Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and Sexual Functioning. JAMA. 1999;282(20):1934-1941. doi:10.1001/jama.282.20.1934
Author Affiliations: Departments of Epidemiology and Preventive Medicine (Ms Rhodes and Drs Kjerulff and Langenberg) and Obstetrics and Gynecology (Dr Guzinski), School of Medicine, University of Maryland at Baltimore, Baltimore. Dr Guzinski is now with the Department of Obstetrics and Gynecology, St Joseph's Medical Center, Towson, Md.
Context Women considering hysterectomy often are concerned about its potential
effects on their sexual functioning but the effects of hysterectomy on sexual
functioning remain unclear.
Objective To examine changes in sexual functioning after hysterectomy.
Design and Setting A 2-year prospective study (Maryland Women's Health Study) of hysterectomy,
which included measures of sexual functioning prior to hysterectomy and at
6, 12, 18, and 24 months after hysterectomy, performed during 1992 and 1993.
Patients Of 1299 women interviewed prior to hysterectomy, 1101 (84.8%) completed
the study and provided information about their sexual functioning. Most were
between the ages of 35 and 49 years, white, married or living with a partner,
and high school graduates.
Main Outcome Measures Frequency of sexual relations, dyspareunia, orgasm, vaginal dryness,
and sexual desire.
Results 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 distribution 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. Prehysterectomy depression was associated with experiencing
dyspareunia, vaginal dryness, low libido, and not experiencing orgasms after
Conclusions Sexual functioning improved overall after hysterectomy. The frequency
of sexual activity increased and problems with sexual functioning decreased.
Each year more than half a million US women decide to undergo hysterectomy
as treatment for chronic, benign gynecologic conditions.1
Although very little has been published about the hysterectomy decision-making
process, studies show that hysterectomy patients are concerned about potential
negative effects on their sexual functioning.2- 6
In fact, 2 studies found that concern about posthysterectomy sexual functioning
is the most frequent preoperative anxiety.5,6
Patient concerns about sexual functioning after hysterectomy are not
unfounded, since estimates of the percentage of women who report a deterioration
in their sex lives after hysterectomy range from 13% to 37%.5,7- 10
In addition, it seems plausible that removal of the uterus could have adverse
effects on sexual function through 1 or more of the numerous mechanisms that
have been suggested. Jewett11 examined the
possibility that hysterectomy causes dyspareunia through shortening of the
vaginal vault. External orgasms, caused by clitoral stimulation, are not likely
to be affected by hysterectomy; however, Hasson12
postulated that internal orgasms, caused by stimulation of nerve endings in
the uterovaginal plexus, are hindred by hysterectomy with cervix removal.
Finally, vaginal dryness is known to result from estrogen deficiency caused
by premenopausal hysterectomy with bilateral oophorectomy.13
But it may also result from premenopausal hysterectomy without bilateral oophorectomy
since several researchers have found evidence that hysterectomy hastens ovarian
failure and increases menopausal symptoms, including vaginal dryness.14- 16
Although some evidence indicates that hysterectomy has a detrimental
effect on sexual functioning, other evidence suggests the contrary. The same
studies that found that the sex lives of many women deteriorated after hysterectomy
also found that 16% to 47% of women reported no change in their sex lives
after hysterectomy and that 34% to 70% of women reported improvements in their
sex lives after hysterectomy.5,7- 10
The mechanisms for improvement in sexual functioning after hysterectomy are
as plausible as those for sexual functioning deterioration. Huffman17 attributed posthysterectomy improvements in sexual
functioning to relief from dyspareunia caused by excised pelvic pathology.
Helstrom et al18 observed an association between
prehysterectomy dysmenorrhea and posthysterectomy sexuality and interpreted
this finding to indicate that relief from dysmenorrhea causes improvements
in sexual functioning. Richards19 reported
that patients with increased libido after hysterectomy expressed relief from
the fear of conception. Thus, the relationship between hysterectomy and sexual
functioning remains unclear because of the apparent contradictory evidence
showing both beneficial and detrimental effects.
This report presents the sexual functioning outcomes of the Maryland
Women's Health Study, which was designed to measure the outcomes and effectiveness
of hysterectomy for benign conditions in terms of operative and postoperative
complications, symptoms, psychological functioning, sexual functioning, quality
of life, patient satisfaction, and cost. It was a prospective cohort study
in which 1299 patients who were scheduled to undergo hysterectomy for benign
conditions during 1992 and 1993 were interviewed shortly before surgery and
at 3, 6, 12, 18, and 24 months after surgery. The 3- and 18-month posthysterectomy
interviews were conducted by telephone. All other interviews were conducted
at the patients' homes. Additional data were collected through medical record
abstraction of the hysterectomy hospitalization.
At the time of this study, 49 hospitals were performing hysterectomy
in the state of Maryland. Based on 1990 state discharge data, the hospitals
were stratified according to the annual number of hysterectomies performed,
such that large urban hospitals performing many hysterectomies were grouped
together and small rural hospitals performing a small number of hysterectomies
were grouped together. Within strata, 32 hospitals were randomly selected
and invited to participate. Twenty-eight hospitals accepted. All attending
gynecologists at each of the 28 hospitals were asked to participate, and 406
(61%) of 663 agreed. The most common reason gynecologists gave for not participating
was that they rarely performed hysterectomy.
Participating hospitals provided study staff with surgical postings
that listed patients scheduled for hysterectomy. From these lists, the patients
of participating physicians were selected, contacted, and asked to participate.
Patients were also identified directly through the offices of participating
physicians. The majority of patients (65.6%) were identified through the surgical
postings, 33.2% were identified through physicians' offices, and 1.2% were
self-referred. This study was approved by the University of Maryland Institutional
Review Board as well as the institutional review boards of each of the participating
hospitals. All participants provided signed informed consent.
Of the 4858 hysterectomies performed at participating hospitals during
the enrollment period, we obtained the names of 1823 patients. Interviewers
were unable to locate 219 of these eligible patients. Of the 1604 patients
contacted, 81% agreed to participate. The most common reason patients gave
for not participating was having had too little time before surgery to complete
the prehysterectomy in-home interview required of all participants. Women
declining to participate were not significantly different from participants
in age, race, or surgical indications, but were significantly more likely
to have been scheduled for hysterectomy within a week of their posting date.
Study participants were also compared with the total population of 8348 women
who underwent hysterectomy in Maryland during the enrollment period, and participants
were found to be younger (mean age, 43.3 vs 44.6 years; P<.001), have a shorter length of stay (mean, 3.4 vs 3.8 days; P<.001), lower hospital charges (mean, $3226 vs $3721; P = .003), and more likely to be insured by a health maintenance
organization (33.7% vs 29.6%; P = .001).
Prior to hysterectomy and at 6, 12, 18, and 24 months posthysterectomy,
patients were asked, "In the last month, how many times have you had sexual
relations?" Patients who reported having sexual relations at least once were
then asked in the last month, how frequently had they (1) "experienced pain
during sexual relations?" (2) "experienced orgasm during sexual relations?"
(3) "experienced vaginal dryness?" and (4) "desired sex?" The response options
to the questions concerning dyspareunia, orgasm, and vaginal dryness were,
"all of the time," "most of the time," "a good bit of the time," "some of
the time," "little of the time," and "none of the time." The response options
to the libido question were "every day," "5-6 days per week," "3-4 days per
week," "1-2 days per week," "2-3 days per month," "1 day per month," "less
than 1 day per month," and "not at all." Participants who reported that they
had experienced orgasm were asked, "In the last month, how strong has orgasm
been for you?" The response options to this question were "very strong," "strong,"
"mild," or "very mild." These questions were skipped for patients not reporting
any sexual relations in the previous month. The entire survey instrument,
including these questions, was extensively pretested and validated.
The percentage of women reporting sexual relations at least once a month
before hysterectomy was calculated and compared with the percentages at 12
and 24 months after hysterectomy. All women who answered the question about
sexual activity frequency at each interview stage were included in these comparisons.
The comparisons were made using McNemar test.20
The sexual frequency distributions were positively skewed. The distributions
were log transformed and the geometric mean number of sexual relations per
month was compared for the before hysterectomy and after hysterectomy data
collection stages using paired t tests.
The distributions of the frequencies of dyspareunia, orgasm, vaginal
dryness, and sexual desire and the distributions of orgasm strength before
hysterectomy are presented and compared with after hysterectomy distributions.
Small differences in the number of patients included in each comparison are
a result of patient refusals.
Response options were collapsed to create 4 separate variables indicating
whether patients were experiencing a problem with each of the 4 aspects of
sexual functioning examined. A problem with dyspareunia was considered as
having pain during sex all, most, or a good bit of the time. Similarly, problematic
vaginal dryness was defined as experiencing vaginal dryness all, most, or
a good bit of the time. Women who desired sexual relations less than once
per month were considered to have low libido, and women who reported having
orgasm none of the time were categorized as not experiencing orgasms.
Analyses were performed to estimate the relationships between specific
problems at 12 months after hysterectomy and each of the following factors:
race (white and nonwhite), self-reported menopausal status at hysterectomy
(premenopausal vs postmenopausal), prehysterectomy depression (score of >26
on a rescaled 100-point Profile of Mood States index),21
partner support (partner in favor of surgery vs partner against, mixed, or
of no opinion vs no partner), hysterectomy approach (abdominal vs vaginal
vs laparoscopically assisted vaginal hysterectomy), oophorectomy (bilateral
vs unilateral vs none), and posthysterectomy hormone replacement therapy [HRT]
use (yes vs no). For each problem, experiencing the problem before hysterectomy
was the strongest predictor of experiencing the problem 12 months after hysterectomy.
Since we were interested in the influence of these factors independent of
a patient's prehysterectomy problem status, the relationships between each
factor and each posthysterectomy problem were estimated after adjustment for
prehysterectomy problem status. All estimates were also adjusted for age.
A separate logistic regression model was used to estimate the relationships
between each problem and each factor. For each model, the dependent variable
was the presence or absence of the problem, the independent variable was the
factor being examined, and the covariates were age and prehysterectomy problem
status. Women who were not sexually active prehysterectomy, 12 months posthysterectomy,
or both were excluded from these analyses.
Of the 1299 women interviewed before hysterectomy, 1132 (87.1%) completed
the 12- and 24-month posthysterectomy interviews. The 167 women who did not
complete the study were significantly more likely to be black and had significantly
less education and lower annual family incomes. Women not completing the study
were also more likely to have a problem with dyspareunia before hysterectomy
(25.9% vs 18.5%), but did not otherwise differ in terms of prehysterectomy
sexual functioning. Among patients completing the study, 1101 (97.3%) were
willing to tell study interviewers whether they had been sexually active in
the months before the hysterectomy and at the interviews 12 and 24 months
after hysterectomy. The characteristics of these 1101 participants are presented
in Table 1. Overall, 71.1% of
participants were between ages 35 and 49 years, 67.5% were white, 73.3% were
either married or living with a partner, 92.6% had graduated from high school,
and 34.1% had an annual income higher than $50,000. Sixty-five percent of
the participants underwent abdominal hysterectomy and 44.0% did not have any
The frequency of sexual relations increased after hysterectomy. The
geometric mean number of sexual relations per month rose from 2.3 before hysterectomy,
to 3.1 at 12 months and 2.9 at 24 months after hysterectomy (P<.001 for both prehysterectomy vs posthysterectomy comparisons).
Likewise, the percentage of patients who had not been sexually active in the
previous month dropped and the percentage of patients having 5 or more sexual
relations per month rose (Table 2).
After hysterectomy the percentage of women experiencing dyspareunia
dropped dramatically: from 40.8% before to 18.4% at 12 months and 14.9% at
24 months after hysterectomy (Table 2).Table 3 shows that 84.4% of women experiencing
dyspareunia all, most, or a good bit of the time before hysterectomy were
not experiencing painful sexual relations this frequently 12 months after
hysterectomy. However, an additional 5.4% were not sexually active after hysterectomy
and may have experienced dyspareunia if they had been sexually active. Table 3 shows that few of the women without
frequent dyspareunia and few of the women who were not sexually active before
hysterectomy were experiencing frequent dyspareunia 12 and 24 months after
Although most of the women experiencing dyspareunia before hysterectomy
were relieved of this problem after, women who experienced dyspareunia before
hysterectomy were more likely to have this problem after hysterectomy than
women not experiencing dyspareunia before hysterectomy (odds ratio [OR], 4.47;
95% confidence interval [CI], 2.14-9.33). After adjustment for age and experiencing
dyspareunia before hysterectomy, women with prehysterectomy depression were
more likely to experience posthysterectomy dyspareunia than women without
prehysterectomy depression (OR, 2.28; 95% CI, 1.09-4.76). Race, self-reported
menopausal status at hysterectomy, partner support, hysterectomy approach,
oophorectomy, and posthysterectomy-HRT use were not significantly associated
with problematic dyspareunia 12 months after hysterectomy.
Orgasm frequency increased after hysterectomy (Table 2). Overall, 62.8% of patients were experiencing orgasms before
hysterectomy. This figure rose to 72.4% and 71.5% at 12 and 24 months after
hysterectomy. This change is consistent with the results in Table 3, which show that approximately two thirds of the women not
experiencing orgasms before their hysterectomies were having orgasms 12 months
after hysterectomy and few women who were having orgasms before hysterectomy
stopped having them after hysterectomy.
The strength of orgasm also rose after hysterectomy (Table 2). Before hysterectomy 44.6% of women were experiencing strong
orgasms. This figure rose to 58.4% and 57.3% at 12 and 24 months after hysterectomy.
Not experiencing orgasms before hysterectomy was the factor most highly
associated with not experiencing orgasms 12 months after hysterectomy (OR,
11.91; 95% CI, 5.75-24.70). After adjustment for not experiencing orgasms
before hysterectomy, each year of age increased the odds of not experiencing
orgasms 12 months after hysterectomy by 7% (OR, 1.07; 95% CI, 1.02-1.11).
After adjustment for age, and not experiencing orgasms before hysterectomy,
bilateral oophorectomy (OR, 2.68; 95% CI, 1.10-6.53) and prehysterectomy depression
(OR, 3.31; 95% CI, 1.49-7.38) were associated with not experiencing orgasms
1 year after hysterectomy. No other factors were found to be significantly
associated with not experiencing orgasms 12 months after hysterectomy.
The overall distribution of vaginal dryness improved after hysterectomy
as the percentage reporting vaginal dryness none of the time rose from 37.3%
before to 46.8% and 46.7% at 12 and 24 months after hysterectomy (P<.001 for both prehysterectomy vs posthysterectomy comparisons, Table 2). Nonetheless, clinically significant
percentages of women experienced both the persistence and development of vaginal
dryness; 35.2% of the women with vaginal dryness before hysterectomy experienced
persistent vaginal dryness and 8.7% of women not having a problem with vaginal
dryness before hysterectomy developed a problem by 12 months after hysterectomy
Prehysterectomy vaginal dryness was highly predictive of posthysterectomy
vaginal dryness (OR, 5.95; 95% CI, 3.75-9.47). After adjustment for prehysterectomy
vaginal dryness and age, prehysterectomy depression was also associated with
posthysterectomy vaginal dryness (OR, 1.65; 95% CI, 1.01-2.70) as was a lack
of partner support (OR, 1.86; 95% CI, 1.01-3.45). None of the other factors
examined was significantly associated with posthysterectomy vaginal dryness.
The frequency of sexual desire increased significantly posthysterectomy:
the percentage of women desiring sexual relations once a week or more increased
significantly and the percentage of women desiring sexual relations less than
once a month decreased significantly (Table
2). More than 70% of the women with low libido before hysterectomy
reported relief from low libido at 12 months after hysterectomy (Table 3). In addition, few women among
those who had not reported low libido before hysterectomy and among those
who were not sexually active before hysterectomy had developed low libido
after hysterectomy (Table 3).
Posthysterectomy low libido was associated with prehysterectomy low
libido (OR, 5.06; 95% CI, 2.71-9.43). Prehysterectomy depression was also
associated with posthysterectomy low libido (OR, 2.83; 95% CI, 1.28-6.23).
None of the other factors examined was significantly associated with posthysterectomy
Of the 1101 participants, 325 (29.5%) were not sexually active in the
month before the prehysterectomy interview. Among these 325 women, 141 (43.4%)
and 148 (45.5%) were sexually active in the months before the 12- and 24-month
posthysterectomy interviews. Few of the women who were not sexually active
before hysterectomy were experiencing sexual functioning problems 12 months
after hysterectomy (Table 3).
This study and several other studies found increases in sexual activity
after hysterectomy.22,23 Prospective
studies by Lambden et al24 and Gath et al25 found that the percentage of patients reporting increased
sexual frequency (21% and 56%, respectively) was significantly greater than
the percentage reporting decreased sexual frequency (12% and 17%, respectively).
In constrast, Kilkku26 observed nonsignificant
decreases in sexual activity after hysterectomy. Increased sexual activity
after hysterectomy may be the strongest evidence of a positive effect of hysterectomy
on sexual functioning. This is because improved sexual functioning and increased
sexual enjoyment are the most obvious explanations for increased sexual relations
Although a few studies have found that women with prior hysterectomy
report high rates of dyspareunia,27,28
many more studies have found that hysterectomy is associated with improvements
In fact, the decline in the rate of dyspareunia observed in this study, from
18.6% before hysterectomy to 4.3% at 12 months and 3.6% at 24 months after
hysterectomy, is very similar to the decline observed in the Maine Women's
Health Study.29 In that study, the percentage
of women reporting that they experienced dyspareunia very often fell from
32% before hysterectomy to 5% 1 year after hysterectomy. Likewise, prospective
research conducted by Kilkku,26 Virtanen et
al,30 and Helstrom et al9
found that the percentage of patients with dyspareunia fell from 31%, 40%,
and 56% before hysterectomy to 16%, 9%, and 10% at 1 year after hysterectomy,
respectively. Taken together these prospective studies provide strong evidence
that hysterectomy is associated with improvement in dyspareunia.
Many researchers have expressed concern that hysterectomy causes less
frequent and/or weaker orgasms.12,31- 33
The mechanisms postulated for these effects include: (1) the formation of
dyspareunia-causing scar tissue in the vaginal cuff,31
(2) the elimination of sexual arousal and cervical movement during orgasm,31- 33 and (3) the necessity
of the cervix for internal orgasm.12 These
hypotheses are biologically plausible. However, the majority of patients in
this study do not appear to have been negatively affected, since among women
experiencing orgasms prior to hysterectomy 83.3% were experiencing orgasms
of equal or greater frequency 12 months after hysterectomy and 84.6% were
having orgasms of equal or greater strength 12 months after hysterectomy.
Moreover, 65.1% of the women who were not experiencing orgasms before hysterectomy
were having them 12 months after hysterectomy.
The orgasm outcomes of this study are consistent with the outcomes of
a retrospective study conducted by Dennerstein et al,5
which found that 75% of women who had a hysterectomy reported no change or
an improvement in their ability to achieve orgasm, while 25% reported a deterioration.
The prospective Maine Women's Health Study29
did not examine the frequency of orgasm directly but did report that problems
with enjoyment of sexual relations decreased significantly 12 months after
hysterectomy. Two other prospective studies of hysterectomy found that the
frequency of orgasm does not change after hysterectomy.23,30
In contrast to these studies and to our results, Kilkku et al31
found that the percentage of hysterectomy patients having infrequent orgasm
rose from 29.7% before hysterectomy to 46.7% a year after total hysterectomy,
while there was no significant increase in infrequent orgasm among supravaginal
amputation patients. Unfortunately, we were not able to examine sexual functioning
in hysterectomy patients keeping their cervixes since only 15 of the patients
in this study underwent supracervical hysterectomy.
Overall, studies examining the effects of hysterectomy on orgasm are
not consistent, and there is evidence of both beneficial and detrimental effects.
In this study, symptoms such as dyspareunia and pelvic pain decreased dramatically
after hysterectomy. This symptom relief may have led to increased sexual enjoyment
and increased orgasm frequency. Furthermore, in terms of sexual functioning,
the improvements due to symptom relief may have outweighed any lost sensation
due to removal of the cervix.
Many women experiencing vaginal dryness before hysterectomy were no
longer experiencing it after hysterectomy. On the other hand, many women without
vaginal dryness before hysterectomy began experiencing it after hysterectomy.
Schofield et al34 conducted a mail survey of
175 women who had undergone hysterectomy 2 to 10 years previously and reported
similar results. In that study, none of the women with vaginal dryness before
hysterectomy reported that their hysterectomies had worsened the vaginal dryness,
and many even attributed improvements in vaginal dryness to their hysterectomies.
At the same time, 25 (69%) of the 36 women with newly acquired vaginal dryness
attributed it to their hysterectomies.34 The
results of Poad and Arnold2 are also comparable:
44% of patients reported less lubrication after hysterectomy, and 56% reported
the same or more.
Among premenopausal patients, bilateral oophorectomy is the most obvious
explanation for posthysterectomy increases in vaginal dryness.13
However, even after adjustment for prehysterectomy menopausal status and posthysterectomy-HRT
use, bilateral oophorectomy was not associated with posthysterectomy vaginal
dryness (OR, 1.30; 95% CI, 0.77-2.20). This may have been because 88% of the
premenopausal women undergoing concomitant bilateral oophorectomy were taking
HRT 12 months after hysterectomy. In addition, it is possible that hysterectomy
without bilateral oophorectomy causes vaginal dryness by hastening ovarian
failure. Oldenhave et al16 found that compared
with women whose uteri are intact, women with prior hysterectomy and no bilateral
oophorectomy were more likely to have vaginal dryness.
The results of Utian35 are frequently
cited as evidence that hysterectomy reduces libido. In that study, "libido
was considered to be normal if patients were having regular intercourse and
achieving satisfaction therefrom." Because we defined libido quite differently
(in terms of sexual desire), the results of Utian are not comparable to ours.
Other researchers defined libido as "the desire for sexual relations" and
"sexual interest/desire" rendering their results more comparable to ours.
The results of 4 retrospective studies using comparable definitions
indicate that hysterectomy has a negative impact on libido; estimates of the
percentage of patients who experienced a reduction in libido after hysterectomy
ranged from 32% to 46%, while estimates of the percentage of patients who
experienced an increase in libido ranged from 16% to 23%.5,10,19,27
Similarly, a clinical trial of hysterectomy vs conservative surgery found
that while approximately one quarter of patients reported increased sexual
interest after hysterectomy, another quarter reported decreased sexual interest.36 A prospective study by Kilkku et al31
found that the frequency of weak or absent libido did not change significantly
after hysterectomy. In contrast, 2 prospective studies, the Maine Women's
Health Study29 and the study by Lambden et
al,24 found that interest in sexual activity
increased significantly after hysterectomy. Likewise, we found that the frequency
of sexual desire increased after hysterectomy, indicating that hysterectomy
had a positive impact on libido. In summary, the results of this study and
2 other prospective studies do not support the findings of retrospective studies
indicating that hysterectomy has a negative impact on libido and indicate
that libido may actually increase after hysterectomy.24,29
Our results indicate that women with prehysterectomy depression did
not experience as much improvement in sexual functioning after hysterectomy
as women without prehysterectomy depression. In contrast to our findings,
Helstrom et al18 did not observe an association
between prehysterectomy psychiatric complaints and sexual desire after hysterectomy.
The findings of Gath et al25 are consistent
with the findings of this study in that the frequency of sexual relations
and enjoyment of sexual relations were associated with psychiatric morbidity
as measured by the Present State Examination.
In addition to sexual functioning, prehysterectomy depression was associated
with poor outcomes of hysterectomy in terms of symptoms such as bleeding,
pelvic pain, back pain, activity limitation, sleep disturbance, fatigue, abdominal
bloating, and urinary incontinence.37 Overall,
the relationship between prehysterectomy depression and posthysterectomy outcomes
is complicated and requires further research since many (28% in this study)
patients undergoing hysterectomy are depressed and may not experience the
same level of problem relief. Additionally, future research should include
evaluations of whether treatment of prehysterectomy depression could improve
This study has several distinct strengths compared with other studies
examining the effect of hysterectomy on sexual functioning. Many of the previous
studies are retrospective and, as a result, may be affected by recall bias
in which patients, particularly those with posthysterectomy problems, idealize
their prehysterectomy sexual functioning.2,5,7,8,10,19,27
In addition, previous prospective studies have been much smaller than the
present study. We followed up more than 1100 patients. In contrast, the previously
conducted prospective studies have included a maximum of 418 patients, less
than half the number included in this study.9,24- 26,29,30
In terms of limitations, this is an uncontrolled comparison of sexual
functioning before and after hysterectomy and, generally, causal inferences
cannot be made from such studies. However, this group of patients was essentially
followed for 4 different 6-month periods, (just prior to hysterectomy to 6
months, 6 to 12 months, 12 to 18 months, and 18 to 24 months after hysterectomy)
and the only dramatic changes in sexual functioning occurred during the period
that included hysterectomy. Moreover, Carlson et al38
followed up patients who were undergoing medical management of abnormal bleeding,
uterine fibroids, and pelvic pain for 1 year and observed no significant changes
in enjoyment of or interest in sexual activity. Thus, it seems reasonable
to attribute the observed changes to hysterectomy.
A more problematic concern is 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. One method of dealing with this issue would have been to ask
patients about their sexual functioning before they decided to have hysterectomy;
however, this would have introduced the possibility of recall bias, which
plagues so many of the retrospective studies. Ideally, the effects of hysterectomy
on sexual functioning would be examined within a large prospective study allowing
for (1) examination of sexual functioning before the onset of benign gynecologic
conditions, (2) estimation of the impact of benign gynecologic conditions
on sexual functioning, and (3) comparisons of posthysterectomy sexual functioning
to sexual functioning before and after the onset of benign gynecologic conditions.
Although there are many plausible mechanisms that could account for
the observed improvements in each aspect of sexual functioning, it is also
possible that women simply feel better after hysterectomy and that sexual
functioning improves along with overall health status and quality of life.
This theory is supported by the fact that the women in this study were highly
symptomatic before their hysterectomies and reported improvements not only
in sexual functioning but also in many other aspects of health and well-being.37 Freedom from vaginal bleeding and fear of pregnancy
may also account for some of the observed improvements.39,40
It is important that these data not be interpreted to indicate that
hysterectomy improves sexual functioning in healthy women. The majority of
patients in this study had identifiable gynecologic pathology,37
and it is likely that the sexual functioning problems experienced before hysterectomy
were a result of these gynecologic disorders. With this in mind, it is not
surprising that removal of an unhealthy uterus would improve sexual functioning.
In contrast, we can see no reason to believe that removal of a healthy uterus
would improve sexual functioning.
Overall, this study found substantial improvements in sexual functioning
after hysterectomy; significantly more women were sexually active after hysterectomy
and for each sexual functioning problem the rate of relief was higher than
60% and the rate of development was lower than 10%. Thus, the results of this
study indicate that women undergoing hysterectomy are likely to experience
a good outcome in terms of sexual functioning.