Did you know that by age 60, more than one-third of women will have had a hysterectomy, and about 11.7% of women ages 40–44 will have had the procedure?1 In other words, if you primarily work with women, you're likely to work with someone who has had a hysterectomy.
As a coach, gaining a better understanding of what your client has undergone is important, as having a hysterectomy will have an impact on a woman’s health, training, well-being, and goals. Not to mention that you’ll be concerned about your client’s ability to return to exercise safely after her procedure.
Unfortunately, how to return to activity after surgery is not very clear. So how do you help your clients when they want to return to resistance training, cardio exercise, or other activities or sports?
In this article, you will:
While we’ll jump into the different types of procedure in just a moment, what’s often forgotten is the “why” behind the hysterectomy. The most common reasons include:
Typically, hysterectomies prompted by noncancerous reasons are only performed when other treatment options have been unsuccessful.
A hysterectomy is a surgical procedure that removes the uterus. There are many types of hysterectomies that are classed depending on which additional organs are being removed. They are usually categorized as 4,5:
Let’s look at each of these in more detail.
A total hysterectomy (also called a simple hysterectomy) includes the removal of the uterus and cervix. It may or may not include the ovaries and fallopian tubes.
A partial hysterectomy leaves the cervix and takes the uterus. While this procedure is common for women who have fibroids, it does continue to leave a woman at risk for cervical cancer.
Finally, there is the radical hysterectomy. This is where the surgeon removes the uterus, cervix, fallopian tubes, and ovaries, as well as the upper part of the vagina and lymph nodes along with possibly some tissue from the pelvic cavity.
This is usually only performed when the patient has a pelvic cancer.
To better support your client, it’s important to know why she had the surgery and how the procedure took place. Depending on her diagnosis, she may have had other procedures done concurrently, and she may have other associated pain or symptoms as she returns to activity. The incision location may also affect her areas of pain or the extent to which her abdominal wall was impacted. You will need to adapt her training accordingly.
Before we go into detail about how to adapt her training, let’s talk about the different ways the surgery can be performed. There are three main types of procedure:
An abdominal hysterectomy is performed through a 4- to 6-inch incision usually right above the pelvic bone. This approach gives the surgeon a clear view of the abdominal cavity and is often used if the patient has large fibroids or other abdominal adhesions (such as those resulting from endometriosis).
The surgeon either cuts the abdominal fascia from the pubic bone or uses their finger to dissect an opening in order to remove the uterus. This procedure typically leaves a scar.
With a vaginal hysterectomy, the surgeon makes an incision near the top of the vaginal tube and removes the uterus through the vaginal opening. Overall, this procedure is reported to be less painful and leaves no visible scar.
A laparoscope is a viewing tube that is inserted via a small incision that allows your surgeon to see the structures within the abdomen and pelvis. Laparoscopically assisted hysterectomies are becoming more common since the incisions are relatively small and pain, scarring, and recovery time are typically much shorter than when a full abdominal hysterectomy is performed.2
A laparoscopic hysterectomy is performed using a laparoscope and other instruments inserted via other small abdominal incisions. The organs are then cut and removed through these small incisions in tiny pieces. If the uterus is removed abdominally in this way, the incision is slightly bigger than that of laparoscopically assisted vaginal hysterectomies, and the surgeon would most likely have done some separation of fascia and muscle, which can be a source of pain and scarring. The considerations are the same as an abdominal hysterectomy when it comes to returning to abdominal strengthening.
Now that you know more about the why and how of hysterectomies, it’s time to talk about how your training plan will be affected. Keep in mind that every woman responds to surgery and recovery differently, so while we will give you some guidelines, it’s important to listen to your client and modify your plan depending on how she feels.
Physically, she may experience:
Lifting can also feel significantly more challenging when your client is recovering the strength in her abdominal muscles, while things like stretching can put unfamiliar tension on the scarring. This can lead to pain, limited mobility, and neurological symptoms like tingling.
Additionally, it is important to note that if your client has her ovaries removed before she has started menopause, she will start menopause after her hysterectomy. This is because the ovaries secrete estrogen (even small amounts after menopause!), and removing them will take away this very important hormone.
The symptoms of menopause can include:
Estrogen is important for heart health and muscle bulk. A lack of estrogen can lead to a decrease of bulk around the urethra, as well as a decrease in the urethra’s ability to compress, which both increase the risk of urinary incontinence. This happens gradually in women going through normal menopause.
When a woman is suddenly thrown into menopause, this effect can be much more significant — especially if she already has pelvic floor issues. If your client has a tendency to hold her breath while lifting, or if she tries to go back quickly to what she was lifting before undergoing surgery, she may experience symptoms she isn’t prepared for.
Note from GGS: You can learn more about how to work with female clients during menopause and beyond in this article.
After a hysterectomy, most women are given specific instructions on activities they can or can’t perform for certain periods of time depending on the extent of their procedure.
Generally, these guidelines are organized into three timeframes:
The first two weeks post-op are for rest and recovery. While women are encouraged to walk (starting with short distances) as soon as they are cleared by their doctor, they may feel easily fatigued and will need to rest as much as possible. They are typically given a 10-pound or less lifting restriction.
After two weeks or so, most women will be able to recommence their normal activities of daily living. The worst of the pain should have passed, but their incision will still be healing.
You probably won’t be working with your client in person during the first six weeks, but she may consult you for some advice or support. As long as your client’s doctor gave her clearance — and if your client feels up to it — she can do some breathing exercises and gentle movements during this period.
Depending on what she’s feeling up to, exercises she can incorporate include:
Most women will be allowed to “return to all activities” around 6–8 weeks. The real-world feasibility of this will depend on the surgical approach. Studies show that many women do not feel ready to return to rigorous activity that early, particularly with laparoscopic and abdominal hysterectomies.3
After a laparoscopic or abdominal hysterectomy, your client may have to start at a lower resistance with her abdominal training. While the muscle bellies themselves are not cut, the procedure can still lead to repeated discomfort when she returns to abdominal strengthening. This discomfort could also be from incision sensitivity or scar tissue. Keep in mind that while discomfort does not always indicate damage, it may mean that you need to take it easy with her for a few weeks as she recuperates.
The case is similar after a vaginal hysterectomy. After the 6–8 week period, your client shouldn’t need anything more than encouragement and some adjustments to her routine as appropriate for returning to exercise after almost two months of rest.
For all types of hysterectomy, as long as there are no complications (or she is told differently by her surgeon), there should be no other restrictions after the 8-week recovery period.
Keep in mind, however, that your client may not feel ready to do full-range movements right away. Remember that she hasn’t done anything other than walking or light stretching for the last 8 weeks, so she may be deconditioned and could benefit from a more gradual return.
There are several exercises that may help your client as she returns to her fitness program after her surgery.
Here are some options you can try:
Many women feel that their abdominal muscles are weaker after an abdominal hysterectomy, and some find it difficult to feel a good connection to the lower abdominal muscles. Start some gentle exercises to connect and strengthen the abdominal wall — this may include exercises in a crook lying position, such as knee fall-outs or leg slides.
The types of gentle mobility movements your client was doing during the 2-6 week recovery period may be suitable as her warm-up now. Try starting your training session with breathing exercises and gentle stretching for moving into more strenuous activity.
As your client returns to training, she may need some additional instruction on avoiding high intra-abdominal pressure (Valsalva) or breath-holding while lifting. If this is the case, she may benefit from learning to practice the Connection Breath. You can learn more about the Connection Breath in this article.
Your client may do some cardio at this point, but the intensity should remain low or moderate at the start of this phase.
By 8–12 weeks post-op, your client may be able to walk up to 45 minutes per day at an easy, restorative pace. Check in with her on how she’s feeling as you go. She may be able to ease back into some moderate-intensity and high-intensity training if she feels up to it and has no other complications or contraindications.
If your client enjoyed running before and during pregnancy, she may be eager to start again. Encourage her to return to it gradually by increasing distance or time, and then speed, over several weeks and months. Girls Gone Strong often recommends a slow progression such as using a beginner “Couch to 5K” program and monitoring for symptoms.
Before your client returns to jogging and running, include some lower-impact exercises to master the technique and minimize any pain or discomfort. Exercises such as:
Your client may participate in strength training two to three days per week, and we recommend staying within 2–3 sets of 8–12 reps to work at a load that elicits tissue changes and minimizes the risk of causing damage. You may also want to try having her incorporate pelvic floor contractions with exercises like squats, lunges, and bridges. It may be beneficial to plan progressions into her training sessions that will help her safely transition into more intense exercise.
If your client has had an abdominal incision, she should make sure the incision is well-healed before starting any resistance abdominal exercises that use a full range of motion, either in flexion or in rotation. Your client shouldn’t feel pulling on her incision during the healing phase. Once her incision is healed, the sensations around her scar will be different (keep reading for more information about this!)
Your client should be aware that vaginal discharge may be a sign that she’s doing too much, especially if it is tinged with bright red blood. During the first six weeks, her tissues are healing. While she can do some light walking, any bright red-colored discharge may indicate that she’s too active. If there is any greenish or yellow color to the discharge or a smell, it may be a sign of infection and your client should contact her physician.
As a practitioner training women after a hysterectomy, you need to keep a couple of additional things in mind.
If a woman has had fibroids, cancer or endometriosis, there may be scarring or other sources of pain. In general, this doesn’t need to change your training regimen. If your client experiences unusual pain, it may warrant a referral to a pelvic health physical therapist.
When the surgery is from prolapse or incontinence, your client may have a lifting restriction that is longer than the standard eight weeks, particularly if any other surgical procedure was performed. Also, the underlying cause may be from pelvic floor muscle and hip weakness. The surgery would fix the symptoms but not necessarily the problem and the weakness could still be there.
Patients rarely get any instructions regarding how to take care of their surgical incision(s). As such, women may be surprised when their scars cause increased sensitivity or discomfort. The good news is that scar management does not have to be complicated.
Once the incision is healed (usually about 6 weeks) you can tell your client to massage the incision site in a circular way and use various fabrics (such as silk, cotton, and terry cloth) to improve the sensitivity of the area. The pressure should not be so much as to open the incision, cause redness that lasts more than a couple hours, or result in bleeding.
This scar massage technique helps improve pain and mobility restrictions by encouraging the collagen that caused the scar tissue to loosen up and become less restrictive.
You can also visually assess her scar and how the scar site feels for her as she moves. The scar should be well healed, with no fluid leaking. The skin around the scar should not look red or inflamed. If you or your client have any concerns, refer her back to her health care practitioner.
Note from GGS: This article on C-section scar care can give you good pointers on how to care for a hysterectomy scar as well.
After having a hysterectomy, your client may experience some unfamiliar feelings as she recovers from her surgery.
Often, women are scared that something is “going to fall out” or they are going to “ruin the surgery.” It’s important to be encouraging and empowering in a safe space. It takes a lot to "ruin" these surgeries once they are healed!
While we expect the physical symptoms and the need for the body to recover from surgery, as coaches and trainers, we also need to take into account the psychological and emotional changes that may be spurred by this procedure. Just as a start, pain can be a cause for mental distress in and of itself.
Your client may feel the loss of her uterus; after all, this is the loss of her ability to bear children. Surgery and diagnoses like cancer can also cause depression and anxiety.
Moreover, your client might be worried about injury or frustrated by her “loss” of endurance or strength after two months of rest.
If you are worried that your client is experiencing depression, anxiety, or another mental health issue post-surgery (or in general), it’s important to refer her to a mental health professional.
Girls Gone Strong recommends taking a person-focused approach by focusing on your client and her lived experience, rather than treating her based on her life stage or surgical history. We want to avoid an “over-focus” on her hysterectomy so as not to make it seem like it has defined her or her worth in any way.
When your clients share some of the issues they might be facing, you need to be sensitive to them while respecting their desire for privacy. Ask them how they are feeling, inquire about their energy level, and be prepared to change exercises on the go if you feel like they are struggling to be successful.
Being aware of the emotional component of training a client post-hysterectomy will take you from being a simple personal trainer to being a full-fledged coach.
Maintaining meaningful connections and open communication will help you build trust with your client so that you can best help her achieve her goals. Part of this is also gaining as much knowledge as possible that you can also share in a clear and well-received way. This means being able to explain complex health information in terms they can understand and use while also communicating with empathy, compassion, and understanding.
As you help your client return to exercise after a hysterectomy, it is important that you stay within your scope of practice. While you can help guide her in her training program and provide some basic advice on scar care, most coaches and trainers are not able to diagnose problems or post-surgical complications. A client’s return to exercise should also always be approved by her doctor first.
If you are concerned that your client may be dealing with either a physical or emotional issue that is out of your scope of practice, it is important to refer her to an appropriate health care provider. This may be her primary care physician or surgeon or someone new, such as a licensed mental health counselor or a pelvic health therapist.
Note from GGS: To find a pelvic health physical therapist in your area, search through one of the following websites.
If nothing comes up in your area, try a general Internet search using one of the following terms: pelvic health, pelvic floor, women’s health physical therapist, or women’s health physiotherapist and the name of the city will provide some leads. In the U.S. use the term physical therapist. Outside of the U.S., use the term physiotherapist.
Many women have anxiety and hesitation when returning to exercise and training after their hysterectomy. Their concern is understandable, and you’ll need to take their unique situation and feelings into consideration as you help them return to activity.
In general, after the initial 6–8 week recovery time, training doesn’t need to be greatly altered. Changing the workout resistance for the time off, encouraging her that she is strong and capable, and asking her to listen to her body and give you feedback will be the perfect combination for training any woman after a hysterectomy.
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