SEXUAL FUNCTION SEXUAL FUNCTION

AFTER HYSTERECTOMYAFTER HYSTERECTOMY

ABOUBAKR ELNASHAR

BENHA UNIVERSITY HOSPITAL, Egypt Aboubakr Elnashar

Aboubakr Elnashar

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

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

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

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

Aboubakr Elnashar

Systematic

(non-journalistic) review of the impact of

hysterectomy for

non-malignant conditions on sexual function

Aboubakr Elnashar

Aboubakr Elnashar

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

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

Aboubakr Elnashar

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

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

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

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

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

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

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

Confounding factors

Preoperative: Age

Quality of life.

Marital relationship.

Preoperative counseling.

Operative: Oophorectomy

Postoperative: HRT

Psychological factors

Relief of gynecologic symptoms.

Aboubakr Elnashar

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

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

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

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

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

Aboubakr Elnashar

•• 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

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

Aboubakr Elnashar

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

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

Aboubakr Elnashar