• Rest
• Activity
• Medications
• Potential developments such as fever, increased pain, and bleeding (You will be instructed to call your doctor immediately should any of these symptoms occur.)

You will also be given an appointment to see your doctor after your discharge from the hospital (usually in 1 to 2 weeks). The discharge instructions are the joint responsibility of your doctor as well as the nursing staff at the hospital.

Carolyn’s comment:

Even during my first few days of recovery, I felt better. I felt more like my normal self. I was ready to resume all normal activity after about 4 weeks, including exercise, and by week 6, I got my doctor’s approval to do so. It is a relief to know that the fibroid is gone now; I hadn’t realized how much it had affected me all this time. A thin line of a scar is a small price to pay for how much better I feel now.

1. Pain: To prevent pain, you will be given adequate anesthesia during the operation, and postoperatively you will be placed on pain medication as the need dictates.
2. Infection: Two very important steps are essential during this type of surgery:
   - Observation of sterile techniques
   - Administration of preoperative preventative antibiotics (these may at times also be administered during the operation)
3. Blood clots: Clots are a very serious potential risk. The surgeon will place special compression stockings on both lower extremities during and after surgery. In patients who, because of their medical history, are at increased risk for developing blood clots (thromboembolism), special blood-thinning medication (heparin) may also be administered.
4. Injury to internal organs: This is prevented by:
   - Keeping the bladder drained and empty during surgery
   - Packing the intestines away from the immediate surgical field with sterile towels
   - The surgeon’s paying very strict attention to the various anatomical structures that he or she encounters
5. Bleeding or hemorrhage: The surgeon’s skill and expertise will be used to identify the vascular structures,and he or she will ligate (tie), occlude (clamp), or cauterize the blood vessels as the need dictates.

In the preoperative area, you will be asked to state your doctor’s name and the proposed surgical procedure you will be undergoing. You will then be asked to sign a consent form, which ensures that the hospital and your doctor have your legal and informed permission to perform the surgery.

The staff at the hospital will identify themselves to you and will explain what their respective duties are. You will then be asked, in an appropriately private location, to change into a hospital gown furnished by the staff. Next, the anesthesiologist usually introduces himself or herself to you and fully explains what type of anesthesia will be used. Your questions and concerns about the anesthesia should be discussed at this time. Your surgeon will be present at this time and will be available for any questions that may arise.

The anesthesiologist will then start an intravenous line (IV) in one of your arms. You may receive some preoperative antibiotics intravenously at this point.

You will then be transported, usually in a gurney (mobile bed) to the operating room. Attending to you in the operating room will be your doctor, an assistant surgeon (if needed), the anesthesiologist, and at least two nurses. You will then be placed on the operating table, which may resemble a narrow bedlike structure.

At this point, a number of monitoring devices will be attached, painlessly, to you. These generally include:

• A blood pressure cuff,
• A pulse oximeter, which measures the amount of oxygen you are utilizing, and
• A cardiac monitor to constantly evaluate the activity of your heart.

The anesthesiologist will then administer medication intravenously to put you to sleep and will inform the surgical team when you have been adequately anesthetized.

An indwelling catheter (Foley catheter) will then be inserted through your urethra into the bladder. This catheter will be left in place throughout the surgical procedure for three basic reasons:

1. To keep the bladder deflated (empty), thereby reducing the risk of surgical injury to the bladder
2. To keep the bladder as small as possible to prevent blocking the surgeon’s view during the operation
3. To indicate to the surgical team, through the constant draining of urine, how well your kidneys are functioning during the operation The area on your body, through which the surgery will be performed (i.e., the abdomen and/or the vagina), will then be meticulously washed with special cleaning solutions in order to achieve a sterile surgical field.

The surgeon, dressed in sterile surgical gown and gloves, will then place sterile drapes over the proposed surgical area. Then the surgical procedure will begin.

1. Your doctor will thoroughly review your medical history and your physical examination.
2. The planned surgical procedure should be explained in detail to you in simple language, and all your questions should be fully answered.
3. Based on your age and medical history, there are certain laboratory evaluations that must be done. These may include:
   - A complete blood count to ensure that you have enough blood in your system to safely withstand a major operation.
   - Coagulation studies to indicate whether your blood clots normally and to help establish that you have no abnormal bleeding tendencies.
4. An electrocardiogram (EKG) may be performed to evaluate the status of your heart. This test is usually dictated by your age (45 years or older) and your medical history.
5. A chest X-ray is performed based on your age and medical history.
6. Medical clearance from your internist or primary care physician may be indicated. This also may depend on your age and medical history. If you have any significant medical problems such as heart disease, diabetes, or lung disease, a medical clearance may be requested by your gynecologist prior to
   surgery.
7. Finally, you will always be instructed to have NOTHING to eat or drink for at least 8 hours before the scheduled time for your surgery.

Authorization for your hospitalization and surgery should have been obtained from your medical insurance company. This is important, so that you will fully understand what your financial obligations are to the
hospital as well as your doctor.

Ideally, it is best to seek a second opinion at a major teaching hospital (which is an institution where medical students, interns, and residents are trained). There you will find expert physicians on staff who would be willing to evaluate your case. Another way of finding a physician is to ask friends or family members, especially women who have had a medical problem similar to your own. If that route is not feasible, you can contact the local medical societies in your area or go online to the Web site of the American College of Obstetricians and Gynecologists (www.acorg.org), which maintains a database of member physicians throughout the United States. You may also elect to ask your family physician to refer you to another doctor for a second opinion.

What if the second opinion differs from the first?

You are an active participant in your health care, and when two doctors render completely different opinions, it is not a time for you to shy away in confusion. You should ask both physicians how they reached their conclusions, and why each has such divergent recommendations. You may also want to seek a third opinion. A third opinion that corroborates one of the first two may provide guidance on which path would be the best for you to take.

What medical information do I give the second gynecologist?

All of the medical information that has been gathered in your case is relevant for a second opinion. That information includes your medical records, ultrasound images, medication history, the outcome of previous alternative procedures, and your own oral history of your pain and/or abnormal bleeding. You can request as many opinions as you wish. As mentioned in the previous answer, two differing opinions can seem confusing, leaving the patient uncertain as to which physician is offering the best medical judgment in her case. When patients become their own health advocates, they actively seek answers to their questions.

In the first few years when uterine artery embolization (UAE) became available, few doctors felt confident performing the procedure, and many others did not refer patients to physicians who were well trained in the technique. Doctors now are finding that UAE is becoming an important option that helps women avoid a hysterectomy.

On the other hand, a second opinion also can confirm that a hysterectomy is the best solution after what may have been a long and frustrating series of alternate treatments that proved futile. In instances when multiple fibroids have obstructed the uterus growing within its cavity and between its walls, procedures that attempt to remove the fibroids alone may not be possible.When the patient is suffering significant pain and excessive bleeding is causing severe anemia, a hysterectomy may be the best way to achieve relief. The surgery eliminates the source of pain and permanently stops the blood loss.

For your peace of mind, you should actively seek the opinion of another physician to make certain the first doctor’s recommendation for surgery is indisputable. Second opinions are important when major surgery is planned, regardless of the reason for the operation. Hysterectomy is just one of many procedures for which an insurer may demand a second opinion. In fairness to insurance companies, many are recommending evaluations by a disinterested second party because the companies have found some surgeries and diagnostic tests are performed unnecessarily and that patients may be better served by a less expensive procedure.

Most insurers will pay for the cost of a second opinion, as will Medicare. In many states, Medicaid also will cover the cost. However, if your insurer is demanding a second opinion but will not cover the expense, you still may consider handling the cost yourself because of the value you will gain by having a second physician review your chart and tests. In instances when an insurer will not pay for the second opinion, it is also possible for you to appeal the refusal. Given that the insurance company demanded the second evaluation, you can make a case to the administrators of your health insurance plan.

While all of this may seem harassing at a time when you may not be feeling your best physically, bear in mind that a second opinion helps you more than it helps the insurance company. Hysterectomy can have a profound psychological impact on some women. As with any form of surgery, hysterectomy can produce anxiety, but it also causes postoperative pain and may even bring about menopause at an early age. Therefore, you will want to be certain that the procedure is warranted and necessary. You do not want to be misled into an operation that is irreversible.

Finally, you may even want to start a journal that will help you understand where you have been in your journey and whether you are comfortable with the prospect of having your uterus and possibly other reproductive structures removed, no matter what your age. Keep in mind that a hysterectomy can have a different effect based on how it is performed. For example, if your ovaries are left intact, you will continue to produce your natural flow of hormones. If you are being treated for a condition other than cancer and you have been told that your ovaries should be removed, you certainly will want a second opinion to fully understand the need for the more radical procedure.

Physicians are not insulted when their patients seek second opinions. They are accustomed to their patients going elsewhere for an additional opinion. Your doctor also is well aware that insurers often ask for second opinions, and many welcome an evaluation that will likely corroborate their medical judgment. Conscientious physicians welcome second opinions and encourage their patients to seek them. Your physician probably has given dozens of second opinions involving the recommendations of other physicians and is familiar with the need to offer an evaluation on another physicians’ cases.

It’s easy to say that you have seen your gynecologist for years and fully trust his or her medical judgment, but even in instances where there is a strong bond between doctor and patient, you owe yourself the peace of mind of knowing your doctor’s diagnosis has been corroborated by another expert.

Also, it is important to note that standards mandating surgery can differ from one region of the country to another, from one hospital to the next, and even from one physician to another.With that in mind, it again is in your best interest to seek a second opinion.With respect to elective procedures (and a hysterectomy is one of them), you are the final arbiter on whether surgery is best in your case; you determine whether the pain associated with an invasive surgery is worth the time, money, and temporary physical discomfort. The most effective way to make this decision is by listening to what more than one doctor has to say. Every patient who is scheduled to have a hysterectomy or any major surgery should be encouraged by her physician to get a second opinion.

The object of this procedure is to destroy or alter the lining of the uterine cavity by applying heat or thermal energy, with the aid of the hysteroscope. Two of the more frequently used methods are laser ablation and hydrothermal ablation.

In some patients, endometrial ablation is effective in treating the abnormal uterine bleeding caused by submucosal fibroids.

Myolysis is believed to work best on smaller fibroids and is not recommended for those that may have grown to the size of a cantaloupe. Treatment through myolysis allows your doctor to eliminate the fibroids’ blood supply by using a laser or electrical current to cauterize (burn) the blood vessels feeding the growths.

The technique usually is recommended to those who are not planning to have children, as serious complications of pregnancy have been known to occur among women who have been treated with this technique. Theoretically, once the blood supply to the fibroid has been eliminated, the growth then shrivels and dies. However, there have been no long-term studies on myolysis.

Cryomyolysis is very similar except that it uses a super cooled probe to freeze the fibroids, which causes the growths to wither and die. A benefit is that it helps to prevent invasive surgery and removal of the uterus. Both procedures take about an hour to perform, and patients do not have to be hospitalized. After either procedure, patients have reported abdominal pain and cramping. Their discomfort can be treated with mild painkillers. Recuperation requires a few days compared with 6 weeks for a hysterectomy.