Effect of Hysterectomy on Sexual Functioning, The

Effect of Hysterectomy on Sexual Functioning, The

Maas, Cornelis P

The effect of hysterectomy on sexual function is an issue of debate. There are reasons to believe that removal of the uterus can have adverse effects on female sexual functioning by disrupting the anatomical relations in the pelvis. In this article, we review the literature on the impact of hysterectomy (without oophorectomy and for benign conditions) on the sexual functioning of premenopausal women. There is evidence that women for whom there is a clinical indication for hysterectomy are often experiencing a decreased quality of life. After successful treatment of dysfunctional uterine bleeding, either by hysterectomy or uterus-saving alternatives, the majority of women report experiencing improved sexual functioning. Nonetheless, the research on the effect of hysterectomy on female sexual functioning is not conclusive. Prehysterectomy sexual functioning and psychosocial state are significant predictors for posthysterectomy sexual dysfunction and depression. A minority of women report developing sexual dysfunctions as a result of hysterectomy. The nature and extent of these dysfunctions have not been adequately investigated. Many investigations in this area are flawed by methodological imperfections. For example, qualitative changes in sexual functioning and changes in the physiology of sexual function often were not adequately addressed. In the future, researchers should include both objective measures of physiological functioning and use standardized and validated self-report questionnaires. A critical attitude towards the indications of hysterectomy remains mandatory.

Key Words: autonomic nervous system, dyspareunia, female genitalia, hysterectomy, sex disorders, sexual dysfunction, vagina, uterus.

Hysterectomy is the most common major gynecologic operation (Department of Health, 1999; Lepine et al., 1997). Approximately 600,000 hysterectomies are performed each year in the United States, making the procedure second only to Cesarean section as the most frequently performed major abdominal operation. In 1990, the rate for hysterectomy in the U.S. was 5.5 per 1,000 women, and in 1997 it was 5.6 per 1,000 women (Farquhar & Steiner, 2002). An audit of general practice records in the United Kingdom in 1991 revealed that excessive menstrual blood loss accounts for more than 10% of outpatient referrals to gynaecology consultants and that about half of the referred women undergo hysterectomy within 5 years (Coulter, Bradlow, Agass, Martin-Bases, & Tulloch, 1991).

The term hysterectomy literally means “removal of the uterus.” The surgery can be done by an abdominal incision or vaginally. In the recently introduced laparoscopic procedure, the uterus is removed through a number of small incisions in the abdomen. The term “total hysterectomy” refers to the surgical removal of the uterus and the cervix. When the cervix is conserved the term “subtotal hysterectomy” is used (see Figure 1). The term “oophorectomy” refers to removal of the ovaries, which is sometimes performed simultaneously with hysterectomy.

Among premenopausal women, most hysterectomies are performed for benign conditions, such as dysfunctional uterine bleeding (i.e., irregular menstrual blood loss, resulting from hormonal imbalance and/or intrauterine fibroids or polyps) and uterine fibroids. In postmenopausal women, most hysterectomies are performed as a part of surgical treatment of prolapse of the uterus. Prolapse of the uterus is defined as spontaneous descent of the body of the uterus down into the vagina, due to laxity of the pelvic ligaments and the pelvic floor. A small percentage of hysterectomies are done for endometrial cancer and operable cervical cancer. In these cases, a hysterectomy is performed as part of a much more extensive surgical procedure.

The potential negative effects of hysterectomy on sexual functioning have gained interest in recent decades, with researchers reporting both detrimental and beneficial outcomes.

In this review, we will discuss the literature from a medical point of view. First, we present a brief history of hysterectomy and the debate about its side effects. Subsequently, we discuss the scientific background concerning the question as to why hysterectomy is thought to compromise sexual function, and we review the experimental and patient-related studies on which these hypotheses are based. Finally, we review the available clinical evidence on the effect of hysterectomy on sexual functioning, and we suggest directives for clinical counseling and future research.

History of Hysterectomy

There are several references to removal of the uterus in early ages (Benruby, 1988). There is, however, no evidence that hysterectomy was performed prior to the 16th century. Thereafter, primitive procedures have been reported. Fabricus Haldanus (1560-1624), for instance, described the removal of the uterus after inversion of the organ at delivery. The subsequent development of anesthesia and the discovery of antiseptic techniques in the 19th century were crucial for the success of surgery of all types. An Englishman, Charles Clay, performed the first well recorded hysterectomy in 1843. A uterus with large fibroids was successfully removed, but the patient died on the 15th postoperative day. Ten years later, others were more successful; the patients survived the operation.

These first procedures were all subtotal abdominal hysterectomies. Until the late 1940s, subtotal hysterectomy remained the standard surgical technique, although total abdominal hysterectomy had been introduced in 1929. A subtotal hysterectomy was easier to perform, with less potential surgical complications than total hysterectomy because only the body of the uterus was removed, leaving the cervix. When the cervix was left in place, it provided an effective barrier against contamination of the peritoneal cavity by microorganisms indigenous to the vagina. To carry out a total hysterectomy, the vagina had to be opened in order to be able to remove the cervix, which predisposed the patient to development of a potentially deadly peritonitis during this preantibiotic era.

After the discovery of penicillin and other antibiotics, the medical preference changed to the total abdominal hysterectomy. The procedure was now safer and was preferred because of the fear that cervical carcinoma would develop in the retained cervical stump after subtotal hysterectomy (Benruby, 1988; Johns, 1997). The preference for total hysterectomy remained, even after the subsequent introduction of the cytological cervix smear provided an effective method for the screening for cervical neoplasia. Screening reduced the incidence of invasive cervical cancer, and the risk of cervical cancer after subtotal hysterectomy was reported to be less than 0.1% (Herbert, 2000; Kilkku & Gronroos, 1982).

Today, both subtotal and total hysterectomy are performed for benign conditions. Between 1988 and 1998, the rate for total hysterectomies in Denmark decreased, and the rate of subtotal hysterectomies increased (Gimbel, Settnes, & Tabor, 2001). In the United States, the rates of total and subtotal hysterectomy showed a similar pattern. From 1991 to 1994, the U.S. total hysterectomy rate decreased significantly, from 25.7 to 20.5 cases per 1,000 females. During the same interval, the subtotal hysterectomy rate increased significantly, from 0.16 to 0.41 cases per 1,000 (Sills, Saini, Steiner, McGee, & Gretz, 1998). Surveys of gynecologists still reveal a strong preference for total hysterectomy as the standard surgical procedure (Zekam et al., 2003). The reasons for this preference seem to be that there is a small risk of a recurrence of vaginal bleeding symptoms resulting from bleeding of the cervical stump (7%) (Thakar, Ayers, Clarkson, Stanton, & Manyonda, 2002) and an underlying, nonevidence based, fear of cancer among both gynecologists and patients (Zekam et al., 2003).

The Development of Less Invasive Treatment Options

Since the 1950s, the indications for hysterectomy and the choice of the surgical technique have been the subject of an ongoing discussion among gynecologists, as well as among women themselves. Because the majority of hysterectomies are performed electively, patient satisfaction with treatment has been considered one of the main outcome measures. Worries about the steadily increasing hysterectomy rates and reports of negative sequelae after hysterectomy by patients (e.g., psychiatric illness, such as depression [Polivy, 1974; Richards, 1973], difficulties in sexual functioning [Dennerstein, Wood, & Burrows, 1977]) led gynecologists to re-evaluate their criteria for the procedure. As a consequence, alternatives to hysterectomy, especially in the case of dysfunctional bleeding, have been introduced.

Three examples of new treatment options, all of which have been reported to effectively reduce blood loss (Hurskainen et al., 2001; Pinto et al., 2003), are endometrial ablation, embolisation of the uterine artery, and the levonorgestrel intrauterine system. In endometrial ablation, the endometrium, which is the source of bleeding, is removed from the uterine cavity through the vagina, leaving the body of the uterus and the cervix in place. Embolisation of the uterine artery is a new approach to treat fibroids. With the aid of noninvasive radiological imaging techniques, the blood supply to fibroids can be identified and blocked, causing regression of fibroids. The levonorgestrel-releasing intrauterine system is an intrauterine device (IUD), which is similar to the copper-containing IUD that is used for contraception. The copper is replaced by prostagen (levonorgestrel). Prostagen is delivered locally to the endometrium, causing endometrial atrophy.

The development of these new treatment options has changed the decision-making process concerning whether to undergo hysterectomy. The extent to which negative sequelae of hysterectomy are considered to be an important factor in this decision has also changed over time in that negative side effects of treatment are less accepted nowadays. However, because surgical removal of the uterus is the only treatment option that completely guarantees amenorrhoea, hysterectomy is, by definition, more effective than other treatment modalities for dysfunctional uterine bleeding. Therefore, it is expected to remain a major treatment option that gynecologists will offer to women in the future.

Sexual Dysfunction as an Outcome Measure

In the past, medical professional’s interest in the sexual functioning of women and their partners in relation to various medical and surgical treatments was minimal. As a consequence of the growing openness concerning talking about sexuality, however, the effect of treatment options on sexual functioning has become an important consideration. Women who are to undergo hysterectomy are reported to be concerned about potential negative effects on their sexual functioning (Dennerstein et al., 1977; Lalinec-Michaud & Engelsmann, 1985). As a consequence, more data on the effect of hysterectomy on sexual functioning have become available.

Hypotheses on the Etiology of Sexual Dysfunction After Hysterectomy

Physical Factors

There are several reasons to believe that removal of the uterus can have adverse effects on sexual functioning as a result of disruption of the anatomical relationships in the pelvis. A total hysterectomy, in which the cervix is also removed, sometimes causes shortening of the vaginal vault (see Figure 1). This could cause severe dyspareunia (i.e., pain during coitus while thrusting) and altered sensation during coitus (Jewett, 1952). The formation of scar tissue in the vaginal cuff could also be a reason for dyspareunia (Kilkku, Gronroos, Hirvonen, & Rauramo, 1983).

The uterus and cervix play a role in the physiology of orgasm. Orgasm appears to be a neurological genital reflex. A biphasic motor response results first in contractions of the smooth muscles of the fallopian tubes, uterus, and paraurethral glands of Skene. The second phase consists of contractions of the striated muscles located within the pelvic floor, perineum, and anal sphincter. The sensation of orgasm is probably caused by the sensory stimuli from the contractions of the internal genitalia (i.e., uterus, cervix, vagina) that reach the brain. The conscious recognition of these sensory impulses is believed to be the experience of orgasm (Hasson, 1993; Segraves & Segraves, 1993). As a consequence, it is conceivable that surgical removal of the uterus can affect orgasm.

Recent anatomical and surgical studies have shown that surgical damage to the pelvic autonomic nerves during total hysterectomy partially disrupts the nerve supply to the blood vessels of the vaginal wall,. which is responsible for the neural control of the lubrication response (Butler-Manuel, Buttery, AHern, Polak, & Barton, 2000; Hasson, 1993; Maas, DeRuiter, Kenter, & Trimbos, 1999).

Surgical damage to the pelvic autonomic nerves is thought to lead to disrupted vaginal vasocongestion during sexual arousal. The neuroanatomical basis for this view is the fact that the vagina clearly has only a single blood vessel plexus, innervated by nerves containing nitric oxide synthetase (NOS), calcitonin gene related peptide (CGRP), neuropeptide Y (NPY), and vasoactive intestinal peptide (VIP), which are typical for the autonomic nerve system (Hoyle, Stones, Robson, Whitley, & Burnstock, 1996). Immunohistochemical staining of resection planes after simple and radical hysterectomy has shown that both radical hysterectomy for cervical cancer and hysterectomy for benign indications are associated with disruption of these nerves (Butler-Manuel et al., 2000).

The notion that the autonomic nerves are essential to a normal female sexual function has only recently gained the attention of pelvic surgeons. This is partly explained by the fact that both the surgical anatomy of the autonomic pelvic nerves, as well as their importance for the neurophysiology of the sexual response of females, was still not fully clear (Maas, Moriya, Kenter, Trimbos, & van de Velde, 1999). Shown in Figure 2 is the basic anatomy in a diagram. The superior hypogastric plexus (SHP) is a fenestrated network of fibers anterior to the lower abdominal aorta. The fibers of the SHP exit the spinal cord at thoracic level 10 to lumbar level 2. The hypogastric nerves exit bilaterally at the inferior poles of the SHP, which lie at or just below the level of the sacral promontory. The hypogastric nerves unite the SHP with the inferior hypogastric plexus (IHP) or pelvic plexus bilaterally. The IHP has connections with the sacral roots from S3 and some contributions from S4 and S2 through the pelvic splanchnic nerves. The end branches of IHP supply the uterus, vagina, and clitoris. Shown in Figure 3 are the anatomical relations in the female pelvis.

In order to get insight into female sexual neurophysiology, it is worthwhile to look at the extensively studied management of labor pain. These studies have contributed a great deal of information concerning the afferent pathways of the female reproductive organs. The pain in the first stage of labor is due to dilatation and consequent stretching or tearing of the cervix. The pathway for the pain in this stage is as follows: the uterine plexus-the pelvic IHP-the hypogastric nerve-the SHP-the lumbar and lower thoracic chain-the white rami communicants associated with the 11th and 12th nerve-the dorsal roots of these nerves. The pain is referred to the skin overlaying the lower lumbar and upper and middle sacral area, which can be explained by the migration of the cutaneous branches of the posterior division of the lower thoracic and the upper lumbar nerves to these cutaneous areas. Towards the end of the second stage, when perineal distention causes stretching and tearing of the tissue surrounding the pudendal nerve, the pudendal nerve is blocked, and the pain is mainly felt through visceral afferents in the vagina (Eltzschig, Lieberman, & Camann, 2003). The knowledge about the existence of these afferent nerves, running through the pelvic plexus, is derived from embryological and animal studies. At least part of the vagina is embryologically derived from the endoderm of the urogenital sinus. This portion is also known to be innervated by sensory fibers of the pelvic plexus. After bilateral pelvic plexus neurectomies in rats, all the intravaginal mucosa becomes anesthetic and analgesic. Pinching of the vaginal mucosa and other intense noxious stimuli fail to elicit a response. In an animal model, the pelvic plexus has shown to be activated by stimulation of the vaginal wall, rectal wall, and cervix (Kumazawa, 1986). The autonomic innervation of the vaginal wall originates mostly from the inferior hypogastric plexus. The autonomic nerves supply the blood vessels of the internal genitalia and are involved in the neural control of vasocongestion and, consequently, the lubrication swelling response (Levin, 1980).

Data from patient-related studies on the sexual functioning of women after spinal cord injury and clinical data from patients with a history of radical hysterectomy provide strong evidence that the IHP plays an important role in female sexual arousal. Women with injury between spinal thoracic level 10 and 12, which is the origin of the sympathetic nerves, do not experience either reflexive or psychogenic lubrication. Women with lesions below T12 do experience psychogenic lubrication. In women with high lesions, above T9, reflexive lubrication occurs, but there is no psychogenic lubrication. Sensation is also absent in paraplegic women with injuries between T10 and T12. If the injury is below T12, there is loss of sensation. It appears that the sympathetic pathways, originating from spinal level T10-T12, play an essential role in lubrication and sensation of the internal genitalia in the female sexual response cycle (Berard, 1989). The sensation of the external genitalia is not related to the IHP The pudendal nerve supplies the labia and clitoris. This somatosensory nerve reaches the external genitalia through a canal within the pelvic floor and is, therefore, not at risk for damage during hysterectomy.

Radical hysterectomy for cervical cancer has been associated with a greater amount of nerve damage than hysterectomy for benign indications (Butler-Manuel et al., 2000). In order to ensure maximum oncologic radicality, the radical surgical procedure involves removal of the uterus and cervix, together with its lateral anterior and posterior ligaments. These ligaments, however, are also the anatomical pathways for the pelvic autonomic nerves, and, therefore, disruption of these nerves seemed unavoidable. As a consequence, radical hysterectomy for cancer is associated with more severe sexual dysfunctions than hysterectomy for benign indications. Women with a history of radical hysterectomy for cervical cancer reported a decrease in lubrication and genital swelling during sexual arousal, which compromised sexual activity and resulted in considerable distress (Bergmark, Avall-Lundqvist, Dickman, Henningsohn, & Steineck, 1999). Recently, surgical techniques have been introduced in which the autonomic nerves are identified and spared during radical hysterectomy with the aim to prevent postoperative bowel, bladder, and sexual dysfunction (Hockel, Konerding, & Heussel, 1998; Possover, Stober, Plaul, & Schneider, 2000; Trimbos, Maas, DeRuiter, Peters, & Kenter, 2001). These data lead to the inevitable conclusion that disruption of the autonomic nerve supply during a hysterectomy will lead to specific sexual disturbances. Disruption of the sympathetic nerve supply to the IHP would lead to impaired lubrication and altered sensation of the female internal genital organs. The motor component of orgasm in both men and women would be severely impaired. Damage to the parasympathetic nerve supply would lead to impairment of vasocongestion.

The nerve disruption theory is also the basis for the ongoing debate about the best surgical technique. The central question in this debate is whether subtotal hysterectomy results in less sexual dysfunction than total hysterectomy for benign conditions. Because the subtotal procedure minimizes anatomical disruption, it may be less likely to have adverse effects than total hysterectomy (Hasson, 1993; Thakar et al., 2002). The anatomical location of the IHP at the level of the cervix and lateral vaginal fornix makes it reasonable to conclude that the risk of damage to this plexus is lower when the cervix is left untouched, as in subtotal hysterectomy (Maas, DeRuiter, et al., 1999).

Hormonal Changes

Finally, a fourth theory on the etiology of sexual dysfunction is that a hormone deficiency results from hysterectomy in premenopausal women. Physiological ovarian failure that takes place in postmenopausal women results in marked decreases of estrogen and androgen levels. The physiological decrease in estrogen levels is thought to be the cause of sexual dysfunctions in women, such as reduced vaginal lubrication and dyspareunia (McCoy, 1994). Androgen deficiency is thought to be the cause of reduced libido and reduced sexual arousability (Apperloo, van der Stege, Hoek, & Weijmar Schultz, 2003). Estrogen and androgen levels in postmenopausal women do not change after hysterectomy with bilateral oophorectomy because these women have already had physiological ovarian failure. Surgical removal of the ovaries in premenopausal women leads to a marked decrease of estrogen and androgen levels. The surgical intervention results in a postmenopausal hormonal state (Laughlin, Barret-Connor, Kritz-Silverstein, & von Muhlen, 2000). Hysterectomy without oophorectomy in premenopausal women would not be expected to lead to ovarian failure because the ovaries are left untouched. However, some believe that premenopausal hysterectomy with conservation of the ovaries may hasten ovarian failure and may increase postmenopausal symptoms, including vaginal dryness.

Experimental studies. Hysterectomy is thought to possibly compromise the vascular supply to the ovaries. The ovary is supplied by the ovarian arteries, which find their way to the ovaries from the pelvic sidewall. These blood vessels are not located in the surgical field of a hysterectomy procedure, and, therefore, it has been thought that the blood supply to the ovaries was altered by hysterectomy. However, after reaching the ovaries, the ovarian arteries continue onwards along the fallopian tubes to supply the upper part of the uterus. Ligation of the fallopian tubes is an essential surgical step in a hysterectomy without oophorectomy, which includes ligation of this continuation of the ovarian arteries. Cattanach (1985) postulated that ligation of the continuation of the ovarian artery, as is done in hysterectomy, as well as in tubal ligation, might change the blood flow dynamics in the artery and damage the ovarian microcirculation. He reported a reduction in estrogen production in four out of seven women after ligation of the fallopian tubes.

Alternatively, the uterus may make an endocrine contribution to normal ovarian function. In 1933, Sessums and Murphy showed that rabbits that had undergone hysterectomy 1 year previously had only half of the number of ovarian follicles as compared with nonhysterectomized rabbits. Hysterectomized rabbits in which uterine endometrium had been implanted into the anterior abdominal wall had 40% more follicles than the hysterectomized rabbits without reimplanted endometrium (Sessums & Murphy, 1933).

Patient related studies on estrogen levels. Siddle, Sarrel, and Whitehead (1987) retrospectively determined the age at ovarian failure in 90 women with a history of abdominal hysterectomy with bilateral ovarian conservation and in 229 women who had undergone a “natural” menopause. The mean age of ovarian failure in the hysterectomized group was 45.5 (SD = 4.0) years, which was significantly lower than the mean age of 49.5 (SD = 4.0) years in the control group. The authors suggested a causal relationship between hysterectomy and premature ovarian failure. The retrospective design of the study makes it difficult to draw generalized conclusions. The hysterectomized women in the study might have been more perceptive of climacteric symptoms because they had a history of gynecological disease and surgery, and, therefore, they might have sought medical consultation for their climacteric symptoms earlier than women in the control group. Furthermore, a large proportion of hysterectomies were done for dysfunctional uterine bleeding. The exact nature of these menstrual disorders was not described, and a proportion of these women may have already suffered from metrorrhagia as a first sign of premature ovarian failure. In their literature review, including studies from 1932 to 1984, however, Siddle et al. concluded that most of the published evidence indicates that hysterectomy is associated with premature ovarian failure. The mean percentage of premature ovarian failure in their review was 23.5% (SD = 5.3%). Unfortunately, no information was given on the quality and design of the included studies.

Oldenhave, Jaszmann, Everaerd, and Haspels (1993) administered a questionnaire to a large, cross-sectional sample of 986 hysterectomized women (one or both ovaries present) and 5,636 normal women (uterus and both ovaries present) in the Netherlands. The results showed that hysterectomized women, especially those aged between 39-41 years, reported significantly more vasomotor complaints and vaginal dryness. Out of 1,012 women aged 39-41 years who had not had a hysterectomy, 19% reported moderate to severe vasomotor complaints, and 5.9% reported moderate to severe vaginal dryness. In contrast, out of 106 women aged 39-41 years with a history of hysterectomy without oophorectomy, 36.8% reported moderate to severe vasomotor complaints, and 23.5% reported moderate to severe vaginal dryness. The authors concluded that physicians should be alert to typical climacteric complaints after hysterectomy with ovarian conservation.

Kaiser and co-workers determined serum levels of FSH, LH, and estradiol in 110 women aged between 38-48 years who had undergone a hysterectomy with conservation of the ovaries 2-10 years previously, and compared them with a control group (n = 112). Ovarian failure is associated with a significant rise in FSH and LH levels. They found both FSH and LH levels significantly elevated in the hysterectomized group (Kaiser, Kusche, & Wurz, 1989). They did not, however, assess climacteric symptoms nor vaginal dryness or sexual function, which makes the clinical relevance of these findings unclear. In contrast, Coppen, Bishop, Beard, Barnard, and Collins (1981), using a prospective follow-up design, failed to find any effect of hysterectomy without oophorectomy on either estrogen, LH, or FSH levels. Sixty premenopausal women were assessed before and after hysterectomy for menorrhagia, fibroids, or both. Menorrhagia was defined as excessive bleeding, with menstrual periods lasting 7 days or more. Hormone levels were regularly assessed for a period of up to 3 years after surgery. Patients were randomly allocated to receive either placebo or estrogen sulphate tablets, starting 2 weeks after the operation. No evidence was found that patients in either group showed hormonal changes related to the hysterectomy. The authors found no indication for estrogen replacement to patients after hysterectomy. Thus, the evidence for a causal relationship between hysterectomy with conservation of the ovaries and premature ovarian failure remains equivocal.

Patient related studies on androgen levels. There are no well-designed studies on androgen levels after hysterectomy with conservation of the ovaries. Premature ovarian failure would be expected to lead to a loss of ovarian androgen, as well as ovarian estrogen. Because the evidence for a causal relationship between hysterectomy and premature ovarian failure remains equivocal, the role of androgen loss in women after hysterectomy with conservation of the ovaries in the development of sexual dysfunction is unclear.

When hysterectomy is combined with oophorectomy in premenopausal women, there will be a sudden decline of estrogen production. This hypoestrogenism is related to vaginal atrophy and diminished vaginal vasocongestion during sexual arousal. Because the ovaries are also responsible for ovarian androgen production, oophorectomy in premenopausal, as well as in postmenopausal, women might also result in lower circulating androgens. Levels of total and free testosterone are reported to decrease by 40-50% (Laughlin et al., 2000). Androgens are thought to be essential for libido, sexual arousability, and pleasure. Apperloo et al. (2003) reviewed the literature on the relation between androgens and sexual function, and the evidence for androgen substitution in the treatment of sexual dysfunction after oophorectomy and for postmenopausal women. They concluded that the available literature indicates that androgen substitution, despite leading to supraphysiological androgen levels, improves some aspects of sexual functioning, especially in women who have undergone oophorectomy. What this means in terms of satisfaction with sexual functioning is not clear. Androgen substitution is increasingly being employed to enhance sexual desire in women, based on the assumption that low androgen levels cause low sexual desire. The one randomized controlled trial using physiological testosterone replacement to date showed a significant improvement in pleasure/orgasm in women over 48 years of age but not in thought/desire (Basson, 2003; Shifren et al., 2000).

Clinical Studies on the Effect of Hysterectomy on Sexual Functioning

We reviewed the literature on the impact of hysterectomy without oophorectomy for benign conditions in premenopausal women on sexuality. The literature is almost exclusively on premenopausal women because hysterectomies in these women are done electively, for the most part, for benign diseases, for which alternative treatments are available. Most hysterectomies done in postmenopausal women are done for malignancies or prolapse symptoms, where treatment alternatives are not available to the same extent. The discussion in the literature on the side effects of hysterectomy focuses on the question whether hysterectomy is a wise option for treatment of benign diseases, as compared to less invasive treatment options.

Sexual functioning, or the report of sexual problems, is associated with age, race, mental health problems, relationship problems, and various socioeconomic conditions (Laumann, Paik, & Rosen, 1999). The quality of a woman’s sexuality before and after hysterectomy is likely to be influenced by many of these factors. Psychosocial factors that contribute positively to sexual function include a healthy relationship with a partner, good general health of both partners, freedom from severe life stresses, and absence of financial worry. If one or more of these positive factors is negatively affected, it might disrupt sexual functioning. For example, Kjerulff et al. (2000) found that hysterectomy was not an effective treatment for all women in the Maryland Women’s Health Study, a prospective study of 1,299 women undergoing hysterectomy in the state of Maryland in 1992 and 1993. The women whose symptoms were not relieved after hysterectomy were more likely to be in therapy for emotional problems at the time of surgery and were more likely to have a low household income (Kjerulff et al., 2000). Twenty years earlier Martin and colleagues found, in a prospective study, that women who had an excess of psychiatric symptoms after hysterectomy were those women who had similar psychiatric problems before the surgery (Martin, Roberts & Clayton, 1980). These study results make it clear that both the surgical intervention and also the premorbid psychosocial factors can cause a personal imbalance resulting in impairment of sexual functioning (Darling & McKay-Smith, 1993; Farrell & Kieser, 2000; Helstrom, Sorbom, & Backstrom, 1995).

In spite of the firm theoretical grounds upon which hypotheses about the effect on sexual functioning as a result of a hysterectomy are based, clinical studies fail to confirm most of the hypotheses that we have just reviewed. The discussion of the influence of anatomical changes due to hysterectomy on sexual functioning was brought into sharp focus by a series of reports from Finland in the 1980s. Kilkku interviewed 105 women before total abdominal hysterectomy with bilateral oophorectomy, and then again 6 weeks, 6 months, 1 year, and 3 years postoperatively. He also interviewed 107 women who underwent subtotal hysterectomy with bilateral oophorectomy. He compared coital frequency, dyspareunia, libido, and frequency of orgasm. Both groups showed an equal but slight reduction in coital frequency. However, dyspareunia decreased from 30.8% preoperatively to 15.6% postoperatively in women in the total hysterectomy group, whereas the decrease in the subtotal group was greater (28.6% to 6.3%). No statistically significant differences were noted in libido, but the frequency of orgasm was signif icantly reduced 1-year postsurgery in the total hysterectomy group, but it remained unchanged in the subtotal group (Kilkku, 1983; Kilkku, Gonroos, Hirvonen, & Rauramo, 1983). Because similar differences in urinary symptoms were found (Kilkku, 1985), the authors concluded that subtotal hysterectomy was advantageous, and the numbers of subtotal hysterectomies increased dramatically in Finland in the period from 1981 to 1986 (Thakar, Manyonda, Stanton, Clarkson & Robinson, 1997). However, the results of subsequent studies by Virtanen and coworkers, from the same institute, did not concur with Kilkku’s findings: The negative effect of total hysterectomy on sexual functioning was not as great as originally perceived. Their prospective study on 102 women undergoing hysterectomy showed no differences in orgasmic function before and after the operation. Twenty-one percent of the women reported “decreased orgasm” both preoperatively and 1-year postoperatively. Dyspareunia, however, dropped from 40% preoperatively to 9% 1 year after the operation (Virtanen et al., 1993). By 1991 the rate of subtotal hysterectomies in Finland had dropped from 53% to 13% (Virtanen, Makinen, & Kiilholma, 1995).

During recent decades, a vast number of clinical studies have been published on the topic of sexuality after hysterectomy. In 2000, a highquality systematic review of the English and German language literature was conducted using the search terms sexuality, hysterectomy, libido, orgasm, and outcomes (Farrell & Kieser, 2000). Eighteen studies were found, 8 prospective and 10 retrospective. The studies were evaluated for methodological quality and for their findings concerning the impact of hysterectomy on sexuality. With a few exceptions, the methodological quality of the studies was poor. Dependent variables were ill defined and varied greatly across studies. In the majority of studies, simplified concepts of what constitutes sexual fulfillment were used. In none of the studies, was a definition of libido provided. Interest in sexual contact with a male partner was assumed to reflect libido indirectly. Specific questions included whether the women had sexual interest or desire for sexual contact with the opposite sex (Dennerstein et al., 1977; Kilkku, 1983; Virtanen et al., 1993) and asked for the frequency of intercourse (Ewert, Slangen, & van Herendael, 1995; Helstrom, Lundberg, So(angstrom)rbom, & Ba(angstrom)ckstrom, 1993; Munday & Cox, 1967). Many questions were simply asked without defining the issue (e.g., whether libido was increased, decreased, or unchanged [Dennerstein et al., 1977; Ewert et al., 1995; Munday & Cox, 1967; Virtanen et al., 1993]). Also, the questions on orgasm were simple: Was orgasm achieved? (Chapman, 1979; Dennerstein et al., 1977; Poad & Arnold, 1994), how frequent were orgasms during intercourse? (Kilkku, 1983; Helstrom et al., 1993), and was orgasm normal, decreased, or increased? (Virtanen et al., 1993). Most of the authors, however, did not inquire about the sexual experience of the women before surgery, in particular, whether orgasm was normally achieved with vaginal penetration or only after clitoral stimulation. Outcome measures were usually not validated, and most researchers did not consider important confounding factors, such as relationship with partner, hormonal effects, psychological well-being, indication for surgery, or type of surgery (Farrell & Kieser, 2000). Only one properly designed study was identified (Alexander et al., 1996). Alexander et al. compared in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding in a prospective randomized controlled trial. Validated questionnaires were used. However, the method of measuring sexual functioning in this study is unclear and seems insufficient to draw general conclusions. Sexual function seems to have been assessed with a subscale analysis of the Psychosocial Adjustment to Illness Scale. No details were given about the questions that were asked. It is unclear which aspects of sexuality were assessed. The use of a validated sexual function questionnaire would have brought greater meaning to the results in terms of the effect of hysterectomy and the uterus saving procedure on sexual function.

In most of the studies reviewed by Farrell and Kieser, either no change or an enhancement of sexuality in women who had a hysterectomy was found. The percentage of women with unchanged or enhanced libido ranged between 60 and 100%, and the percentage of women with decreased libido ranged from 0 to 40%. For orgasm, these figures were 75 to 92% unchanged or enhanced, and 8 to 25% decreased (Farrell & Kieser, 2000). The results from these studies have led investigators to infer that the quality of life improved for most women who had hysterectomy and that hysterectomy did not adversely affect sexuality. The same conclusions were drawn in a similar review that was more recently published by Katz (2002).

Since these reviews were published, four prospective studies have been published in major medical journals, which we will discuss in more detail now. Rhodes, Kjerulff, Langenberg, and Guzinski (1999) conducted a well-designed and important study in which changes in sexual functioning after hysterectomy were examined. In this 2-year prospective study of 1,101 women conducted in the state of Maryland, measurements of sexual functioning prior to hysterectomy and at 6, 12, 18, and 24 months after hysterectomy were taken. In this study, 89.2% of the women were premenopausal and 10.8% were postmenopausal. Fortythree percent had a bilateral oophorectomy during surgery. Most women were between the ages of 35 and 49 years, white, married or living with a partner, and high school graduates. The percentage of women who engaged in sexual relations increased significantly from 70.5% before hysterectomy to 77.6% and 76.7% at 12 and 24 months after hysterectomy. The rate of frequent dyspareunia dropped significantly from 18.6% before hysterectomy to 4.3% and 3.6% at 12 and 24 months after hysterectomy. The rates of not experiencing orgasms dropped significantly from 7.6% before hysterectomy to 5.2% and 4.9% at 12 and 24 months after hysterectomy. Low libido rates also decreased significantly from 10.4% before hysterectomy to 6.3% and 6.2% at 12 and 24 months after hysterectomy. The percentage of women not reporting vaginal dryness in the past month improved significantly from 37.3% before hysterectomy to 46.8% and 46.7% at 12 and 24 months after hysterectomy. Although the rate of relief for each sexual problem was approximately 60% in this study, the results also showed that some women developed a sexual problem after hysterectomy. Ten per cent of women without a problem before hysterectomy were not sexually active after hysterectomy. There was no information about their sexual functioning. Of the women who were still sexually active posthysterectomy, 9.4% developed vaginal dryness, 2.3% developed anorgasmia, 5.2% developed a low libido, and 2% developed dyspareunia that was still present after 24 months.

Further analyses were performed to estimate relationships between specific problems at 12 months after hysterectomy and race, menopausal status, prehysterectomy depression, partner support, hysterectomy approach, oophorectomy, and posthysterectomy hormone replacement. For each sexual problem, experiencing the problem before hysterectomy was the strongest predictor of experiencing the problem 12 months after hysterectomy. Out of all listed factors, only prehysterectomy depression was associated with experiencing dyspareunia, vaginal dryness, low libido, and not experiencing orgasms after hysterectomy. Moreover, the overall health status and quality of life improved after hysterectomy for the women in this study (Kjerulff et al., 2000). Women might simply have felt better after hysterectomy and sexual function might have improved along with this. However, hysterectomy did not relieve symptoms for 8% of the women. The women whose symptoms were not relieved were more likely to be in therapy for emotional problems at the time of surgery and were more likely to have a low household income.

In order to interpret the results of this study, some points of criticism must be discussed. It is important to realize that they did not include all hysterectomized women during a chosen period of time. Of 4,858 hysterectomies performed at participating hospitals in 1992 and 1993, the names of 1,823 patients were obtained, 1,604 of whom could be contacted. Only 1,299 (81%) agreed to participate. Of these, 1,132 completed all interviews. Among patients completing the study, 1,101 were willing to tell the interviewers whether they had been sexually active in the months before hysterectomy and at the interviews 12 and 24 months, which equals 22% of the total sample of hysterectomies. Moreover, women who were not sexually active prehysterectomy, 12 months posthysterectomy, or both, were excluded from these analyses (Rhodes et al., 1999). Importantly, the 167 women (12.9% of 1,299) who did not complete the study after initial agreement on participation, and who were thus excluded from analyses, were more likely to have a problem with dyspareunia before hysterectomy than women who did complete the study (25.9% vs. 18.5%). The reported overall percentages of sexual dysfunction could therefore be underestimates.

Others have criticized the fact that the interview focused on the quantity rather than the quality of sexual activity. Rhodes et al. (1999) measured sexual functioning with closed-ended and multiple-choice questions (e.g., “In the last month, how frequently have you experienced pain during sexual relations?”) rather than standardized sexual response questionnaires or interviews. No questions were asked whether orgasm was experienced in a qualitatively different way (e.g., noting uterine contractions). Relationship dynamics were not measured. Questions regarding the subjective experience of sexual arousal were not asked (Rozenman & Janssen, 2000). Furthermore, the authors of the study pointed out that patients were interviewed shortly before hysterectomy, a time during which sexual functioning may have been negatively affected by anxieties about the upcoming surgery. If so, the results of this study may overestimate the positive effects of hysterectomy on sexual functioning (Rhodes et al., 1999). Nonetheless, keeping the limitations of the study in mind, some important conclusions can be drawn. The overall figures show that when the indication for the hysterectomy is a valid one, a majority of the women report fewer or less severe sexual dysfunctions after hysterectomy as compared to before hysterectomy. This could be due to the fact that hysterectomy relieves women from symptoms, such as vaginal bleeding and dyspareunia. The sexual functioning problems experienced before hysterectomy could have been a result of the gynecological disorders with which these women were diagnosed.

Another important finding is that 28% of the women who were to undergo hysterectomy were depressed. Prehysterectomy depression was associated with poorer outcomes in hysterectomy, in terms of symptoms such as pelvic pain, back pain, activity limitation, sleep disturbance, fatigue, abdominal bloating, and urinary incontinence (Kjerulff et al., 2000; Rhodes et al., 1999). Women with prehysterectomy depression did not experience as much improvement in sexual functioning after hysterectomy as did women who were not depressed.

Hurskainen et al. (2001) recently reported the results of a randomized double-blind trial in which they compared a levonorgestrel-releasing intrauterine system (IUS) with hysterectomy in terms of quality of life and cost-effectiveness for women with menorrhagia. Of 598 women, all premenopausal, referred with menorrhagia to five university hospitals in Finland, 184 were not eligible, 178 refused participation, and 236 were eligible and agreed to take part. They were randomly assigned to treatment with the levonorgestrel-releasing IUS (n = 119) or hysterectomy (n = 117). Quality of life was assessed by the RAND 36-item health survey (Hays, Sherbourne, & Mazel, 1993) and EQ-5D (EuroQol Group, 1990). Depression was measured with the Beck’s depression inventory (Beck, Rial, & Rickels, 1974). Anxiety was measured with the State Trait Anxiety Inventory (STAI) of Spielberger (Spielberger, Gorsuch, & Lushene, 1970). Sexuality related factors were assessed by the McCoy sex scale, as modified by Wiklund, Karlberg, and Mattsson (1993). This scale has three subscales: sexual satisfaction (five items), sexual problems (two items), and satisfaction with the partner (two items).

Quality of life scores were significantly lower for both groups of women with menorrhagia, compared to Finnish women of the same age, and they were comparable to the scores of women with chronic illness. The greatest disparities between the women under study and the normal population were in scores for pain and physical and emotional role functioning. Health-related quality of life improved significantly in both the IUS and hysterectomy groups, as did other indices of psychological well-being. The authors did not report whether depression, anxiety, and sexual dysfunction scores were elevated at baseline. The anxiety and depression scores improved significantly after treatment.

The primary criticism on this study is that the women who were allocated to the hysterectomy group had to wait for their operation for an average of 6.7 months, with a maximum of 21 months after randomization. Women allocated to the IUS group had the IUS inserted at the randomization visit. If the waiting time is taken into account, the follow-up visits in the hysterectomy group were on average 1 and 1.5 years after randomization, whereas the follow-up visits in the IUS group were actually at 6 and 12 months. Consequently, the groups are not as equal as the baseline characteristics suggest, which could compromise comparison between the two groups (Mol, Bongers, & Brolmann, 2001).

It is hard to judge whether selection bias was introduced by the refusal of a large proportion of women (178 or 30%) to participate in the study. The authors do state that these women did not differ from the study group in terms of age, employment status, or occupation. However, there is no information on sexual functioning among these women.

Hypothetically, if a substantial portion of the women that were unwilling to participate did, indeed, have significantly more, or less, sexual dysfunction and depression before treatment, the results of the randomization and the principal outcome of the study would not be altered, but the generalization regarding decreasing sexual problems through hysterectomy could be invalid. The main conclusion that can be drawn from this study is that women in general feel better after treatment due to relief of symptoms from menorrhagia. This effect occurs after hysterectomy, as well as after noninvasive treatment. Again, the main predictor of the psychological well-being of women after having a hysterectomy seems to be their preoperative psychological state, rather than the mode of treatment of menorrhagia.

Thakar et al. (2002) compared total and subtotal abdominal hysterectomy in 279 women referred for hysterectomy because of benign disease using a randomized, double-blind trial design. Of these, 117 (88%) out of 133 women in the subtotal randomization arm and 132 (90%) out of 146 women in the total hysterectomy group were premenopausal. The main outcomes were measures of bladder, bowel, and sexual functioning at 12 months. The rates of bladder dysfunction were similar in the two groups. The frequency of bowel symptoms (as indicated by reported constipation and use of laxatives) did not change significantly in either group after surgery. Sexual functioning was analyzed through a questionnaire that had been evaluated in a pilot study, but no data about the pilot study were provided. The two groups were similar postoperatively with respect to the frequency of orgasm, extent of vaginal lubrication, and rating of the sexual relationship with a partner. Compared to the prehysterectomy state, the incidence of deep dyspareunia reduced from 43% (75 out of 175) to 11% (20 out of 175) 1 year after hysterectomy. The incidence of superficial dyspareunia decreased from 11% (20 out of 176) to 5.7% (10 out of 176) after 6 months but increased to 14% (24 out of 176) 12 months after hysterectomy. Frequency of intercourse increased in both groups after surgery, with no significant effect of either type of surgery on this outcome. The authors concluded that neither type of surgery showed an adverse effect on sexuality.

The conclusions of this study are compromised by important problems in the analysis. The analysis was restricted to women who were sexually active before surgery, as well as 6 and 12 months after surgery. As many as 24% (57 out of 234) of women who were preoperatively sexually active were no longer sexually active at some point after surgery and were excluded from the analysis. Moreover, there seemed to be a difference between randomization groups: 30% (36 out of 122) in the total hysterectomy versus 19% (21 out of 112) in the subtotal hysterectomy group were excluded because of cessation of sexual activity. The authors provided no information about sexual problems among these women; they may have refrained from sexual activity because they feared or had sexual dysfunction. The reported percentages of women experiencing sexual dysfunction after hysterectomy may, therefore, be underestimates, and differences between the treatment groups may be obscured (Maas, Kenter, & Trimbos, 2003). The observed increased frequency of intercourse does not necessarily relate to increased satisfaction. The frequency can increase because the underlying cause (e.g., vaginal bleeding, that prevented it) has been eliminated (Rozenman & Janssen, 2000).

Bilateral oophorectomy was performed in 81 women in the total hysterectomy group, compared to 61 in the subtotal hysterectomy group. It is unclear how many of these women were pre- or postmenopausal before surgery. The effects of oophorectomy on sexual functioning should have been analyzed. Furthermore, the use of validated standardized sexual response questionnaires would have brought greater meaning and specificity to the results. Moreover, the analysis was restricted to assessment of only sexual, and bladder and bowel function. Depression or anxiety were not assessed. Quality of life instruments were not used. Subtle, qualitative effects on sexual function may, therefore, have been missed by this study.

In a recent Dutch study, Roovers, van der Bom, van der Vaart and Heintz (2003) did attempt to evaluate the quality of sexual function in women after hysterectomy. In a prospective observational study over 6 months, they reported on 352 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometrioses. All women had to have a male partner. The main indications for surgery were heavy or irregular bleeding (menorrhagia/metrorrhagia), abdominal pain, and/or dysmenorrhoea (painful menstruation). Of the 352 women in the sample, 104 underwent vaginal hysterectomy, 84 underwent subtotal hysterectomy, and 164 underwent total abdominal hysterectomy. A Dutch questionnaire was used to assess sexual pleasure, sexual activity, and bothersome sexual problems. The questionnaire consisted of 36 items assessing the presence and experienced discomfort of sexual dysfunctions. The first 16 questions concerned the general perception of the patient’s own sexual functioning and frequency of sexual activity. The next 18 questions concerned different types of problems during sexual activity. Questions were selected from this part of the questionnaire to identify patients with bothersome problems with lubrication, orgasm, pain or unpleasant sensation in the genitals, and arousal. The authors did not include the frequency of occurrence of symptoms in the analyses. Of the 477 women who were asked to participate, 413 agreed; 34 women were excluded because they did not have a male sexual partner at the beginning of the study. Of the remaining 379 women, 352 (93%) responded 6 months after surgery, and 310 women were sexually active both before and after surgery. These 310 (65% of the original sample of 477) were analysed for sexual functioning. Of the 173 patients who reported one or more bothersome sexual problems before the hysterectomy, the problems were still reported by 29 out of 49 (59%) after vaginal hysterectomy, 23 out of 43 (54%) after subtotal hysterectomy, and 45 out of 81 (56%) after total hysterectomy. New sexual problems developed in 9 (23%) patients after vaginal hysterectomy, 8 (24%) patients after subtotal hysterectomy, and 12 (19%) patients after total hysterectomy. The authors concluded that sexual pleasure improves with hysterectomy, irrespective of the surgical technique.

Interestingly, compared with patients who had undergone vaginal hysterectomy, those who had undergone total or subtotal hysterectomy had an increased, but not statistically significant, prevalence of persisting problems with lubrication (total, adjusted odds ratio 1.6; 95% confidence interval 0.7-3.6; subtotal 2.3, 95% confidence interval 0.4-11.9) and arousal (total, 1.2, 0.6-2.5; subtotal 2.1, 0.5-8.6). Problems with sensation in the genitals more often persisted after total or subtotal hysterectomy than after vaginal hysterectomy. These data could suggest an association with vaginal pelvic autonomic nerve damage.

This study also had several imperfections in design which compromise its validity. Firstly, although the questionnaire for sexual functioning used in this study seems to be a promising instrument, it has never been validated. This is in contrast to what the authors stated in the conclusion of their paper. Normative data from nonclinical Dutch women are not available for this questionnaire (Vroege, 1994). The prevalence of bothersome sexual problems before surgery in this study is very high. Fifty-six percent of the women (173 out of 310) reported one or more bothersome sexual problems before surgery. The prevalence of one or more bothersome sexual problem after hysterectomy was 43% after vaginal hysterectomy, 41% after subtotal hysterectomy, and 39% after total hysterectomy. Comparison of the study group outcome with outcome values of the normal population would have given more insight in the severity of sexual problems in women both before and after hysterectomy as opposed to those in the normal population. Furthermore, this questionnaire is designed to assess both the frequency of occurrence and the experienced discomfort. The first choice of analysing these item-scores is to combine both scores to one single score (Vroege, 1994). Roovers et al. (2003) only used the discomfort score in their analyses. In light of the ongoing discussion about the relation between the occurrence of a sexual dysfunction and the experienced discomfort or distress about sex, one might wonder what aspects of sexual functioning were actually analysed in this study. Recently, Bancroft, Loftus, and Long (2003) found that the best predictors of sexual distress were general emotional well-being, as well as the emotional relationship with the partner during sexual activity. Physical aspects of sexual response in women, including arousal, vaginal lubrication, and orgasm, seem to be poor predictors. As Roovers et al. excluded the frequency of occurrence from their analyses and only reported on experienced discomfort without providing additional data on general well-being or quality of life, it is very difficult to interpret their findings unequivocally

Secondly, women were not randomly allocated to one of the three types of surgery. Too few gynaecologists were willing to participate in such a study design. The gynaecologist’s decision to perform a surgical technique does not only depend on personal preference and surgical skill but could well be influenced by the symptoms and the preference of the patient. Thirdly, the authors did not give any information as to how often oophorectomy was performed during hysterectomy. The group of women that was studied seems to be very heterogeneous. Drawing conclusions on the differences between the three techniques are, therefore, hazardous. Once again, an alternative interpretation for the improvement of sexual functioning following hysterectomy could be that this improvement is mediated by an improved general well-being and quality of life following the relief of symptoms from the diseased uterus.

Conclusions

In conclusion, although the hypotheses about the potential negative effect of hysterectomy on sexual functioning are based on strong experimental and patient-related data, a critical review of the published clinical studies on the effect of hysterectomy for benign conditions in premenopausal women showed that there is no scientific proof for either a worsened or an improved sexual function as a result of the surgical procedure.

General Conclusions

The recent major studies on the clinical outcome of hysterectomy did show that the population of women that has an indication for hysterectomy is characterized by an elevated incidence of depression and a decreased quality of life. This may negatively influence their sexual functioning. Moreover, women may suffer from sexual dysfunctions as a result of the symptoms of their gynecological disease.

Overall quality of life seemed improved after successful treatment of dysfunctional uterine bleeding (i.e., both after hysterectomy and after uterus-saving alternatives). Likewise, it seems that a majority of women report an improvement of sexual functioning as a result of the relief of symptoms from the diseased uterus. A minority of women reported development of sexual dysfunctions as a result of hysterectomy. The nature and extent of these dysfunctions have not been adequately identified. Another very important finding was that a substantial proportion of women were depressed before hysterectomy Prehysterectomy depression was associated with poorer outcomes after hysterectomy in terms of symptoms such as pelvic pain, back pain, activity limitation, sleep disturbance, fatigue, abdominal bloating, and urinary incontinence. Women with prehysterectomy depression did not experience as much improvement in sexual functioning after hysterectomy as women without depression.

Clinical Data and the Hypotheses on the Relation Between Hysterectomy and Sexual Dysfunction

There is no evidence from clinical studies to either support or refute many of the hypotheses on the etiology of sexual dysfunction after hysterectomy. The Finnish studies and the randomized study by Thakar and co-workers (2002) did not show a beneficial effect of conserving the cervix, questioning the assumption that changes in the vaginal vault cause dyspareunia after total hysterectomy. An increased frequency of orgasm disorders was not observed in either of the major studies, denying the role of the uterus in orgasm.

Premature ovarian failure as a result of hysterectomy was not reported. Even oophorectomy at hysterectomy and estrogen hormone replacement were not correlated with sexual dysfunction. However, all of the studies contained imperfections in design. The most striking is the lack of research comparing sexual functioning in premorbid women. In all the studies described, women were asked to answer questions immediately before surgery at a time when they were symptomatic. Logically, women were more likely to report improved sexual functioning after surgery because their symptoms had been alleviated (Katz, 2002).

Qualitative changes in sexual function were not properly addressed. It has proven difficult to design clinical research protocols that adequately address the potential contribution of both psychosocial and anatomical changes to the development of female sexual dysfunction. Could there be changes in sexual function that we have not been measuring in clinical studies so far?

The hypothesis that surgical damage to the pelvic autonomic nerves during hysterectomy disrupts the nerve supply to the blood vessels of the vaginal wall and leads to a disturbed vasocongestion and/or lubrication response is probably too specific to be answered by the questionnaire evaluations that have been used so far. Objective measures could prove to be useful in resolving this question. Psychophysiological assessment using photoplethysmographic vaginal pulse amplitude (VPA) (Sintchak & Geer, 1975) is reliable in assessing the increase in vaginal blood flow during sexual arousal (Laan, Everaerd, & Evers, 1995; Rosen, 2002). This increased vaginal blood flow reflects a highly automatized genital response mechanism, occurring irrespectively of subjective appreciation of the sexual stimulus (Laan, Everaerd, van Bellen, & Hanewald, 1994; Meston, 2000). The influence of neural control on the vaginal blood flow and vaginal pulse amplitude has been demonstrated by Levin and Macdonagh (1993), who were able to stimulate the sacral anterior nerve roots in a conscious, young female paraplegic by using the subject’s intradural implanted Finetech/Brindley stimulator. Stimulating sacral levels 2 and 3 caused significant increases in VPA monitored by a vaginal photoplethysmograph, indicating direct neural control of genital vasodilatation. Surgical damage of the pelvic autonomic nerves during hysterectomy would result in a disrupted vaginal blood flow response, reflected by a lowered maximum VPA during sexual stimulation. Patients with a history of hysterectomy could be subjected to the same neutral and erotic stimulation. The increase of vaginal blood flow could be compared with the increase of vaginal blood flow in controls without a history of hysterectomy. The ideal design would involve both a pre- and a posthysterectomy VPA assessment, and a well-selected control group. VPA could also be useful in the ongoing debate on whether subtotal hysterectomy results in less sexual dysfunction than total hysterectomy because a similar nerve disruption model could be applied.

Hysterectomized women have been subjected to vaginal plethysmography in one study by Bellerose and Binik (1993) on body image and sexuality in oophorectomized women. No significant differences in VPA were found between a nonsurgical control group, a hysterectomized group, and three oophorectomy groups. However, the hysterectomized group included patients treated for cancer and patients treated for benign diseases, and the extent and type of hysterectomy were not described. VPA was not assessed before surgery. Patient numbers were small and unequal, diminishing the power to detect real differences.

Future Research

In general, we feel that there are still firm scientific grounds to assume that hysterectomy does, to some extent, change the physiology of the sexual response. The question is, however, whether these physiological changes have clinical significance. Are we unable to assess these changes in physiology in clinical studies because we are using the wrong instruments to assess them, or do the women themselves simply not experience them and, therefore, do they have no importance in the subjective appreciation of sexuality? Even if the last is true, we feel that research efforts should be directed to both the subjective and the physiological changes in sexual functioning. More knowledge about the physiological processes that take place after hysterectomy would inform us better and could provide arguments to advise patients more adequately as to whether to undergo hysterectomy as opposed to uterus-saving treatment alternatives.

Future research on the effects of hysterectomy on sexual functioning should, therefore, include both objective measures, such as VPA, and standardized self-report measures on sexual functioning, as well as on depression, anxiety, and quality of life issues, including relationship parameters. Self-report questionnaires should be validated in nonclinical samples. A number of self-report and diary-based methods have been developed for multidimensional assessment of sexual function, such as the Brief Sexual Function Index For Women (BSFI-W, Taylor, Rosen, & Leiblum, 1994), the Female Sexual Function Index (FSFI, Rosen et al., 2000), and the Sexual Function Questionnaire (SFQ, Quirk et al., 2002). These have demonstrated adequate psychometric properties, including test-retest reliability, internal consistency, and discriminant validity. Only one structured interview has been described in the literature thus far (Derogatis, 1997), and this method has not been widely used to date (Rosen, 2002). Studies should be done prospectively, ideally using a randomized design, with pre- and posthysterectomy assessments. Studies should confirm or deny a well-described hypothesis, based on a clear theoretical model. The surgery women receive should be well-defined and preferably standardized within the study. To qualify for the diagnosis of sexual dysfunction, a woman should show evidence of significant personal distress to her sexual problem. Personal distress can be assessed by means of an interview or questionnaire (Rosen, 2002). Likewise, quality of life assessment including relationship parameters should preferably be included in clinical research protocols.

Clinical Implications

In patient care, medical professionals should address sexual functioning when they discuss hysterectomy as one of the treatment options with patients. The patient should be invited to talk about the consequences of the gynecological disease on her sexuality and sexual life with her (male or female) partner. Sexual problems or dysfunctions could come up but also problems with partner communication or, more generalized, with body image and her identity as a woman. Irregular vaginal bleeding might cause a change in libido, diminished lubrication during sexual play, and difficulty in reaching orgasms. The woman might feel insecure and guilty because she considers herself not to be a “good” sexual partner.

Berman et al. (2003) made it clear in their web-based survey of 3,807 women that although 40% of the women reported that they did not actively seek help from a physician for sexual functioning complaints, 54% indicated that they would like to do so. Only 39% of those surveyed had the feeling that the physician took their concerns seriously and tried to find a solution. The study strengthens the notion that it is crucial for medical professionals to be aware of the psychological aspects of sexual functioning complaints and that they bring them up.

When systematically asked for, some women may reveal their sexual abuse history. Such a traumatic history could impair sexual functioning as well but could also have far reaching consequences on the woman’s feeling of well-being during the course of hysterectomy and recovery after surgery.

Patients should be informed that when the indication for hysterectomy is a valid one, the majority of women have reported experiencing improved sexual functioning as a result of the relief of symptoms from the diseased uterus and that about 10-15% of women reported newly developed sexual dysfunctions.

Given the data available, a critical attitude towards the indications of hysterectomy remains mandatory. The further development of uterus-saving alternatives should be encouraged. The research on the effect of hysterectomy that has been performed to date is not conclusive, and the future might bring new insights as to whether hysterectomy is associated with a decreased or increased quality of sexuality.

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Cornelis P. Maas

Philomeen Th. M. Weijenborg

Moniek M. ter Kuile

Leiden University Medical Center

Cornelis P. Maas is affiliated with the Department of Gynecology. Philomeen Th. M. Weijenborg is affiliated with the Department of Gynecology and the Department of Psychosomatic Gynecology and Sexology. Moniek M. ter Kuile is affilicated with the Department of Psychosomatic Gynecology and Sexology. Correspondence concerning this article should be addressed to C.P. Maas, Department of Gynecology, K6p-76, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.(C.P.Maas@lumc.nl.)

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