Dear Carol,

We don't live in the Bay Area any more, and don't have anyone we can ask questions like this. My wife had a total hysterectomy eight years ago. How safe or not safe is sex toy use for a woman who is "sewn up"? Does such surgery make intercourse dangerous? There have to be millions of women who would like better source information about this -- how to prevent damage to stitches, etc. Do you have an opinion about female surgeries in general? A related question -- we hear that some gynecologists "tack down" other organs, such as the bladder, to keep internals from bouncing around after the uterus is removed. Attaching what to what? Also, how to adjust to rapid changes in desire?
-- K and G

Dear K and G,

Sex toy use should be quite safe for a post-hysterectomy woman -- depending on what toy she's using, and how she's using it. You'll want to be cautious about using vaginally insertable vibrators and dildos. With these, the primary considerations being how long the toy is, and how hard. Short and medium-length softer material toys are likely to be fine, and there'd be no reason under ordinary circumstances that she should refrain from orgasm -- so vibrator use clitorally should be perfectly okay. The thing to watch, depending on any post-hysterectomy scarring she might have, is really vigorous penetration with something hard enough to disrupt the surgical site. Scar tissue isn't as strong or flexible as normal tissue, so if she has anything to worry about, it's going wild with a long, hard dildo or vibe.

The same goes for intercourse -- if the penis in question (yours, I'm guessing) is longer than she can comfortably accommodate, go easy; let her control the depth of thrusting. If you have problems holding back, she might want to try cupping your shaft with her (lubricated) hands -- she can keep control of your depth of thrusting this way, and you'll get the touch of her palms so the rest of your penis doesn't get lonely. If you've refrained from intercourse because you're concerned about this, she can explore herself with a not-too-firm dildo and measure the depth at which penetration becomes difficult or painful. Penetration -- solo or with you -- will always be more comfortable and some degree safer when she's well aroused, because that enhances blood flow and tissue flexibility.

Arousal may be a problem, though, with a woman who is post-hysterectomy, because hormone production may go down so much that early menopause results. This can happen even if her ovaries have been left intact, because the surgery can so affect blood flow to the ovaries that they can't keep up. It's also possible that blood flow to the entire genital region could be impacted, and blood flow is one of the physiological ways, in women as well as men, that sexual arousal manifests itself. When it's decreased, as it's possible to be in a woman post-hysterectomy, it's hard for a woman to get as turned on as she wishes she could, even when she emotionally wants to have sex. The two of you should take your time, and definitely have lube by the bed. Many women have sexual side effects from hysterectomy -- about half, it's estimated -- so she, and you, are not alone.

Your wife's doctor is the one who can give you two a real update on the surgical site and how easily disrupted it might be by intercourse. The doc can also discuss hormone replacement therapies with her. In the case of substantially reduced libido, a testosterone cream or patch can be prescribed which might make a real difference. Before this can be done, though, she'll need a complete physical (or consultation with a doc who already knows her medical history and current status). If she can't discuss sexual issues with her physician at all (or if the doctor doesn't seem to know or care about these issues), it would be wise to look for a new doctor. Old-fashioned physicians still tell women post-hysterectomy sexual side effects are "all in their heads," but this isn't the current view, nor is it a very hopeful or empathetic way for a doctor to address a patient distressed about changes in sexual ability and desire.

Besides the possibility of testosterone replacement, there is another option you and your partner might want to explore to deal with her changed (I am guessing you mean lowered) sex drive. Sex therapist JoAnn Loulan suggests that women, especially, can benefit from a change in attitude about libido: Instead of waiting to get actively interested, a woman can choose to go into a sexual encounter feeling simply "willing" -- willing to explore a sensual and sexual space with her partner, and letting the journey take her, hopefully, into a more aroused frame of mind then she'd have experienced if they waited for it to show up before starting to have sex. I should emphasize that being "willing" doesn't just mean that a woman passively goes along with whatever is happening, as in "Well, he wants to do it, and I guess I'm willing." She's still very much an active participant, giving feedback and taking the initiative on pacing and how things feel, and it's important that both of you communicate about how it's going. If you discover something in these explorations that feels especially good to her, you're going to want to remember it next time! I should also mention one possibility you might not want to hear: that she may be basically satisfied with a quiescent libido. These strategies -- toys, HRT, etc. -- should all be ones she actively wants to explore, and if she doesn't wish to explore them -- well, there are always toys for you!

You asked about my take on these surgeries. In general, I think they're performed too often, frequently with an underlying attitude that the uterus is just about baby-making, and if a woman's already done that (or is getting to be "too old" to do so), the uterus isn't equipment that she'll need to keep. But many women experience sexual sensations in or through the uterus, especially those who are orgasmic with vaginal thrusting, and, as I noted above, the evidence is mounting that an intact uterus makes a difference to hormonal levels and general pelvic health. Having said this, there are a number of medical conditions that your wife might have had -- cancer, uncontrollable pelvic inflammatory disease, severe uterine bleeding -- that would have made her an appropriate candidate for hysterectomy. Our Bodies, Ourselves for the New Century has a good discussion of this procedure, including information on when it is, and isn't, medically necessary.

Finally, the bladder shouldn't, to my knowledge, have to be "tacked" anywhere. It butts up against the front wall of the abdomen and should pretty much stay there after surgery. Abdominal contents are basically squished in together -- it's not like there's empty space inside -- and they are often attached to one another, or, as docs might say, "invested." The uterus is a relatively small organ, and its removal shouldn't leave a void where things will "bounce around."