super-plus tampon and two pads; yet there I was, 40 minutes later, in my nightmare scenario. I turned to my daughter, standing oblivious at my side, and said quietly, “We need to step out of line.”
I have never had a regular period. Diagnosed at 13 with polycystic ovarian syndrome (PCOS), I was put on the pill to regulate my periods and minimize the pain until my 30s. At that time, I was ready to start a family and switched to fertility treatments—a combination of Metformin, Femerra and hormone injections to stimulate ovulation. After both of my children were born, my periods finally regulated, but the accompanying pain and heavy bleeding were unbearable. I learned to tell myself, “It’s not such a big deal.”
I tried a Mirena IUD, but found the extra hormones made me cranky; after four years, I had it removed. Since then, doctors recommended different hormones, different IUDs—and nothing worked. Doctors whispered about a hysterectomy, but I balked. Even my closest friend, who is also a doctor, pushed me to do it. I felt I was way too young for such a thing—I just wasn’t ready for menopause.
But enough was enough. Standing in line at the community arena that summer afternoon at the age of 43, I was ready for a solution.
I went to see my doctor and he spoke to me about an ablation, a procedure in which the lining of the uterus is surgically removed. The first step was an ultrasound to ensure I was a good candidate. As it turned out, I was not: The PCOS was gone, but it had been replaced with adenomyosis, a condition in which the tissue that lines the uterus grows into the muscle wall. The result is heavy, painful periods. Seeing as it would be impossible to completely remove the lining of my uterus, the ablation was out of the question.
My doctor once again recommended hormonal treatment and I once again walked out of his office empty handed. Another five years passed and I continued convincing myself it wasn’t such a big deal.
The change came when I found a new gynecologist. My original doctor had passed away, and his replacement retired. I was fed up with the advice I was getting from the interim doctor; he was quick to suggest hormonal treatments and pass me off to his interns. After 35 years with my previous doctor, it was difficult to adjust to someone so dismissive. I sought advice from my family doctor, and I was eventually referred to Dr. Jaclyn Madar in 2019.
Madar looked over my ultrasounds and we discussed my options: We could try medication again, an ablation supported by an IUD that might stop the bleeding—or a hysterectomy. We kept returning to the latter, which is often what happens in cases of adenomyosis, fibroids and other conditions that cause heavy, painful periods. My mother had recently passed away from ovarian cancer. There is a common genetic mutation within the Ashkenazi Jewish community that leads to an increased risk of breast and ovarian cancer. While my mother tested negative for the BRCA mutation—responsible for breast and ovarian cancers—her own father died of pancreatic cancer, which points to an increased risk of ovarian cancer for me. The surgery was a valid way to mitigate my own risk, which was still in question due to both their histories. All that, plus the fact I was approaching menopause, made me much more amenable to the idea of a hysterectomy this time around. It was late May 2021, and Madar told me to think about it while we booked another appointment for July.
By the time I got home that day, I’d made up my mind. I was tired of being dragged down by my uterus. I was done bleeding 18 out of 28 days. My 50th birthday was around the corner and childbearing was a thing of the past. What was I waiting for?
When I went back to see Madar six weeks later, I was confident in my decision but dejected about how long it would take to book an elective surgery during a pandemic. It turns out luck was on my side: Dr. Madar had a cancellation for late August, a little more than a month away. After a lengthy discussion, which revisited my mother’s cancer and my grandfather’s pancreatic cancer, we decided to do a total hysterectomy with bilateral salpingo-oophorectomy (BSO). In other words, all the plumbing—fallopian tubes and ovaries included—was coming out.
How do you know if a hysterectomy is right for you?
The day of my surgery came and went, and everything went smoothly—despite my uterus weighing in at a whopping three times the size of a typical one. And recovery was faster than I’d thought possible. In fact, due to the laparoscopic procedure, I was out of the hospital the same day.
The first 48 hours post-surgery are a bit of a blur. All I remember was not wanting to spend the night in the hospital and asking what I had to do to get home. That meant getting out of bed and being able to urinate and pass gas. I looked at my husband and said, “I’ll do all those things… after a little nap.” (Thankfully, there was pea soup for dinner.)
The recovery was nowhere near as bad as I thought it would be. In fact, I was off of painkillers after the first four days. I was left with a dull ache, like I was carrying a bowling ball around in the pit of my stomach. I had been looking forward to six weeks (the dictated recovery time) of being waited on hand and foot, but in the end, I was up and about by the end of the week.
I realize that major surgery isn’t the answer for every woman suffering from heavy, painful periods. But it might be the answer for some. There are many factors that play into the decision, including age, health, family history and symptoms. So when should you consider a hysterectomy?
If you aren’t interested in medical management, like pills or an IUD, Dr. Madar says it may be time to explore surgical options. “If you’re 40 and you know there are 11 years ahead of you and you don’t want to take medication or have an IUD for birth control, for example,” she says. “Or if you’re suffering from a condition such as adenomyosis, fibroids or dysmenorrhea, which results in severe, frequent, and painful menstrual cramps.” If a patient has tried other treatments, or if other options aren’t right for her, the next natural conversation may be about hysterectomy. “As long as she understands all the risks inherent in any surgery, and there are no contraindications, that option is open to her,” Dr. Madar says.
The good news: With the widespread use of laparoscopic surgery, these risks have been significantly reduced. Still, problems can occur with the initial procedure of putting the camera inside the belly button. There’s a one-in-1,000 risk of damaging an organ, such as the bowel or a large blood vessel. In terms of general surgical risks, there is always the chance of causing damage to surrounding organs, excessive bleeding requiring transfusions or a post-surgical infection. The first two are rare, but infections can occur in five to 10 percent of patients, depending on the patient and their overall state of health.
As with all surgeries, blood clots can occur, but recovery is often quick with laparoscopic procedures, making mobility less of an issue. If there is a hospital stay, the surgeon might prescribe blood thinners to mitigate the risk.
Once you’ve decided to go ahead with the procedure, figuring out just how much to remove requires a dialogue between you and your health care provider. Madar says she almost always recommends removing the cervix, as 30 percent of women who choose not to remove it can continue to have cyclic bleeding. They will also require regular Pap smears. “Scientific articles have disproved the idea that the cervix has any function in sexual health. It plays no role in preventing prolapse. There’s no additional risk in removing it, and no benefit to keeping it,” she says. “Removing it during surgery avoids someone having to come back.”
Current research also shows that the place of origin for about 70 percent of ovarian cancers are the fallopian tubes. It’s believed the cells from the tubes shed onto the ovaries, causing the cancer. “[Even] when we do a hysterectomy for benign reasons [no cancer involved], we recommend removing the fallopian tubes, as they don’t play a role in hormone production or serve any central function other than being a conduit to get the egg inside the uterus,” Madar says. “We have good data now that shows removing the tubes is a protective measure against ovarian cancer.”
The biggest decision comes with the ovaries. If the patient is post-menopausal and their ovaries are no longer producing hormones, Madar will offer to remove them, as there is no increased risk and doesn’t take significantly longer during surgery. It’s also one less chance of getting ovarian cancer.
But if a woman is in her late 40s and hasn’t yet reached menopause, there may be greater considerations. Typically, Dr. Madar does not remove ovaries in patients under 45, as the production of estrogen plays a protective role in both heart and bone health. Madar points to literature-proven benefits derived from the Nurses’ Health Study, which began in 1976 and tracks the largest risk factors for major chronic diseases in women. But there is a more recent study, undertaken at St. Michael’s in Toronto and led by Dr. Maria Cusimano. This study was done because there is a lot of data that is still unclear related to the health impacts of estrogen, especially related to women in my age range.
“We know that estrogen is critical to long-term health before menopause,” Cusimano says. “We wanted to be able to guide women through that choice [of removing the ovaries]. That’s what the crux of the study was about.” It’s the first study to map out how the risk associated with removing the ovaries changes as a woman ages. The study found that removing the ovaries may be linked with an increased risk of death in younger women because it prematurely stops all ovarian hormone production; but that risk is mitigated in women over the age of 50. “We saw the risk of death steadily decline and eventually disappear as women approached age 50 and beyond,” Cusimano says. “This information should hopefully help women of all ages, and their surgeons, come to the right course of action for their health. It’s likely a safe procedure we can offer women over age 50 as a means of ovarian cancer prevention.”
Still, Cusimano and the study’s researchers admit their findings have their limits: The study separated the women involved in the research into age groups that showed drastic differences between them, despite there realistically being no sudden drop in mortality rate between 49- and 50-year-olds. Using more advanced modelling methods, however, researchers found that the relationship between removing a patient’s ovaries and mortality rate did shift toward less harm the closer the patient was to the years when women typically begin to experience menopause (which is usually around age 50 and up). “Researchers say the findings will allow surgeons to help patients make more informed choices about their health, but that more research is needed on the impact of BSO to quality of life and sexual function to more fully guide decision-making in this area,” a press release about the study reads.
How does a hysterectomy change your sex life?
Once the date for my hysterectomy was set and pre-op testing was done, the only thing left to do was wait. I wasn’t nervous about the surgery, but I was losing a lot of sleep wondering what it would be like to be plunged into menopause literally overnight.
“You’re lucky,” I said to Dan, my husband. “Most husbands have no idea when it’s going to hit. You’ve got an exact date and time. If I were you, I’d be on a flight to Mexico.”
After 25 years together, Dan and I been experiencing a sort of post-children sexual re-awakening. I was terrified of losing that. I was scared of the hot flashes, the changes my body would go through. Dr. Madar had already told me about estrogen patches and creams, but my online research yielded herbs (black cohosh) and interventions (MonaLisa laser procedures, anyone?). It’s enough to make anyone panic. Once my hormones were gone, would I even feel desire?
Luckily (or not), six weeks of recovery put an end to that question. By the time I got the all-clear from the doctor, I was bursting at the seams.
I won’t lie: Sex was different. For starters, lubrication is definitely an issue. And I hadn’t counted on the scar tissue from the operation making intercourse uncomfortable. But the most surprising thing was that parts that used to be incredibly sensitive were no longer so (hello, nipples)—and that required a conversation about what was working and what wasn’t.
“Post-menopausal sex is a question of letting go of expectations,” says Dr. Laurie Betito, author of The Sex Bible for People Over 50. “Just because something changes doesn’t mean it’s bad. It’s like if you’re a runner. When you’re younger, you can run faster and longer than when you’re 50 or 60. But that doesn’t mean you can’t run. You just adjust to the new conditions.”
Issues like lubrication can be fixed with an estrogen cream, which I quickly discovered was a simple and painless routine. But when it comes to things like loss of sensitivity, communication with your partner is essential. As Betito says, it’s a matter of discovering other areas of your body that respond to sexual touch.
“You have to find other zones that create those pleasurable sensations,” she says. “With age and reduced hormones, we know for example that the clitoris needs more intense stimulation. You also have to adapt and expand your definition of sexuality. It’s not just about intercourse. Your body can still give you pleasure.”
I took her advice to heart and my husband and I have fully enjoyed rediscovering my body.
Taking control of my body and health
Six months post-surgery, I’m kicking myself for not having done it sooner. There was so much that prevented me from taking control of my body and health: the procedure and its implications, the idea of such permanence, fear of the unknown, and perhaps most of all, the underlying feeling that it just wasn’t that important.
But if I could go back in time and talk some sense into myself, I would. The occasional hot flash is nothing compared to what I was living with before. Being pain-free is one of the greatest gifts I’ve ever received. And never having another period has literally changed the way I go about my everyday life—there’s no more planning around “heavy days.” I still keep my period app on my phone, though, because there’s nothing better than seeing a screen that says, “163 days late” and thinking to myself, Guess again.