Effect of Hysterectomy on Sexual Functioning, The

Annual Review of Sex Research, 2003 by Maas, Cornelis P, Weijenborg, Philomeen Th M, Kuile, Moniek M Ter

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.