Hysterectomy and Sexuality

Abstract & Commentaries

Synopsis: In a prospective study, all sexual functioning improved after hysterectomy.

Source: Rhodes JC, et al. JAMA 1999;282:1934-1941.

Rhodes and associates from the university of Maryland performed a two-year, prospective study of hysterectomy. This, the Maryland Women’s Health Study, began with 1299 patients scheduled to undergo hysterectomy and concluded with 1101 women providing information about their functioning at six, 12, 18, and 24 months after a hysterectomy performed in 1992 or 1993. Bilateral removal of the ovaries was documented in 43.7% of the patients. Frequency of sexual relations increased after hysterectomy and the percentage of patients who had not been sexually active decreased. These changes were statistically significant, comparing post-hysterectomy to prehysterectomy behavior. An impressive change in dyspareunia occurred, decreasing from 40.8% to 14.9% two years after hysterectomy. Two-thirds of the women not experiencing orgasms prior to hysterectomy were having orgasms one year after surgery. Another striking feature involved libido, defined as frequency of sexual desire. More than 70% of the women with low libido before hysterectomy reported an improvement postoperatively. Approximately 30% of the participants were not sexually active just prior to hysterectomy, and of those 325 women, 45.5% were sexually active for two years after surgery. Rhodes et al conclude that overall hysterectomy was associated with an improvement in sexual functioning.

Comment by Leon Speroff, MD

The idea that hysterectomy adversely affects sexual functioning is a common anxiety among our patients and has been intermittently promoted in the medical literature. Women who undergo hysterectomy experience an overall improvement in their health and quality of life. Therefore, it is not surprising that sexual functioning reflects this overall improvement. It is also commonly observed that hysterectomy frees the patient from vaginal bleeding and the fear of pregnancy. The study is noteworthy in documenting an improvement in quantity- and quality of life. Many writers have postulated that hysterectomy could affect orgasm, either through scar tissue or the elimination of tissue providing sensory response. In my view, the documentation of improved frequency and strength of orgasms is one of the most valuable contributions of this report. Many of the women who reported vaginal dryness prior to hysterectomy were no longer experiencing it after surgery. This improvement was present even when Rhodes et al adjusted for the post-hysterecomy use of hormone therapy. However, this adjustment was confounded by the fact that 88% of the premenopausal women who underwent bilateral oophorectomy were using hormonal therapy. It is likely that the postoperative use of hormone therapy was a major factor in the problem of vaginal dryness.

Comment by Sarah L. Berga, MD

The much-neglected topic of women’s sexuality is now receiving needed investigative attention. I am happy to have the opportunity to bring this meticulously done study from the Journal of the American Medical Association to your attention. The current study clearly demonstrates that when the gynecologic condition to be relieved is benign and associated with symptoms that interfere with sexual functioning, hysterectomy is not likely to further impair sexual functioning. In fact, improved sexuality is likely in these circumstances. While not all women contemplating hysterectomy may ask about the effect of the procedure upon sexual functioning, they most certainly think about it. When three prospective studies concur, reassurance is in order. Obviously, it is better for the physician to bring this to the patient’s attention rather than waiting to be asked.

It is often held that the quality-of-life parameters cannot be validly assessed in a clinical investigation. This study clearly demonstrates that such nihilism is unwarranted. The importance of including quality-of-life measures is gaining ground. Validated assessment tools are available, and the expertise for developing and implementing such tools is not as rare as in the past. Therefore, there is really no excuse for not foraying into this arena when attempting to understand the effect of clinical therapies, be they procedures or pharmaceuticals. Quality-of-life information is critical and does much to clarify, guide, reassure, and dispel myths. (Dr. Speroff is Professor of Obstetrics and Gynecology, Oregon Health Sciences University, Portland; and Dr. Berga is Associate Professor, Departments of Obstetrics, Gynecology, Reproductive Sciences, and Psychiatry, University of Pittsburgh.)

The following statements are true of hysterectomy and sexual functioning except:

a. There is no evidence that any specific surgical approach for hysterectomy has a better or worse outcome in terms of subsequent sexual functioning.

b. Overall, the surgical removal of an unhealthy uterus improves general health and sexuality.

c. The uterine cervix is an essential element in the physiology of an orgasm.

d. Psychological morbidity prior to hysterectomy is associated with continuing problems, including decreased libido after hysterectomy.