SEXUAL FUNCTION AFTER HYSTERECTOMY

SEXUAL FUNCTION AFTER HYSTERECTOMY

1. SEXUAL FUNCTION SEXUAL FUNCTION
AFTER HYSTERECTOMYAFTER HYSTERECTOMY

ABOUBAKR ELNASHAR
BENHA UNIVERSITY HOSPITAL, Egypt
Aboubakr Elnashar

2. Aboubakr Elnashar

3. Historically:
The uterus has been regarded as a sexual organ, a source
of energy & vitality & a maintainer of youth & attractiveness
(Sloan,1978).
Little wonder, therefore, that removal of such organ may:
make her less than a woman, alter her perception of self,
feminity, sexual desire & ability to respond sexually.
Aboubakr Elnashar

4. Anatomically:
1.The reduced quantity of tissue:
decreased vasocongestion: decreased S arousal & probability of
multiple orgasm.
2. Vaginal shortening.
3. T.H.:
•Loss of a major portion of the uterovaginal plexus
through excision of the cervix: adverse effect on sexual arousal &
orgasm in women who previously experienced cervical
orgasm(caused by stimulation of nerve endings in uterovaginal
plexus) (Kilkku et al,1983).
•Reduction of cervical mucous:
vaginal dryness & decreased genital sensation.

Aboubakr Elnashar

5. Physiologically :
1.Decrease intensity of orgasm:
uterine smooth muscle contractions play an important
role in perception of orgasm
(Fox &Fox,1971).
2. Scar tissue:
prevents full expansion of the vagina: SI more painful
(Naught & Mcbee,1977)
Aboubakr Elnashar

6. However,
the above are merely theoretical considerations.
Era of EBM not TBM
In reality
the impact of hysterectomy on S. function is more
complex since both physical & psychological factors
have influences on human sexuality.
Aboubakr Elnashar

7. Aboubakr Elnashar

8. Systematic
(non-journalistic) review of the impact of
hysterectomy for
non-malignant conditions on sexual function
Aboubakr Elnashar

9. Aboubakr Elnashar

10. Data sources
1. MEDLINE data base: relevant articles in the English
language between 1970 & 2000.
2. MEDLINE data base of the Egyptian National STI
Network.
3. Additional studies were located by reviewing
bibliographies of the articles located by MEDLINE.
Me SH
Hysterectomy; sexual function; libido; orgasm & dysparunia
Aboubakr Elnashar

11. Methods of study
Studies were reviewed
1. Type of hysterectomy.
2. Type of study.
3. Method of assessment
4. Outcome measures
5. No of patients.
6. Confounding factors
Aboubakr Elnashar

12. Aboubakr Elnashar

13. ProspectiveProspective RetrospectiveRetrospective
Total abdominal Total abdominal 13 13 9 9 44
Subtotal Subtotal 5 5 33 22
Laparoscopic Laparoscopic 4 4 33 11
Vaginal Vaginal 2 2 -- 22
Unspecified Unspecified 4 4 2 2 22
Total Total 2828* * 1717((6161%) %) 1111((3939%)%)

No.No.
**4 4 studies are Egyptian.studies are Egyptian.
Aboubakr Elnashar

14. Total abdominal hysterectomy: Total abdominal hysterectomy: 9 9 Prospective Prospective
studiesstudies

YrYr MM LibidoLibido OrgasmOrgasm DysparDyspar
Carlson Carlson 1994 355 1994 355 I I 3636//1515% % 1212//99% % 3232//55%%
Rhodis Rhodis 1999 110 1999 110 Q Q 2929//1212% % 88//55% % 1919//44%%
Lambden Lambden 1997 178 1997 178 Q Improve Improve NEQ Improve Improve NE
Bernhard Bernhard 1992 26 1992 26 Q U/I: Q U/I: 8585% % U/I: U/I: 6565% NE% NE
Clarke Clarke 1995 300 1995 300 I NE I NE 5050//2828% % 3232//1010%%
Gath Gath 1982 156 1982 156 I U/I:I U/I:8383% % NE NENE NE
Virtamen Virtamen 1993 102 1993 102 I U/I:I U/I:7575% % NE NENE NE
Alexander Alexander 1996 85 1996 85 Q NE NE NEQ NE NE NE
Weber Weber 1999 43 1999 43 Q NE NE NE*Q NE NE NE*


NoNo
*Global sexual score: *Global sexual score: 12 12 questions. Low= better S functionquestions. Low= better S function
Aboubakr Elnashar

15. Total abdominal hysterectomy: Total abdominal hysterectomy:
4 4 Retrospective studiesRetrospective studies
Study Yr No M Libido OrgasmStudy Yr No M Libido Orgasm
Eicher Eicher 1994 105 1994 105 I u/I:I u/I:9292% % u/I:u/I:9292%%
Ferroni &Ferroni & 1996 656 1996 656 Q improve improveQ improve improve
DeepDeep

Munday &Munday & 1967 290 1967 290 Q u/I: Q u/I: 7373% %
CoxCox
Carranza Carranza 1997 285 1997 285 I u/I: I u/I: 6060%%
et alet al
Aboubakr Elnashar

16. Subtotal hysterectomy: Subtotal hysterectomy: 5 5 studiesstudies

Kilkku et al* Kilkku et al* 1983 1071983 107//105 105 I NE SH:NE D but I NE SH:NE D but
ElsherbeniElsherbeni 1997 1051997 105//98 98 I TH: SD more in I TH: SD more in
& Elbahie& Elbahie SHSH
Helstrome et alHelstrome et al 1993 104 1993 104 I NE NE NEI NE NE NE
Nathorst Nathorst 1992 1461992 146//532 532 Q No sig difference between both Q No sig difference between both
et al groupset al groups
Scot et alScot et al 1997 1997 decision prbability of impaired S responsedecision prbability of impaired S response
analysis**analysis** SH: SH: 00..005 005 TH: TH: 00..0101
Yr No M Libido Orgasm DyspYr No M Libido Orgasm Dysp
**Who well benefit sexually from SH? Who well benefit sexually from SH?
**Systematic quntitative approach to predict the results of different **Systematic quntitative approach to predict the results of different
therapeutic options based on uncertain data.therapeutic options based on uncertain data.
Aboubakr Elnashar

17. Laparoscopic assisted hysterectomy: Laparoscopic assisted hysterectomy: 4 4
studiesstudies
Yr No M Libido Orgasm Dyspar Yr No M Libido Orgasm Dyspar
Prospective:Prospective:
Shawki Shawki 1997 48 1997 48 I NSD NSD NSDI NSD NSD NSD
Elshihawy Elshihawy 1998 201998 20//20 20 I NSD NSD NSDI NSD NSD NSD
Elgamal Elgamal 1996 501996 50//50 50 I Time needed to regain Sex I Time needed to regain Sex
. was shorter after LAH. was shorter after LAH
Retrospective:Retrospective:
Ewert et al Ewert et al 1995 55 1995 55 Q u/I: Q u/I: 9595% %
Aboubakr Elnashar

18. Vaginal hysterectomy: Vaginal hysterectomy: 2 2 retrospective studiesretrospective studies
Yr No M Libido Orgasm Yr No M Libido Orgasm
Craig & Craig & 1974 49 1974 49 Q U/I:Q U/I:6767% U/I:% U/I:8686% %
JacksonJackson
Poad & Poad & 1994 251994 25//25 25 Q u/I:Q u/I:7676% u/I:% u/I:7878% %
ArnoldArnold

The poorer the results when The poorer the results when
anterior colpoperineoraphy is doneanterior colpoperineoraphy is done
Aboubakr Elnashar

19. Unspecified hysterectomy: Unspecified hysterectomy: 4 4 studiesstudies
Yr No M Libido OrgasmYr No M Libido Orgasm
ProspectiveProspective
Martin et al Martin et al 1980 44 1980 44 Q NE NEQ NE NE
Coppen &Coppen & 1981 60 1981 60 Q u/I:Q u/I:100100% % NE NE
BishopBishop
RetrospectiveRetrospective
Schofied et alSchofied et al 1991 175 1991 175 I/Q u/I:I/Q u/I:9696%%
Denerstein et al Denerstein et al 1997 89 1997 89 I u/I: I u/I: 6363% u/I: % u/I: 7575%%

Aboubakr Elnashar

20. Confounding factors
Preoperative: Age
Quality of life.
Marital relationship.
Preoperative counseling.
Operative: Oophorectomy
Postoperative: HRT
Psychological factors
Relief of gynecologic symptoms.

Aboubakr Elnashar

21. 1. Age:
>45 yr: Decrease libido & orgasm
(Kilkku et al,1983)
< 50 yr : S. unsatified
(Schofield et al,1991).
2. Detailed preoperative counseling
improves postoperative S function
(Harris,1997)
Indications of hysterectomy the nature of operation & the
expected postoperative course.

Aboubakr Elnashar

22. 3. Poor marital relationship
significantly increase sexual unsatisfaction
(Helstrome et al,1995).
4. Quality of life:
depend on: social status, economic resources, physical &
psychosexual health (Farrel&Kieser,2000)
Higher education (Ewert et al,1995),
lack of physiological health problems, support from husband
(Darling & Smith,1993) are correlated with S. satisfaction
after hysterectomy.

Aboubakr Elnashar

23. Oopherectomy: reduction in E & A.
No sig. Negative effect
(Munday & Cox,1967; Utian, 1975; Nathorst et
al,1992)
Increase risk for weak or absent libido &
decrease orgasmic frequency
(Kilkku et al, 1983)



Aboubakr Elnashar

24. 1. The evidence for an association between depression,
anxiety & hysterectomy is mixed.
Higher incidence of depression
(Hughes et al, 1991)
No correlation betwwen depression,anxiety & S health
(Helstrome et al,1994; Dennerstein et al,1997)
2. Relief of gynecologic symptoms: greater
postoperative S. satisfaction
(Schofield et al,1991; Darling et al,1993; Helstrome et
al,1994)


Aboubakr Elnashar

25. 3.HRT:
No effect of ERT
(Dennerstein et al, 1997; Weber,1999)
T-ERT: higher sex desire
(Sherwin,1987)
Tibilon: improves libido & sexual enjoyment
(Moore,1999


Aboubakr Elnashar

26. Aboubakr Elnashar

27. •• MetaMeta--analysis was not possible:analysis was not possible:
the study design did not provide the necessary information.the study design did not provide the necessary information.
•• Research has not provided clearResearch has not provided clear--cut answers:cut answers:
40% of the studies are retrospective.
Poorly designed & unrandomized.
Samples are mixed
Many confounding factors
Lack of base line assessment,
Absent control groups.

Aboubakr Elnashar

28. The ideal study
Prospective in which subjects are randomly assigned
either to hysterectomy (without oopherectomy) or to an
alternative treatment, such as E. ablation.
Outcomes should be based on a validated measure of S
function before & after hysterectomy.
Significant confounding factors should be considered &
other factors should be eliminated (Farrel & kieser,2000).
The one properly designed study by Alexander et al, 1996
found no effect of hysterectomy on S.function.

Aboubakr Elnashar

29. Aboubakr Elnashar

30. 1. Sexual function after hysterectomy is
unchanged or improved for the majority of women
2. Subtotal hysterectomy is associated with
No effect on libido or orgasm.
Reduction in incidence of dysparunia.
Less impairment of S response than total
hysterectomy.
3. Preoperative S function is the best predictor of
postoperative S function.
Aboubakr Elnashar

31. 4. Detailed preoperative counseling improves
postoperative S function.
5. Concomitant removal of the ovaries leads to a
significant increase in psyhosexual dysfunction in
the premenopausal women.
6. Preoperative S function is the best predictor of
postoperative S function.
7. Detailed preoperative counseling improves
postoperative S function.


Aboubakr Elnashar

32. Aboubakr Elnashar