Back pain is now a global epidemic and the second most common reason why people visit the doctor. It`s been called an epidemic even by government organizations like the Department of Environmental Safety, Sustainability & Risk at the University of Maryland.
Some 60 per cent of US citizens and up to 80 per cent of people in the UK will experience back pain in the course of their lives,1 but women bear the greater brunt of back pain even though, on average, women maintain more healthy lifestyles and are less frequently overweight, one classic cause.2
Chronic back pain is defined by medical officialdom as pain that persists for 12 weeks or longer. The most frequently cited causes are sprains, injury and trauma, age, weight gain, disc degeneration or rupture, spinal compression, skeletal irregularities, infections, pregnancy, kidney stones, poor posture, arthritis, osteoporosis, endometriosis and fibromyalgia.
But strangely, there is rarely, if ever, any mention of surgery as a contributing factor. In fact, according to Scottish pain specialist W.A. McCrae, chronic postoperative pain in general "has . . . been a neglected topic" until a recent survey of patients attending pain clinics in Scotland and Northern England revealed that around 20 per cent of those surveyed listed surgery as either a partial or even the sole cause of their complaint.3
Considering the prevalence of chronic back pain in women, it seems odd that no formal studies have ever looked at the links between hysterectomy and chronic back pain. Why is this odd? Hysterectomies are known to have, over time, a direct, negative impact on pelvic-floor muscle strength and stability, contributing to pelvic organ prolapse (POP)—when organs normally in the lower abdomen, like the bladder, cervix, small intestines and rectum, drop down into the vagina.
This can cause urinary stress incontinence, bowel dysfunction and low back pain, according to the Harvard Medical School Family Health Guide (online).4
As the Hysterectomy Association of the UK puts it, "The pelvic organs and tissues are linked by connective, supportive tissues that attach them to the pelvic bone structure. When a hysterectomy is performed and the uterus is removed, this structure becomes vulnerable, as weakening support tissues pull away and other pelvic organs, like the bladder, cervix or rectum, start to collapse into the vagina."
Of course, there is also the direct damage done to ligaments and soft-tissue support structures that happen during hysterectomy, even when it's done laparoscopically (with keyhole surgery). In fact, the rate of injury to the ureter alone is as much as 35 times more likely with laparoscopic hysterectomy than with the usual open abdominal approach.5
The trunk and pelvic floor muscles in women work together to help maintain an upright posture by helping to keep the trunk and spine stable, and also contribute to stability of the pelvic ring, or 'girdle', made up of the two hip bones and the sacrum (tailbone), which are all connected by the sacroiliac joints.6
This means they also control the lumbar spine and help keep a normal blood pressure within the abdominal cavity, which helps with proper breathing.7 If the intra-abdominal pressure rises too much, it can restrict the movement of blood into the pelvic organs and gut, causing organ dysfunction or failure.8
Although studies show that prolapse following hysterectomy happens 5.5 times more often in women who had a hysterectomy for prolapse symptoms in the first place, the majority (up to 61.5 per cent) of operations for prolapse recurrences are in a different part of the pelvic cavity, indicating a "redistribution" of effects in the pelvic area after the initial hysterectomy was performed.9
"It's not unusual for women to have back pain after hysterectomy, or stress incontinence, because the uterus is not there," says Simone Ross, one of the founding osteopaths at Kane & Ross Clinics in London. "The uterus is normally something like four to seven centimeters and if you're going to have a hysterectomy, it's probably a lot larger than that because there are fibroids or a problem with endometriosis. That empty space has to be filled. The structural dynamics change along the spine and the pelvic floor."
Infection is another common complication of hysterectomy that contributes to back pain. Up to 25 per cent of women who have a hysterectomy will go on to develop some sort of pelvic infection, and up to a third will develop an infection with fever.10 Osteopath Peter King of the King Clinic in Epsom says that, mechanically, it makes sense that inflammation induced by hysterectomy can trigger back pain.
"If you have inflammation in the abdomen and pelvic region, then that will potentially cause a mechanical shift that will either increase or decrease the lumbar curve, which can then cause either problems in the lumbar spine or even a greater loading on the lower lumbar [vertebrae] or the sacroiliac joints," he says.
Even undergoing a surgical procedure that uses the traditional lithotomy position—lying on your back, knees up and feet in stirrups—can have damaging effects to the back, such as acute lumbar disc prolapse, or a 'slipped' disc. If the disc presses on a nerve root, it will then cause severe lower back pain, as well as other symptoms and pain in the leg.11
Connecting the dots
As a direct cause-and-effect relationship between hysterectomy and back pain hasn't yet been established in the world of traditional medical studies, a bit of lateral thinking is called for. In other words, to get a handle on the connection between hysterectomy and back pain, we need to take a hard look at the kinds of conditions that hysterectomy is known to cause that, in turn, are confirmed causes of chronic back pain.
As we've seen, an unstable spine, pelvic remodelling and abdominal organ redistribution are the most obvious potential causes of chronic back pain in women who've had a hysterectomy. According to Christine Kent, registered nurse and POP expert in the US, the centre of gravity in the female body is located around 2 to 3 cm in front of the second sacral vertebra, in alignment with the cervix.
It's easy, she says, to imagine a "plumb line head-to-toe, and try to become as straight as possible". But the spine is not vertical, but curved, which gives us a "wide, stable platform from which to stand and move".12
Dr Darren Weissman, Chicago chiropractor and creator of the LifeLine Technique®, agrees on the importance of the central pivot line in female anatomy. He says that, from a Chinese medical perspective, even with surgical advances in hysterectomy, if you cut into the midline of the female body, you slice over what's called the Ren (Conception Vessel)—an energy meridian that runs from the perineum up through the midline of the belly button to end on the inner part of the lower lip. "It controls a massive amount of other energetic circuits of body function, from structural integrity of muscles to the function of so many different organs and glands."
The implications of disrupting this energy circuit are enormous, he says.
But even the less-structural side-effects of hysterectomy, such as stress incontinence and constipation, have direct links to chronic back pain. Studies show that constipation can affect as much as 73 per cent of women with POP-related disorders.13 And what is one of the classic symptoms of long-term constipation?
The Cancer Research UK website lists back pain as the first symptom. And many studies have been conducted over the years on the use of various opioids in an attempt to circumvent one of the major side-effects of opioids for pain relief—namely, constipation and . . . yes, back pain.14
Deterioration of bladder function, or bladder prolapse (cystocoele), is common after hysterectomy, and there is the further risk that stress urinary incontinence (SUI)—involuntary urine loss because the muscles that control urine release don't work well—will have to be managed surgically within 10 years of the original hysterectomy.15 These operations include sling and bladder-neck suspension procedures—where a strip of mesh or tissue is inserted to create a sling to support the urethra or bladder neck to keep it closed, so preventing urine leakage.
And SUI also has a "significant association" with chronic low back pain.16
And then, of course, there's weight gain. Women who have undergone hysterectomy tend to put on weight within the following year and have higher mean body mass index (BMI) scores than women who haven't had the procedure.17 And as we all know and as the NHS and NIH websites tell us, excess weight and chronic back pain go hand in hand.
Depression is another common symptom after hysterectomy. Osteopath Simone Ross believes it can contribute to chronic back pain because "you have the whole emotional side of having a hysterectomy and not standing up straight".
What quality of life?
If you're a woman 60 years old and living in the UK, there's a one in five chance you've had a hysterectomy. If you live in the US, the chances jump to one in three. The second most frequent surgical operation in the world, the vast majority of hysterectomies—about 90 per cent—are for non-life-threatening, benign reasons like fibroids and endometriosis.18
This means that some 540,000 hysterectomies a year in the US and 90,000 hysterectomies in the UK are performed for 'quality of life' reasons to manage problems like period pain, heavy menstrual flow, constipation and even—chronic back pain.19
But what kind of quality of life are we talking about?
An ongoing study conducted by the Hysterectomy Educational Resources and Services (HERS) Foundation in the US reports that, of the 1,000 women aged 12 to 84 who responded to the HERS Questionnaire within one to 33 years after their hysterectomy, 79 per cent reported both a personality change and irritability, 77 per cent reported loss of energy and profound fatigue, 66.4 per cent a diminished or lack of sexual pleasure with intercourse, 59.9 per cent had pain in joints and bones, and 52.6 per cent reported back pain.
"You can't say this isn't a damaging surgery," says Nora Coffey, co-author (with Rick Schweikert) of The H Word and president of the HERS Foundation. "One in three women experience displacement of organs which affects the way they walk. Hip problems are common because all the bones have shifted. The major uterosacral ligament is severed, so no surprise there is a connection to back pain. Even women's neurotransmitters don't fire the same way afterwards."
Post-hysterectomy complaints and conversations about chronic back pain as a major symptom abound on women's internet health sites dedicated to hysterectomy topics.
And most of the stories are similar, if not worse, than the experiences of the women interviewed for this article.
Conspiracy of silence
If chronic back pain really does affect upwards of half the women who have had a hysterectomy—whether they have a partial (removal of the uterus only) or total (removal of both the uterus and cervix) hysterectomy—and if chronic back pain is such a socially costly as well as physically and mentally debilitating condition, then why hasn't there been a global conversation about it? Why haven't formal medical investigations been done to find ways to avoid it and to improve its management? One reason we don't talk about it is because we don't know about it. And part of the why is because of the length of postoperative care.
In the US, the national Medicare Global Surgery Fact Sheet lists three types of global surgical insurance packages, which range from zero postoperative days to up to 90 days for major procedures. Ninety days is considered sufficient for the human body to recuperate from major surgery, which is what regular abdominal hysterectomy is. But nowadays, robot-assisted laparoscopic hysterectomy is often an outpatient procedure, so even shorter follow-up symptom-tracking is done.
Most of the studies of chronic pain (none specifically for back pain) after hysterectomy researched for this article covered an average follow-up of one to five years. Yet, many symptoms and complications of hysterectomy often don't show up for many more years, or even decades after the fact.
According to Dr Weissman, the body compensates as much as it can to hold things together physically. But by the time chronic back pain becomes a problem, many women who've had a hysterectomy haven't a clue that there might be a connection. "Women are coming in with definitely chronic low back pain and not really recognizing that it's hysterectomy-related," he says.
Another reason is that gynaecologists and obstetric surgeons don't do follow-up care. "The doctors don't see the problem because medicine is so segregated," says osteopath Simone Ross. "They don't relate to it because they don't see the patients who come in with back pain. They don't see them for the abdominal infection or the discharge. They don't see the back-pain patients. We [osteopaths] see them."
Then there is the conspiracy of silence.
Several of the gynaecologists and obstetric surgeons that Nora Coffey relied upon in the past for medical corroboration when talking to media stars like Oprah have clammed up because of intense peer pressure. She says one doctor she brought onto the national US TV news show 20/20 was subsequently "blackballed".
Indeed, none of the gynaecologists and obstetric surgeons approached for this article would speak to WDDTY even under the guarantee of anonymity.
Before you have a hysterectomy . . .
Seek fully informed consent (which includes full disclosure of possible side-effects) before even considering having a hysterectomy in the first place. That's HERS (Hysterectomy Educational Resources and Services) Foundation's president Nora Coffey's best advice.
As one of America's foremost hysterectomy experts, she's been interviewed by Oprah Winfrey and most major news shows in the US about hysterectomy and the vital importance of informed consent prior to agreeing to the surgery.
"I've counselled one and a half million women over the years," she says. "And not one was given a full disclosure about the facts and repercussions of hysterectomy. Not one."
According to the HERS website, gynaecologists, hospitals and drug companies make more than $17 billion dollars a year from the business of hysterectomy and female castration (removal of ovaries).
Most shocking of all, 98 per cent of the women HERS referred to board-certified gynaecologists after they were told they needed hysterectomy discovered that, in fact, they did not need the operation at all.
Life after hysterectomy
Back pain after hysterectomy is a painful reality for these two women
A.D. (who didn't want her name published), age 71 from California, says she can't remember exactly when the back pain started. "Seems like a couple of years after my hysterectomy. And then in 2007 I was told I had cystocoele [a prolapse condition where the bladder protrudes into the vaginal wall]." Over the past eight years, her condition has progressed from mild to moderate. "I'm hoping I can at least maintain my present condition or improve but not get any worse. I want to keep my quality of life the best I can as I age."
Tonya Norwood, 51, from Enid, Oklahoma, had a full hysterectomy after the birth of her fourth child and says, because of the debilitating back pain she has when sitting, standing and walking, she can't find or hold a job. "I've also had my rectum lifted because it was coming out of my vagina and my bladder as well," she says. "I haven't found anything to help me—just the pain pills. But I try not to take them because then I have no life. I just sleep."
Exercises for pelvic organ prolapse (POP)
Christine Kent, registered nurse and founder of Whole Woman, Inc. in the US, has a programme designed to teach women how to avoid and mitigate the symptoms of POP—and the back pain it can cause—in the first place (see WDDTY's article on prolapse, December 2014).
Her best advice is never to stand in the typical military posture—with butt tucked in and stomach sucked in. Instead, let the body relax into the natural deep curvature of the lumbar spine we were born with. This posture places the pelvic bones underneath to help support the remaining pelvic organs and is the natural stance of the female body.
Whole Woman Posture
Stand with feet parallel and toes pointing straight ahead. Keep the knees straight, but not bowed back. Relax the abdominal wall and strongly lift the chest. The abdominal wall is pulled up by a lifted chest, never sucked or pulled in. Keep the shoulders down, not pulled back, and the upper back flat and broad. Pull up through the back of the head and neck by slightly tucking in the chin.
Whole Woman Belly Toss
This is one of the most effective exercises for prolapse: With feet parallel and comfortably apart, bend at the hips and knees, and place your hands on the thighs just above the knees. Keep one long line from the crown of the head to the tailbone (sacrum). Breathe in and out through the nose and, on the in-breath, allow the belly to expand outwards and, on the out-breath, bring the belly in towards the spine. This accentuates natural breathing.
Treatments for chronic back pain after hysterectomy
All of the following treatments or do-it-yourself approaches have evidence of helping patients.
Get needled. Acupuncture has proved to be an effective treatment for low back pain.1 Even fake acupuncture was found in one German study to be almost twice as effective for managing low back pain than conventional treatment.2
Get manipulated. In a Cochrane review update, spinal manipulative therapy (SMT) was as effective for reducing pain and increasing physical function as conventional methods in people suffering from chronic low back pain—without the side-effects of drugs.3
Keep moving. Nora Coffey, president of the HERS Foundation in the US, recommends not sitting for long stretches and setting a timer for 10-minute intervals: sit 10 minutes, walk 10 minutes, sit 10 minutes, walk 10 minutes . . .
Keep it cool. Ice is a tried-and-true method that gives some women relief from low back pain for up to two weeks. Place four ice packs wrapped in a light towel over the buttocks for 20 minutes, then remove for 20 minutes. Repeat three times.
Jump rope. While it sounds counterintuitive, this form of exercise helps a lot of women and works better than walking and running hard. But be sure to jump with feet together; jumping rope by alternating one foot at a time often makes low back pain worse and causes more knee problems.
Stretch. Some women are helped by simply standing, hands by the sides, then raising the hands as high above the head as possible and holding that position for 10 seconds. "Stretching is very important," says Coffey. "You start to lose elasticity from the day the surgery happens."