Overview

What Is It?

Facing surgery can be a frightening experience fraught with questions, doubts and uncertainties. However, most surgeries are elective, meaning that you decide if surgery is the best option for you and elect to have the procedure.

Millions of Americans undergo surgery every year, most of them women. Many women will face a recommendation for surgery that involves their reproductive system, typically called gynecologic surgery. For example, hysterectomy—surgery that removes the uterus and sometimes other parts of the reproductive tract—is the second most common gynecologic surgery after cesarean section.

Facing surgery can be a frightening experience fraught with questions, doubts and uncertainties. However, most surgeries are elective, meaning that you decide if surgery is the best option for you and elect to have the procedure. This decision process often gives you needed time to prepare, which is an important step. Research suggests that women who prepare mentally and physically for surgery have fewer complications, less pain and recover more quickly than those who don't prepare.

Following the invention of anesthesia in the mid-19th century, operations were developed for conditions ranging from appendicitis to uterine fibroids. Enthusiasm for gynecologic surgery was especially intense, and the first hysterectomy was performed in 1843 in Manchester, England.

Today, the trend in gynecologic surgery is toward less invasive techniques that don't require surgeons to cut into the abdomen with large incisions. Doctors are even trying incisionless surgery—a new technique where internal organs are removed through body orifices such as the mouth or the vagina. Also, new, faster-acting anesthetics have been developed that have fewer side effects than traditional anesthetic agents.

Settings for surgery have changed, too. Not long ago, having surgery meant being admitted to the hospital a day ahead and discharged a week later. Today, more than half of all surgeries, including many gynecological procedures, are done on an outpatient basis. Outpatient surgery refers to operations that do not require an overnight hospital stay. Instead, the surgery is performed at an ambulatory surgery center or a health care professional's office, and you return home in less than 24 hours. Now there is also a choice between hospitals' ambulatory surgery centers and free-standing ambulatory surgery centers, which are becoming more popular and can often be found in the suburbs, even in shopping malls. They are physically separate from—and sometimes even distant from—a hospital.

Generally, outpatient, or ambulatory, surgery is appropriate for healthy individuals and for simple procedures that can be done in 60 to 90 minutes and don't require a person to be closely monitored afterward. Outpatient surgery offers several advantages over surgery that requires hospitalization, such as:

• a lower risk of infection after surgery
• recovery at home
• fewer delays and shorter waiting times
• lower cost
• less disruption of your schedule

However, if a large incision has to be made or if the risk of complication is high, same-day surgery or having surgery performed at a free-standing surgical center may not be an option. Outpatient surgery is not for everyone. Women with chronic conditions such as diabetes, heart disease or high blood pressure (hypertension), or who are otherwise at risk for complications that could require hospitalization, might not be eligible.

Same-day surgery also puts more responsibility on the patient to manage pain medications, keep incisions clean and follow through with postoperative care on their own. A woman who has small children to care for at home may be unwilling or unable to take on the added responsibility and may not be a good candidate for same-day surgery. If you face a recommendation for surgery, be sure to consider which type of setting will work best for you.

Preparing Emotionally

Surgery also has an emotional impact. A woman who has heard, perhaps incorrectly, that a hysterectomy will ruin her sex life or leave her tired for months, for example, may become depressed, fearful or angry with her body. For some women, the anticipation of being hospitalized and separated from family members makes coping difficult. Even simple procedures done in a doctor's office can provoke a strong reaction. Advances such as same-day surgery may make surgery more convenient, but they haven't necessarily made it less stressful. Regardless of what kind of surgery you have, stress is involved. Hormones released in response to stress can cause symptoms ranging from headaches to high blood pressure. Stress hormones can also weaken the immune system and disrupt the body's ability to manage pain and infection.

Some experts advocate preparing for surgery through a series of relaxation techniques: deep breathing, positive thinking and visualization—imagining or mentally seeing—a positive outcome from surgery and a quick recovery period, for example.

Preparing Physically

While emotional preparation is a necessary, often-overlooked step, preparing physically is also important for a successful surgical outcome. In the weeks before your surgery, you should:

• Stop smoking and avoid excessive alcohol.
• Eat a well-balanced diet including plenty of foods rich in vitamin C, which may help promote tissue healing.
• Avoid aspirin or other aspirin-like medications that interfere with blood clotting for five to seven days before your surgery, but be sure and discuss it with your health care provider before stopping any medication.
• Exercise regularly to build energy and maintain strength.
• Ready your home, including preparing food and rearranging furniture if necessary.
• If necessary, arrange for someone to take care of your children while you are in the hospital.
• Arrange for help at home after discharge, if you will need some time to recover.

If you decide to have surgery, discuss the following with your health care professional:

• Determine when elective surgery can be scheduled, taking into consideration your job and family commitments. Sometimes it is not possible to know the exact time of the surgery until the business day before the actual date.
• Learn which routine laboratory tests may be needed, which may include x-rays, blood tests, urine tests and an electrocardiogram (EKG or ECG), a measurement of electrical impulses produced by the heart.
• Ask if you need to change the schedule and dosage of any medications you are taking.
• If you are diabetic, discuss how to manage or modify your insulin intake during the time before your surgery when you are not eating.
• Since there are often several ways to perform a specific procedure, ask your doctor to explain the surgery and how it is done and to explain if there is more than one way to do it. For example, if you have fibroids, you have an option to choose between a hysterectomy (removal of the entire uterus, which can be done in several ways), a myomectomy (removal of the fibroid tumor alone), a uterine artery embolization (cutting off blood supply to the uterus), plus a couple of other noninvasive ways to remove fibroids. Discuss the risks and benefits of each alternative.
• If you are preparing for elective surgery, you get to choose your surgeon and may want to do some homework about the surgeon: What are his/her qualifications? Board certifications? Sub-specialities? How many similar procedures has the surgeon performed? What is the success rate? Remember, however, that the most important reason to choose a surgeon is that you feel respected and listened to; you communicate well with the surgeon; and you are not intimidated by him or her.

Legal Considerations

Once you've decided on surgery, had the necessary tests done and prepared mentally and physically, you'll be asked to sign a consent form. This may also be a good time to consider donating blood for your surgery, if you wish to, and drawing up advance directives. These instructions communicate your health care plans if you cannot speak for yourself in the future.

There are two kinds of advance directives: a living will and a health care proxy. States differ in the directives they recognize. Discuss your wishes with your health care professional and your lawyer, if you have one. State-specific directives are available from the National Hospice and Palliative Care Organization website at www.caringinfo.org, or you can obtain one from your local health department, state medical associations, a hospital admissions office or your primary care provider.

A health care professional is required to have a detailed discussion with you before your surgery so that you are fully informed when making the decision whether and how to have it. This is called obtaining your "informed consent" to have the procedure. The informed consent process should include discussion of the risks and benefits of the proposed surgery.

Consent forms differ from one health care professional to another and may include permission for additional procedures to be performed if needed. Ask to sign the consent form several days in advance to avoid being confronted with a list of risks immediately before surgery, which can create anxiety. Do not sign the consent form until you understand and feel comfortable about what is being done. Don't let this part of the process feel rushed. Ask questions if you need to.

Before surgery you may also be asked to sign a form allowing a blood transfusion to be performed, if necessary. Normally, blood donated to the Red Cross four to six weeks in advance of your surgery is shipped to the hospital a few days before your surgery. However, you can also donate your own, called an autologous blood donation. Or you can ask family members or friends with the same blood type to donate units of blood for you. You'll need to inform your surgeon whom you have chosen to donate blood for your use.

If you're considering autologous blood donation:

• Ask your surgeon if you are likely to need blood and if so, how much.
• Consider taking iron supplements to rebuild your blood supply before surgery.

Call the Red Cross and ask about fees and insurance coverage and about freezing your blood if your surgery is delayed.

Financial Considerations

Familiarize yourself with the extent of your medical benefit plan before your operation so you will know what portion of the costs will be your responsibility. Your physician's office staff may be able to help you find out how much your medical benefit plan will cover. If your medical benefit plan will not pay all of the anticipated costs and you cannot afford the difference, then discuss this situation with your surgeon to see if you can work out an acceptable solution.

Some procedures and some health plans require pre-authorization before your operation. Become familiar with your insurance plan requirements to avoid unpleasant surprises after your surgery.

Understanding Pain

Knowing what to expect after surgery is as important as knowing what to expect beforehand. Pain is an inevitable part of surgery. Pain is the body's way of sending a warning to the brain that it has been damaged and needs attention. Although a normal reaction to surgery, pain can interfere with recovery by:

• causing you to suppress coughs, which can lead to a build-up of fluid in the lungs and pneumonia
• slowing the return to normal digestion
• preventing you from getting out of bed, raising the risk of blood clots
• increasing stress, depression, and anxiety

There are several ways to relieve pain after surgery. Narcotics, such as morphine and codeine may be prescribed for severe pain following surgery via IV, pills or patches. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or other non-narcotic pain relievers may also be used, either as liquids or in pill form. Local anesthetic injections or anesthetic creams and patches may help prepare your body for a procedure or relieve pain afterward.

Depending on the type of surgery you are having, you may also be given pain relievers through patient-controlled intravenous analgesia (PCA), which is usually used in hospitals for acute pain following surgery. In PCA, the patient is connected to a machine called a PCA pump. When the patient pushes a control button, the machine delivers a dose of narcotic or other pain reliever through the veins. The doses are smaller than what would be given by injection, but because the drug goes directly into the bloodstream, relief can occur within seconds.

Ask the surgeon or anesthesiologist to discuss these options with you beforehand. Other nonmedical approaches to pain management can be very successful. These may include:

• relaxation techniques
• applying heat or ice to the surgical site
• massage and stretching exercises

When preparing for surgery, discuss with your health care professional what possible pains to expect after your procedure and how to best manage any possible symptoms.

Diagnosis

When your health care provider informs you that surgery is a recommended treatment option, there are a number of decisions for you to make. These include whether to have surgery at all, and if so, when to schedule it and whom to choose as your surgeon. Typically, several options are available before surgery and must be seriously considered. Generally, surgery should be considered only after more conservative measures have been exhausted. Though it may be tempting to take the last step first, because surgery may seem like the most definite solution, you need to remember that surgery may not be the only answer. Every procedure has risks, and no surgeon can guarantee a good outcome.

Because most conditions are not emergencies, alternatives to surgery are often good choices. One alternative may be watchful waiting to see if a condition improves or worsens on its own. For example, small fibroids that cause no symptoms may need no treatment at all. Fibroids shrink after menopause, so a woman who is close to menopause may try waiting to see if her symptoms subside once she stops menstruating. Fibroids and abnormal uterine bleeding may also be treated first with hormones or with minimally invasive surgery. By choosing to wait or investigating other options, women may be able to postpone surgery indefinitely.

Once the decision to have surgery has been made, a woman should have a clear idea of what is treatable by surgery and what is not. For some women, having too much detailed information about an impending operation is stressful. Still, a woman needs to be informed enough about the surgery to tell the surgeon what she wants done and what her wishes are in the event of unexpected findings.

Surgeries are designed to relieve symptoms, diagnose a condition or extend life. Having a good understanding of the procedure beforehand can make surgery less stressful and result in a better outcome. The informed woman should ask her health care professional what precisely an operation is meant to do, and if something is going to be removed, she should know why exactly.

If an operation can be done more than one way, a woman can weigh the benefits of having a less invasive procedure. A woman should ask the surgeon whether the procedure she is considering is one he or she does frequently or only on occasion. Often, a surgeon who is used to doing a procedure a certain way and has performed a lot of them has better results.

You should also discuss possible complications, such as infection, bleeding or reactions to anesthesia. Knowing what to expect after surgery allows you to feel more in control and better able to cope with recovery. Getting answers to certain questions can help. (See "Questions to Ask" section.)

Developing a good relationship with your health care team can help you feel more comfortable about your treatment and the outcome of your surgery. Some physicians are better communicators than others. Look for a physician who:

• is patient and approachable
• is forthcoming with information
• is a good listener
• is willing to address your concerns
• is competent and experienced
• has a team in place that shares these traits and is willing to help you if you ask

Getting a second medical opinion on any medical recommendation, if possible, can help make your options clearer to you. The advice of another health care professional can:

• verify your diagnosis
• ensure that all other forms of treatment have been explored
• satisfy health insurance requirements
• be a source of more information

A competent health care professional should not be insulted if you decide to get further advice. Sources for finding a medical expert to provide a second opinion include your primary health care provider—ask him or her to refer you to another surgeon; family or friends who have had success with a particular health care professional; and a local medical society or national association of specialists. Your health insurance coverage may require a second opinion and require you to choose from its list of providers.

Treatment

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 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 Presurgical 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 examined and questions will be asked about your health. Blood and urine samples will be taken. You may undergo 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 professionals.

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.

• Myolysis. This laparoscopic procedure uses an electric current or laser to destroy fibroids and shrink the blood vessels that feed them. A similar procedure called cryomyolysis freezes fibroids with liquid nitrogen. Safety, effectiveness and risk of fibroid recurrence with these procedures are yet to be determined.
• 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. Endometrial ablation involves using heat, electricity, laser, freezing or other methods to destroy the lining of the uterus. These procedures are recommended only for women who have completed their families because they affect fertility. However, following treatment, you must use contraception. Although endometrial ablation destroys the uterine lining, there is a small chance that pregnancy could occur, which could be dangerous to both mother and fetus. Overall, endometrial ablation procedures have a good success rate at reducing heavy bleeding, and some women stop having menstrual periods altogether.
  
  Some 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.
• 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 it 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 options with your surgeon or anesthesiologist.

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

Prevention

While there is not really a way to prevent necessary gynecologic surgery, you should carefully consider alternatives to elective surgery. The most common alternatives to hysterectomy as a treatment for fibroids, endometriosis and abnormal uterine bleeding, for example, are watchful waiting and hormonal therapies.

For example, birth control pills may be used successfully to treat abnormal bleeding or pain caused by endometriosis.

If you decide surgery is your best option, ask your surgeon:

• Is there a minimally invasive approach to this type of surgery?
• What are the risks and benefits associated with this choice?
• How many times have you performed this procedure?
• How long will I be hospitalized and approximately how long will it take for me to recover?
• How can I prepare before and after the surgery?
• Where can I learn more about the surgery?

Facts to Know

1. Millions of Americans undergo surgery every year, many of them women. Many women will face a recommendation for surgery that involves their reproductive system, typically called gynecologic surgery.
2. Today, more than half of all surgeries, including many gynecological procedures, are done on an outpatient basis. Outpatient surgery refers to operations that do not require an overnight hospital stay.
3. Generally, outpatient or ambulatory surgery is appropriate for simple procedures that can be done in 60 to 90 minutes and don't require a person to be closely monitored afterward.
4. Outpatient surgery may not be appropriate if a large incision has to be made or if the risk of complications is high. Women with chronic conditions such as diabetes, heart disease or high blood pressure, or who are otherwise at risk for complications that could require hospitalization, also might not be eligible.
5. Same-day surgery puts more responsibility on you to complete the necessary preoperative tests, manage pain medications, keep incisions clean and follow through with postoperative care on your own.
6. In the weeks before your surgery, you should stop smoking and avoid excessive alcohol; eat a well-balanced diet; avoid aspirin or other aspirin-like medications that interfere with blood clotting for five to seven days prior; exercise regularly to build energy and maintain strength; and ready your home, including preparing food and rearranging furniture if necessary.
7. Advance directives are instructions that communicate your health care plans if you cannot speak for yourself in the future. There are two main kinds of advance directives: a living will and a health care proxy.
8. You can donate your own blood prior to surgery, in case you need a transfusion during surgery. This is called an autologous blood donation. Call the Red Cross and ask about fees and insurance coverage and about freezing your blood if your surgery is delayed.
9. Although a normal reaction to surgery, pain can interfere with recovery by: causing you to suppress coughs, which can lead to fluid in the lungs and pneumonia; slowing the return to normal digestion; preventing you from getting out of bed, raising the risk of blood clots; and increasing stress, depression and anxiety.
10. There are several ways to relieve pain after surgery. Narcotics, such as morphine, codeine, hydromorphone (Dilaudid) and meperidine (Demerol), may be prescribed for severe pain following surgery. Acetaminophen, prescription and nonprescription nonsteroidal anti-inflammatory drugs, such as ibuprofen, and similar medications, may also be used, either as liquids or pills. Local anesthetic injections or anesthetic creams may help prepare your body for a procedure or relieve pain afterward. Other nonmedical approaches to pain management may include relaxation, applying heat or ice to the surgical site and massage and stretching exercises.

Questions to Ask

Review the following Questions to Ask about preparing for surgery so you're prepared to discuss this important health issue with your health care professional.

1. How will the surgery improve my health or quality of life?
2. How long can I safely delay the surgery?
3. Where will the operation be done?
4. What presurgical tests are necessary?
5. What type of anesthesia will be used?
6. Who will be in the operating room during surgery?
7. Where will the incision be and will I have a visible scar?
8. Will more surgery be necessary?
9. Will I have bleeding or discharge after surgery?
10. What can I expect during recovery?
11. When can I resume my normal activities?
12. What, if any, limits will I have after surgery?

Key Q&A

Organizations and Support

For information and support on Preparing for Surgery, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Orthopaedic Surgeons (AAOS)
Website: https://www.aaos.org
Address: 6300 North River Road
Rosemont, IL 60018
Phone: 847-823-7186

American Brain Tumor Association
Website: https://www.abta.org
Address: 2720 River Road
Des Plaines, IL 60018
Hotline: 1-800-886-2282
Phone: 847-827-9910
Email: info@abta.org

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American College of Surgeons
Website: https://www.facs.org
Address: 633 N. Saint Clair Street
Chicago, IL 60611
Hotline: 1-800-621-4111
Phone: 312-202-5000
Email: postmaster@facs.org

American Society for Aesthetic Plastic Surgery
Website: https://www.surgery.org
Address: Central Office
11081 Winners Circle
Los Alamitos, CA 90720
Hotline: 1-888-ASAPS-11 (1-888-272-7711)
Email: asaps@surgery.org

American Society for Dermatologic Surgery
Website: https://www.asds.net
Address: 5550 Meadowbrook Dr., Suite 120
Rolling Meadows, IL 60008
Phone: 847-956-0900

American Society of Plastic Surgeons
Website: https://www.plasticsurgery.org
Address: 444 East Algonquin Road
Arlington Heights, IL 60005
Phone: 847-228-9900

Association for Professionals in Infection Control and Epidemiology, Inc.
Website: https://www.apic.org
Address: 1275 K Street NW, Suite 1000
Washington, DC 20005
Phone: 202-789-1890
Email: apicinfo@apic.org

Books

Prepare for Surgery, Heal Faster: A Guide of Mind-Body Techniques
by Peggy Huddleston

The Surgery Coach: Mind-Body Preparation for Faster, Better Recovery
by Joseph Casey

Spanish-language resources

Agency for Healthcare Research and Quality: Having Surgery? What You Need to Know
Website: https://www.ahrq.gov/topics/informacion-en-espanol/index.html
Address: Agency for Healthcare Research and Quality
Office of Communications and Knowledge Transfer
540 Gaither Road, Suite 2000
Rockville, MD 20850
Phone: 301-427-1364

Medline Plus: Surgery
Website: https://www.nlm.nih.gov/medlineplus/spanish/surgery.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov