Sex After Hysterectomy

Hysterectomy is one of the most common treatment for uterine cancer. Many women fear that after hysterectomy, they might lose their desire for sex. It has been reported that some women feel a reduction in orgasm intensity after hysterectomy . But is this true?

There are a few reasons why a women may fear that hysterectomy will reduce their enjoyment of sex:
1) Hysterectomy may shorten the vagina and some women reported failure to lubricate which can cause discomfort.
2) If the ovaries are removed during the surgery (total hysterectomy), may cause a severe drop in women hormones (estrogen) which may cause vaginal dryness and painful intercourse.

However, in the largest study of it's kind ever conducted, a 1999 study by University of Maryland School of Medicine researchers found quite the opposite is true. The sex life of participants of the study improves positively after hysterectomy. The majority of the 1,101 women who took part in the study was followed up for 2 years after hysterectomy. Overall, the frequency of sexual relations increased after surgery.

The study also found that:
1) Sexual activity increased after hysterectomy
2) Orgasm frequency increased - 72% experienced orgasm after surgery compared with 63% before surgery.
3) Stronger orgasm - women in study reported strong orgasm almost 15% more frequently after surgery.
4) Less pain during sex - Women in the study group experiencing pain during sex drop from 41% before surgery to 15% 2 years after surgery.

All these are good news for women who have fear of the side effects of hysterectomy on their sexual life. Common beliefs that hysterectomy leads to sexual problems are proven to be the opposite by the study. Researchers of the study attributes the improvement in sexual interest to the relief of pain and discomfort from complications of the disease before surgery. The freedom from vaginal bleeding and elimination of pregnancy possibility may also contribute to the improvements.

It is also important to note that not all hysterectomy procedures are the same, thus there will be different effects on the sexual functioning of a woman who has undergone a hysterectomy procedure which removes her ovaries or one which did not. Consult your doctor and have him/her explain to you the full implications and the choices of procedure available to you before you make any decisions.

Laparoscopy-assisted surgery: Effective for endometrial cancer?

A new study published in March 2007 in the American Journal of Obstetrics and Gynecology reported that laparascopy-assisted vaginal hysterectomy (LAVM) is a safe and effective treatment for stage I endometrial cancer in women with a BMI (Body mass index) of less than 35.

In this study, laparoscopic hysterectomy was compared to abdominal hysterectomy, and it gave further evidence from previous studies on the safety and effectiveness of LAVM in early stage endometrial cancer.

Although LAVM took longer to perform than abdominal hysterectomy, the study shows that it is associated with reduced blood loss and shorter hospital stay. The recurrence rate, overall and disease free survival are also slightly lower with the LAVM method but did not show a statistical difference in the study.

This is a great option to explore with your doctor if you are considering surgery.

Endometrial sampling or D and C (Dilation and Currettage)?

In diagnosis of uterine cancer, these 2 methods may be suggested by your doctor, but what is the difference and can you request your doctor to opt for the less invasive procedure?

Basically, the D and C method used to be considered as the gold standard for sampling the endometrium for endometrial cancer. However, it is now recognised as a blind sampling method because it often samples less than half the endometrium. After talking to an O&G (obstetric and gynaecology) specialist the other day, she told me that she would recommend her patients for endometrial biopsy (involving a pipelle) instead because it's less invasive and have a few more advantages:

1) There is no need for a general anesthetic.
2) Lower risks of infection, hemorrhage (loss of blood from bleeding).
3) Saves time for patient and doctor.

A check on the web also reveals news of a latest study, published in March 2007 in the American Journal of Obstetrics and Gynecology that have shown that the use of the pipelle is a very accurate endometrial sampling method.

The sensitivity of Pipelle is than 93% for low grade cancer and 99.2% for high grade cancer.

Source.

So make sure you explore this option with your doctor!

External Radiation Therapy No Benefit in Early Endometrial Cancer

A recent clinical study reported in the American Society of Clinical Oncology meeting has found that external radiation therapy done right after surgery do not show any benefit to patients in extending sutvival or reducing risk of recurrence.

This study, done on women with stage I endometrial cancer involves 906 women who are seperated into 2 study group. They were followed up for everage of 4 years and those who recieved external radiation therapy after surgery do not show any difference in overall or recurrence free survival rate.

Source

Hormone Therapy

Hormones are chemicals that occur naturally in the body and they control the growth and activity of cells. A type of female hormone known as progestins, a form of the female hormone progesterone is used in hormone therapy for uterine cancer treatment. It is often given in pill form. Hormones work by slowing the growth of uterine cancer.

Treatment with hormones are suitable for:
1) Young patients who want to have children and so do not want to undergo hysterectomy.
2) Patients not fit to undergo surgery or radiation.
3) Recurrent cases of uterine cancer
4) Advanced cases of uterine cancer (Please discuss the stage of your cancer with your doctor)

Side effects may include:
a) Fluid retention
b) Weight gain
c) Increased appetite
d) Loss of sexual desire

This treatment is condered new and does not guarantee that the cancer will not recur.

Radiation Therapy

Radiation therapy is a method of using high-energy x-ray to kill cancer cells. It destroy the ability of the cells to grow and divide. Radiation therapy is recommended when:
1) Your tumour is fast growing (advanced stage), and invades deeply into the uterus or outside the uterus or involves blood vessels.
2) It is sometimes done after hysterectomy if your doctor thinks you're at high risk of cancer recurrence.
3) Patients not fit to undergo surgery.


There are two types of radiation therapy, and the doctor may recommend you for a combination of both of these at the same time:

External Radiation
A machine outside the body is used to deliver the radiation. This is and outpatient procedure. The treatment is often for a few weeks (normally 5 to 6 weeks), 5 days per week. You would need to visit the Radiotherapy department in a hospital for this procedure and the process is similar to getting an x-ray.

Internal Radiation (Brachytherapy)
This is a method where radioactive materials are placed near the tumour inside your body to kill the cancer cells. For uterine cancer, the radioactive source goes inside into the vagina. There are two ways to give this therapy depending on whether you're receiving radiation therapy as your main therapy or after surgery, or the equipment available in the hospital: low dose treatment and high dose treatment.

Basically, there are no difference in how well the treatment works, because you will be getting the same dosage your doctor has calculated for you needs. The low dose therapy (normally called the 'slow' treatment), the radioactive pellets are usually left in place for a day at a time for between 1 to 5 days.
For the high dose therapy, each treatment is much shorter (usually less than an hour) and you need between 2 to 5 treatments, and you can return home the same day.

Brachytherapy has significantly less side effects than conventional external radiation therapy. Common side effects are bladder irritation, vaginal irritation, diarrhea, skin reactions, fatigue, hair loss and loss of appetite.

Chemotherapy

Chemotherapy is the use of medication or drugs to slow tumor growth and destroy cancer cells. Cancer fighting drugs can be given through the vein(by injection) or by-mouth (oral medication). The way chemotherapy is given depends on the type and stage of the cancer. A combination of drugs may be given to treat cancer as sometimes it is more effective than just one drug alone.

Chemotherapy is often used in conjunction with radiation therapy and surgery. It is used to treat areas inaccessible with surgery or radiation. Some of the drugs commonly used to treat uterine cancer:

1) Doxorubixin (brand name: Doxil)
2) Cyclophosphamide (Cytoxin)
3) Cisplatin (Platinol)
4) Carboplatin (Paraplatin)
5) Paclitaxel (Taxol)

Drugs used in treating cancer kills the cancer cells but also kills certain normal cells and thus causing side effects. These side effects depend on the specific drug, the length of treatment and the dosage (how much) used. Some of the common side effects of anti-cancer drugs:

a) Nausea and vomiting
b) Hair loss
c) Mouth sores
d) Fatique
e) Low blood cell counts (anemia)

Each drugs has a different side effects profile. Make sure you ask your doctor about the side effects that could occur with your medication. Fortunately, most of these side effects will go away after the chemotherapy is completed.

Surgery

Hysterectomy: Removing of the uterus by surgery.

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Removing the cancer through surgery is the most common treatment for uterine cancer. The standard therapy is hysterectomy. It is a major operation and you can't get pregnant after your uterus is removed so you should be very well informed, but surgery is usually the only way to eliminate the cancer.
The doctor will only be sure of the exact stage of your cancer after the surgery because he can have a good look at your organs only when he opens you up! During the operation, the doctor will examine the tissues of your uterus and the surrounding tissues and decide what needs to be removed. More tissues might be collected during the operation from different parts of your body to be further analyzed.


Different types of surgery:

Total Hysterectomy
Surgery to remove the uterus, including the cervix.

If the uterus and cervix is taken out through a large incision(cut) in the abdomen, it is called total abdomen hysterectomy. If it is through a small incision in the abdomen using a laparoscope, it is called a total laparoscopic hysterectomy. If it is removed through a vaginal incision, it is called a vaginal hysterectomy. The disadvantage of vaginal hysterectomy is that it is usually harder for the surgeon to see whether the cancer has spread to other parts of the body.

A laparoscopic hysterectomy is a relatively new technique that has the advantage of shortening the time for recovery after surgery (small incision/cut). Ongoing further studies are being done to determine whether it works as well as the usual operations, so make sure to ask your doctor about this option.

For Abdominal hysterectomy,
Hospital stay: 3 to 7 days
Full recovery: 4 to 6 weeks

For Laproscopic and vaginal hysterectomy,
Hospital stay: 1 to 2 days
Full recovery: 2 to 3 weeks


Bilateral salpingo-oophorectomy (BSO)
Surgery to remove both the ovaries and fallopian tubes. This procedure is usually done along with hysterectomy because cancer cells often spread to the ovaries very early in the disease.

Radical Hysterectomy
This is a surgical procedure to remove the entire uterus, cervix, parametrium (the tissues next to the uterus) and the upper part (about one inch) of the vagina. The ovaries, fallopian tubes and nearby lymph nodes may also be removed (a BSO). This procedure is used when the cancer has spread to the cervix or parametrium.

Hospital stay: 7 days
Full recovery: 4 to 6 weeks


Even after surgery, your doctor may advice other forms of therapies like chemotherapy and radiation therapy to destroy any remaining cancer cells.

What are the treatment options if I have uterine cancer?

Being diagnosed with cancer can make you anxious, but do not rush in making decisions. Ask as many questions as possible to understand more of your condition (the stage of your cancer, treatment options, etc). If you still feel unsure, get a second opinion, especially when your doctor has recommended a treatment option and you would like to have more confidence that it is the best possible course for you.

Some of these treatment options may be recommended by your doctor:
(Please understand that your doctor might recommend other plans of treatments than the ones mentioned here. You should not hesitate to ask your doctor more questions)
1) Surgery
2) Chemotherapy
3) Radiation Therapy
4) Hormone Therapy

Each of these therapies has different success rates and side effects. Therefore, some questions you might want to ask your doctor:
1) What are the treatment options available and suitable for me?
2) How is it done, how will it effect my working life in the short term, and how does it effect me in the long run?
3) What is the success rate of this procedure?
4) How long will this treatment take to determine whether it's working?
5) What are the side effects (both short term and long term) common to this treatment?
6) Any other new options available?

In the next few posts, I'll discuss each of these treatment options in details.

How is uterine cancer diagnosed?

Gyneacologist: a doctor specialised to diagnose and treat dieseases of the female reproductive system

Gyneacologic oncologist: a doctor who is a specialist in treating cancer of the female reproductive system.

Oncologist: cancer specialist.

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If you have any of the symptoms mentioned in the previous post (i.e. abnormal vaginal bleeding), you should consult your doctor who will perform a general physical exam and a pelvic exam. Your doctor may also ask you about your symptoms, risk factors and family medical history. When your doctor sucpects of endometrial cancer, you will most likely be referred to a gyneacologist or a gyneacologic oncologist.

Some of the test that your doctor might perform for diagnosis:

Pap Test (Pap Smear)
A pap test is usually used to detect cervical cancer. It involves taking sample of cells from the cervix. It is usually not useful in detecting endometrial cancer because endometrial cancer begins inside your uterus and cells from inside the uterus do not show up in a pap test.

Endometrial Biopsy
This procudure is generally regarded as the first step in diagnosing endometrial cancer. The doctor will insert a narrow tube into the uterus through the vagina and suction out tissues from a few areas of the uterus lining. The tissue extracted will be examined under the microscope in the laboratory. This procudure usually will not take more than a few minutes. It can diagnose more than 90% of endometrial cancer.

Dilation and Currettage (D and C)
If the endometrial biopsy does not provide enough tissue, or if it suggest cancer, you'll likely be advised to undergo a D and C. This is an outpatient procudure and require general anesthesia (concious sedation). It will normally take an hour or so. During this procedure, the servix is dilated (widening) and an instrument called curette is inserted into the uterus through the vagina to try to get tissue samples to be examined under a microscope for cancer cells. You will be advised to stay in the hospital for a few hours or even overnight to recover. Few women will experience any discomfort after this procedure.

Transvaginal Ultrasound
Some patients with medical condition like diabetes, severe high blood pressure, obesity, etc. may not tolerate anesthesia and therefore will be advised for tranvaginal ultrasound to diagnose endometrial cancer.This test show how thick the lining of the uterus is. Ther procedure involve inserting an ultrasound probe into the vagina. If the lining of the uterus is 5mm or less, uterine cancer is unlikely.This also allows the doctor to see the abnormalities of the uterine lining more clearly.

If endometrial cancer is found, you'll need more test to determine whether the cancer has spread to other parts of your body (called staging: determine the extent of the cancer). These tests may include chest x-ray, a computerized tomography scan (CT scan)and a blood test.

When do women usually develop uterine cancer?

Menopause: The menopause is defined as the cessation of menstruation. It occurs around 45-55 years of age of a woman when the ovaries stops producing the female hormone, estrogen.

Menarche: The first menstrual period of a female.

Estrogen: The primary female sex hormone.

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Uterine cancer usually occur between the age of 50-70 years old (average age at diagnosis is 60 years old). Around 75% of cases occurs in post-menopausal (after menopause) women . It may also occur around the time menopause begins.

According to the National Cancer Institute (US), in the United States in 2007, approximately 39,080 new cases are diagnosed and about 7,400 women die from the disease.

The most common of uterine cancer is endometrial cancer. Even though endometrial cancer is the fourth most common cancer in women, following breast, lung, and colorectal cancer, in that order, it is only the eighth most common cause of cancer deaths because it is usually detected in early stages.
Uterine cancer can usually be detected early because the most common symptom is abnormal vaginal bleeding between menstrual periods or after menopause.

When should you see a doctor?
Consult your doctor if you have one or more of the following symptoms:

1) Abnormal vaginal bleeding/discharge (especially after menopause)
2) Painful or difficult urination
3) Painful intercourse
4) Pain in the pelvic area


What are the risk factors of uterine cancer? (What make you more likely to develop uterine cancer?):

1) Obese women
2) Women who have few or no children (nulliparity).
3) Women who began menstruating at a young age (early menarche).
4) Women who had a late menopause ( later than 52 years old)
5) Estrogen replacement theraphy (Hormone theraphy without opposing the estrogen with a progestrogen)
6) Diabetes
7) Hypertension
8) Tamoxifen (Breast cancer treatment)

Most of the risk factors for cancer of the uterus are related to hormones, especially excess estrogen.

What is Uterine Cancer?

Also called: Cancer of the uterus, cancer of the womb.

Cancer is a disease in which certain body cells becomes abnormal and divide itself very fast to produce too much tissue which forms a tumor. The uterus is the hollow, pear shaped organ in the lower abdomen where the baby grows if a women is pregnant.

Uterine cancer is the most common cancer of the female reproductive system. Other types of cancer of the female reporductive system are cervical cancer and ovarian cancer. There are two types of uterine cancers: endometrial cancer (which accounts for 90% of uterine cancer) and uterine sarcomas.

Endometrial cancer happens when cancer begins in the tissue lining the uterus (endometrium). Uterine sarcomas occur when cancer grows in the muscles or other supporting tissues in the uterus.


Endometrial cancer

Adenocarcinoma, which are more common during perimenopause (i.e., transitional years proceeding and following actual menopause) and usually are associated with an early onset of symptoms. It originates in surface cells of the endometrium, and accounts for 75%– 90% of all cases of endometrial cancer.

Other types of endometrial cancer include adenosquamous carcinoma, papillary serous carcinoma and clear cell carcinoma. These three types of endometrial cancer usually have poor prognosis (i.e. more likely to spread and recur).

Uterine sarcoma

Types of uterine sarcoma include carcinosarcoma (most common type), leiomyosarcoma (develop in the muscle layer of the uterus called the myometrium), and endometrial stromal sarcoma (develop in supporting connective tissue).