Category — Ask Dr. R.

Dear Dr. Romanzi,
(I bet you don’t get too many men writing you for help!) My dearest sweetheart suffers from a prolapsed uterus/bladder and is considering having a hysterectomy at the advice of her gyno. Being a former pre-med student and having seen what my mother and sister-in-law went through in their hysterectomies (cancer related…) I keep trying to convince her that this a radical surgical approach for a problem that demands far less. She has had 2 children, is 52 years old and is physically active. However, “the bulge” is causing her discomfort in her exercising and she is talking more and more of the hysterectomy. I am ordering your book tonight, but in the meantime had some questions… 1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work? 2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery, and 3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure. If the former, what does it typically cost? She is a women of limited means and this obviously comes into the equation. Thanks so much for your help. D

Hello D,

Thank you for writing in – I know there are more men out there trying to help the women they love, and your willingness to post your questions will undoubtedly help other men actively advocate for the health of the women in the lives.
1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work?
She may do perfectly well with a pessary and I often advise pessary use before any other therapies are considered. But some women cannot be fit with comfortable pessary or a pessary that truly holds it all in due to the severity of prolapse (the worse the prolapse the more difficult to find a well fitting comfortable pessary) or idiosyncracies in the boney pelvis that make pessaries uncomfortable, in which case the next option is reconstructive surgery. Some women may be fitted for a pessary that works perfectly well, but they find it annoying or “unsexy” to use, in which case it may be worn until she has time to undergo reconstructive surgery and it’s recuperation (~4 weeks to return to work, 6-8 week til sex is possible). Pessaries that fit well physically and jive with lifestyle and body image provide an excellent non-surgical therapy for prolapse.
2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery,
The major university medical centers all have urogynecology divisions run by fellowship trained specialists – these are a good place to start. You may want to obtain several opinions should you choose reconstructive surgery.
3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure
Prolapse surgery is the same as any other reconstructive surgery, be it a hernia, a knee repair or a rotator cuff repair. While not an emergency, it is a recognized condition that insurance companies do not consider cosmetic.
Finally, hysterectomy does not improve the durability of prolapse surgery, and she DOES NOT need a hysterectomy to benefit from excellent long term (hopefully life-long) results should she choose to undergo reconstructive pelvic surgery. Recurrence is possible with any and all reconstructive operations done anywhere in the body by any technique, and prolapse repair is prone to recurrence in the same way hernias may recur and damaged knee ligaments may not last forever after knee surgery. Reconstructive surgery puts things back together, unlike extirpative surgery that takes things out – appendix out, guaranteed you’ll never have to have it removed again! Hernia surgery – might need another one someday.
In order to help women understand the causes, therapies and surgeries for prolapse, I wrote PLUMBING AND RENOVATIONS as an in-hand resource for women with prolapse and/or incontinence (www.plumbingandrenovations.com). She may find this book a helpful guide as the therapeutic options are considered. Thank you for writing in and please do keep us posted.

Best Regards,
DR R

Likewise, I am 43 and going through the same situation. I had a partial hysterectomy in 2008. For the past two months and currently, I am experience right side pain, and it has been diagnosed as ovarian cyst. The pain stopped for about two weeks, but now it is starting again. Does the cyst rupture and reoccur?

Hello GM:

The ovarian cyst could be de-compressing, leaking cyst fluid as it does so, and this fluid can cause severe but transient pain that is not a sign of damage. Or it could be twisting (this is called ovarian torsion) which IS dangerous and does require close follow-up and may well require surgical intervention. Or the cyst may be growing larger or may be infected, again both requiring close follow-up and intervention. You must report all these symptoms to your doctor immediately as the develop, as I trust you have done.

Best Regards,

Dr R

Preliminary note:  Many people consider surgical removal of the uterus, with ovaries left in the body, to be a “partial hysterectomy”.  Actually, the term hysterectomy refers only to the uterus, not the ovaries.  When surgeons remove the uterus and ovaries it is called a hysterectomy with bilateral (both sides) salpingoophorectomy (tubes and ovaries removed).  To surgeons, the term partial hysterectomy infers removal of the body of the uterus with the cervix left in place, or more accurately, “subtotal” or “supracervical” hysterectomy. 

Read on…

Dr. R, I had a partial Hysterectomy in 2002. I had been having pain on my right side. Find out that it is a cyst. The pain is very intense and is getting worsre. I want my doctor to finish the hysterectomy this time instead of just removing the cyst because he said it could come back. I am 43yrs old. Do you think this is wise to just go ahead and have the full hysterectomy this time? And also do you think that I would go straight into menopause at this age. I don’t want them to keep going in and out.

Thanks Dr. R

Hello,
If indeed the cyst is the source of pain, something that only your examining physician can determine, then at minimum the cyst must be removed if it does not resolve spontaneously, and some cysts, particularly cysts that occur as a result of ovulation, do resolve spontaneously.  Cysts that are large, twisting (called ovarian torsion), not associated with ovulation, or are suspicious of containing cancer must be surgically removed and sometimes cannot be removed without totally removing the ovary from which they arise.
To remove both ovaries will bring on abrupt surgical menopause to any woman at any age, unless of course she has already gone through natural menopause. The average age of menopause is 51, so the decision to induce this in yourself 8 years earlier than might otherwise occur requires careful counseling from your doctor and consideration from yourself. You may benefit from perusing the patient resources on the North American Menopause Society website: http://www.menopause.org/Consumers.aspx.  As with all other complicated surgical decisions, you may want to obtain other clinical opinions from consultants who review your test reports combined with a physical exam to give you the answers to the issues outlined in this response. Obviously, given the pain involved, such second opinions are to be arranged urgently!  Do not delay. Keep us posted…

Best Regards,

Dr R

Saw you on Dr. Oz yesterday. I have bladder prolapse, 64 y.o. female. Rx given for Vagi-fem to help irritation in perianal area (original complaint). I use baby oil for sexual activity so have no pain during intercourse.Planning to have surgery in August to lift bladder. Will be taking Vagi-fem now help revive my interior so that the surgery will be more effective. Does that make sense? I will be using topical Vitamin E for external irritation.

Hello,
Estrogen applied topically to wounds has been shown to improve wound healing, so using Vagifem before your surgery is a good idea. The use of any oil for lubrication must be approached skeptically, as the vagina is not designed to be “oily” and chronic use of oils can throw things out of balance, resulting in chemical or bacterial vaginitis after prolonged use. Also, Vitamin E can thin the blood and increase bruising and bleeding, making it even more difficult to agree with your plan to use Vitamin E oil after the surgery. For more information on preparing for surgery, supplements to augment wound healing, and what to expect during recovery, you may find my book a helpful resource http://www.plumbingandrenovations.com
Best Regards,
Dr. R

I am 79 years old, live in the Chicago area. I have a urinary prolapse. Can you recommend a good urogynecologist for me to see
Hello Chicago,
You will find a comprehensive list of urogynecologists in your area by visiting http://www.augs.org and using the “find a physician” feature. You may also use my book on prolapse as a reference http://www.plumbingandrenovations.com for a description of all the surgical and non-surgical options, including how to figure out if a hysterectomy is smart for you, or if you would be just as well off with a uterine resuspension, should you choose reconstructive surgery.
Best Regards,
Dr. R

My period is on it’s 3rd day. And a moment ago when I went to pee. I wiped myself and felt something somewhat hanging out. So I took my finger and pushed it back in. And then I relized it is my uterus. And this would explain why for the past 11 months. I was not able to empty my bladder fully. I have no pain, and my periods are normal. But, it makes so much sense now. And I did some research saw that they can go back in and re-attach it. So to tell you the truth. I am not that worried anymore.  And I am 34 years old & still single! So I am nervous but, not scared anymore. So what do you think?
Hello,
I think you are an excellent diagnostician, and an excellent candidate for uterine resuspension along with whatever concurrent vaginal prolapse issues may also be present, such as cystocele, rectocele, perineocele, and laxity, if indeed a physical exam proves you right. You also have the option to use a pessary, which would allow you to avoid surgery until you are completed with childbearing, as pregnancy will increased the possibility of recurrent prolapse should you choose prolapse surgery, then proceed to have a baby.
You are correct not to be afraid. It’s a connective tissue problem that can happen to any woman, even young women who have never been pregnant, and it can be managed to suit your lifestyle and personal goals. For a detailed explanation of prolapse, incontinence, pessaries and reconstructive surgery options including various methods of uterine resuspension, see http://www.plumbingandrenovations.com.
Keep me posted. Thank you for sharing your story – it is bound to help someone else with prolapse feel less isolated and fearful.
Best Regards,
Dr. R

Hi Dr!
I had a baby and since then I have problem, to urinate and so much pain that I can not have sex at all.

I was wondering if you take patient from Québec.

Hello Quebec,
While I do take care of many patients from outside the States, I believe you will find your answers readily available close to home. Whether your symptoms are due to the common, transient thinning of vaginal skin in breastfeeding mothers or due to other childbirth factors, I am certain your obstetrician or midwife can help you without leaving home. If you’d like a second opinion, please do call my office, where my staff can help you arrange lodging in New York City.
Best Regards,
Dr. R

names locations doctors John Hopkins Baltimore &Florida Keys 33043 uterine resuspension NO HYSTERECTOMY YOUR PROCEDURE
uterosacral vaginal hysteropexy
THANK YOU

Hello Florida,

My specific procedure is available through me and a few colleagues I have trained, all here in New York. The good news, however, is that there are several techniques of uterine resuspension, and if you cannot come to New York (we take care of patients from all over, and have arrangements with several NYC hotels for surgical patients) then I recommend looking for specialists geographically close to you at http://www.augs.org, calling the offices and asking if the doctor advocates for and is experienced in uterine resuspension by another technique. For more information that is travel-free, you may want to peruse my book on prolapse and vaginal rejuvenation at http://www.plumbingandrenovations.com. All the various techniques areillustrated and explained in great detail in the book!
Best Regards,
Dr. R

I recently read your book, “Plumbing and Renovations” and appreciated the way you talked about topics that are typically viewed as ‘taboo’ in a conversational and optimistic way. My question is: how do you know if you are experiencing uterine prolapse, as opposed to vaginal prolapse? And which one is a more serious condition?

Hello Orange County,

You ask an excellent question. Most commonly, vaginal and uterine prolapse occur together, because pelvic support of the uterus and vaginal walls are interdependent and vulnerable to the same prolapse-inducing forces. Neither would be “more serious” than the other, and each can occur to variable degrees, as, having read the book, you are likely aware. For women with prolapse, sometimes the different areas of prolapse alternate “taking the lead”, making things even more confusing for the woman with the condition. A careful examination in various positions (lying flat, standing and seated) with a prolapse specialist will give you all the answers. Thank you for your commentary!
Best Regards,
Dr. R

www.plumbingandrenovations.com

Hello Doctor,
I am a 48 year old, one vaginal delivery with stress incontinence since. Recently had difficulty with tampon insertion during period….went to PCP and she said I have a cystocele and prolapse of uterus. I am so stressed about it. I am extremely active and lift weights and kickbox..do a lot of cardio with jumping. Now feels like I have a tampon in when I work out after. I have three fibroids…one in fundus meas. 5cm one central meas. 4.8cm and one at lower margin 2.8cm. I am pertrified of mesh support. What do you as a woman who understands uterine preservation emotionally for a woman think about myomectomy with ligament suspension shortening and pessary when exercising and tabel invertion therapy????? Curious as to what you think.

Hello Ms. S,
You bring many important issues to the table. Your fibroids don’t sound big enough to be an issue here, but the necessity of myomectomy or other fibroid specific therapy can only be determined with a live consultation and recent imaging. Assuming your fibroids are present but of no clinical relevance at present, you may not even need surgery. With mild prolapse, pessary use and Kegel exercise may be all you need to hold the prolapse at bay while you continue to kickbox and live a full and active life. I am very strongly biased toward uterine resuspension for women with prolapse, unless there is a very good reason, aside from the prolapse, to consider concomitant hysterectomy, and completely understand and validate your emotional attachment to your uterus. I also understand your reticence regarding mesh – all graft materials must be carefully considered, and there is a growing concern regarding plastic/permanent mesh support grafting for prolapse repair. There is no data on table inversion therapy for prolapse, but it certainly won’t make anything worse. Or as I say in my book, parachute jumping, no, bungie jumping, yes. If you can travel to NYC, you can ask to speak to my patient advocate, Judy, about scheduling a consultation. Or you may find my book on pelvic organ prolapse and vaginal rejuvenation helpful – exercises, pessaries, graft materials and all the current uterine resuspension techniques are described and illustrated – see http://www.plumbingandrenovations.com. For a specialist in your area, see http://www.augs.org.
All the best!
Dr. R