Sexual function after hysterectomy according to surgical indication: a prospective cohort study

Beyond the cuff: a consideration of factors that affect sexual function after benign hysterectomy

PURPOSE OF REVIEW

Hysterectomy is the most common gynecologic surgical procedure performed on women in the United States. While there are data supporting that hysterectomy for benign indication often does not reduce sexual function and may in fact improve sexual function as fibroids and endometriosis are resected, it remains unclear if there are factors within the perioperative period that affect sexual function in the years following surgery. To date, there is no consensus on what factors can optimize patients' sexual function after hysterectomy.

RECENT FINDINGS

We present the current literature that assesses factors which may contribute to sexual function after hysterectomy. Preoperative demographic factors, including increasing age, pelvic pain, and preoperative sexual dysfunction, play a large role in postoperative sexual function. Perioperatively, there is a growing amount of data suggesting that premenopausal salpingo-oophorectomy at the time of hysterectomy may increase the risk of sexual dysfunction after hysterectomy, and no conclusive evidence that subtotal hysterectomy improves sexual function. The route of hysterectomy and technique of cuff closure can impact sexual function after hysterectomy due to the risk of shortening the vaginal length.

SUMMARY

There is a lack of high-quality evidence that can provide a consensus on factors to optimize sexual function after hysterectomy. A growing area of research in the excision of endometriosis procedures is the consideration of nerve-sparing surgery. Considering the many variables that exist when counseling a patient on benign hysterectomy and its effects on sexual function, it is critical to understand the current research that exists with regards to these factors.

Pelvic Floor Therapy and Initial Interventions for Pelvic Floor Dysfunction in Gynecologic Malignancies

PURPOSE OF REVIEW

This review provides evidence-based updates for the first-line management approaches for pelvic floor disorders in patients with gynecologic malignancies, as well as important provider considerations when referring for pelvic floor physical therapy.

RECENT FINDINGS

Currently, there is strong evidence to recommend pelvic floor muscle training as initial treatment for urinary incontinence and for pelvic organ prolapse; some evidence to recommend a more targeted pelvic floor muscle training program for fecal incontinence; and mostly expertise-based evidence to recommend vaginal gels or estrogen to aid with dyspareunia causing sexual dysfunction. More research is greatly needed to understand the role of overactive pelvic floor muscles in survivors with chronic pelvic pain and the treatment of post-radiation pelvic complications such as vaginal stenosis and cystitis. While pelvic floor disorders are common concerns in gynecologic cancer survivors, there are evidence-based initial noninvasive treatment approaches that can provide relief for many individuals.

Pelvic floor and sexual function 3 years after hysterectomy - A prospective cohort study

INTRODUCTION

Long term effects after hysterectomy, such as a worsening of pelvic floor and sexual function, have been studied with diverse results. Therefore, we investigated the long-term effects of hysterectomy for benign indication on pelvic floor and sexual function as well as differences in outcome depending on mode of hysterectomy.

MATERIAL AND METHODS

In a prospective clinical cohort study, we included 260 women scheduled for hysterectomy who answered validated questionnaires; pelvic floor impact questionnaire (PFIQ-7), pelvic floor distress inventory (PFDI-20) and female sexual function index (FSFI). Participants were followed up to 3 years after surgery. Nonparametric statistics and mixed effect models were used in analyses of the data.

RESULTS

After exclusions, 242 women remained in the study, with a response rate at the 3-year follow-up of 154/242 (63.6%) for all questionnaires. There was an improvement of pelvic floor function with a mean score of PFIQ-7 at baseline of 42.5 (SD 51.7) and at 3 years 22.7 (SD 49.4), (p < 0.001) and mean score of PFDI-20 at baseline was 69.6 (SD 51.1) and at 3 years 56.2 (SD 54.6), (p = 0.001). A deterioration of sexual function was seen among the sexually active women after 3 years with a mean score of FSFI at baseline 25.2 (SD 6.6) and after 3 years 21.6 (SD 10.1), (p < 0.001). However, this was not consistent with the unaltered sexual function for the whole cohort. No difference in pelvic floor or sexual function was detected when comparing robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy.

CONCLUSIONS

Three years after surgery robotic assisted laparoscopic hysterectomy, total laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent. Among the sexually active women, a decline of sexual function was seen after 3 years, not consistent with the entire cohort and independent of surgical methods. Whether this is a trend associated with aging or menopausal transition remains to be studied.

Examining the changes in women's lives after the hysterectomy operation: Experiences of women from Turkey

PURPOSE

The aim of the study is to examine what kind of changes the operation has brought about in the social and psychological life of women.

METHODS

The study was a hermeneutic-phenomenological research conducted using qualitative research methods. It took place between May and July 2023 at a university hospital located in Istanbul, Turkey. Following ethical approval, the study included a total of 24 women who had undergone a 'total abdominal hysterectomy, bilateral salpingo-oophorectomy.' These participants were selected using a combination of maximum diversity sampling and random sampling methods. Data collection was carried out using a semi-structured interview form. The interviews were conducted using face-to-face interview techniques and in-depth interview methods. Qualitative data analysis involved using the coding paradigm of Grounded Theory and Straus and Corbin's coding framework. For the analysis of quantitative data, SPSS version 28.0 was employed, while qualitative data were analyzed using MaxQDA Analytics Pro 2022.

RESULTS

The study found that the participants had a mean age of 47 ± 7.53, and the majority, 66.7%, had not reached menopause before the operation. The qualitative analysis of the semi-structured interviews revealed five main themes, which were identified as follows: 'hysterectomy experiences', 'the impact of hysterectomy on sexual life', 'the significance attributed to the uterus', 'the significance attributed to femininity', and 'self-efficacy after hysterectomy'.

CONCLUSIONS

The study revealed that women experienced changes in self-perception, body image, a sense of organ loss, and developed negative attitudes towards menopause following a hysterectomy. Additionally, there was a noticeable connection between the meanings attributed to the uterus and femininity, which was often influenced by cultural and social factors. In light of these findings, it is recommended that women receive counseling from healthcare professionals before undergoing a hysterectomy. This guidance can help women better understand and cope with the physical, emotional, and cultural aspects of the procedure.

Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain

BACKGROUND

Potential impact on sexual function is an often-cited concern for many patients considering hysterectomy. The existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines after surgery. Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity after surgery or the magnitude and direction of change in sexual function. Although psychosocial factors are strongly associated with overall female sexual function, there is minimal data exploring the potential impact of these factors on the change in sexual function after hysterectomy.

OBJECTIVE

This study aimed to evaluate the relationship between baseline psychosocial factors and both sexual activity and sexual function at 6 months after hysterectomy.

STUDY DESIGN

Patients undergoing hysterectomy for benign, non-obstetric indications were prospectively recruited as part of an observational cohort study evaluating presurgical predictors of posthysterectomy outcomes on pain, quality of life, and sexual function. The Female Sexual Function Index was administered before hysterectomy and 6 months after surgery. Presurgical psychosocial assessments included validated self-reported measures of depression, resilience, relationship satisfaction, emotional support, and social participation.

RESULTS

Complete data was available for 193 patients, of whom 149 (77.2%) reported sexual activity at 6 months after hysterectomy. In the binary logistic regression model examining sexual activity at 6 months, older age was associated with a lower likelihood of sexual activity (odds ratio, 0.91; 95% confidence interval, 0.85-0.96; P=.002). Higher relationship satisfaction before surgery was associated with a greater likelihood of sexual activity at 6 months (odds ratio, 1.09; 95% confidence interval, 1.02-1.16; P=.008). As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (odds ratio, 9.78; 95% confidence interval, 3.95-24.19, P<.001). Analyses using Female Sexual Function Index scores were limited to patients who were sexually active at both time points (n=132 [68.4%]). The total Female Sexual Function Index score did not change significantly from baseline to 6 months, but there were statistically significant changes in several individual domains of sexual function. Patients reported significant improvement in desire (P=.012), arousal (P=.023), and pain (P<.001) domains. However, significant decreases were reported in orgasm (P<.001) and satisfaction (P<.001) domains. The proportion of patients who met the criteria for sexual dysfunction was quite high (>60%) at both time points, but there was not a statistically significant change in the proportion from baseline to 6 months. In the multivariate linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity, or psychosocial measures.

CONCLUSION

In this cohort of patients with pelvic pain undergoing hysterectomy for benign indications, both sexual activity and sexual function remained fairly stable after hysterectomy. Higher relationship satisfaction, younger age, and preoperative sexual activity were associated with a greater probability of sexual activity at 6 months after surgery. Psychosocial factors, such as depression, relationship satisfaction, and emotional support, and history of endometriosis were not related to change in sexual function among patients who were sexually active both before hysterectomy and at 6 months after surgery.

Quality of Life after Risk-Reducing Hysterectomy for Endometrial Cancer Prevention: A Systematic Review

BACKGROUND

Risk-reducing hysterectomy (RRH) is the gold-standard prevention for endometrial cancer (EC). Knowledge of the impact on quality-of-life (QoL) is crucial for decision-making. This systematic review aims to summarise the evidence.

METHODS

We searched major databases until July 2022 (CRD42022347631). Given the paucity of data on RRH, we also included hysterectomy as treatment for benign disease. We used validated quality-assessment tools, and performed qualitative synthesis of QoL outcomes.

RESULTS

Four studies (64 patients) reported on RRH, 25 studies (1268 patients) on hysterectomy as treatment for uterine bleeding. There was moderate risk-of-bias in many studies. Following RRH, three qualitative studies found substantially lowered cancer-worry, with no decision-regret. Oophorectomy (for ovarian cancer prevention) severely impaired menopause-specific QoL and sexual-function, particularly without hormone-replacement. Quantitative studies supported these results, finding low distress and generally high satisfaction. Hysterectomy as treatment of bleeding improved QoL, resulted in high satisfaction, and no change or improvements in sexual and urinary function, although small numbers reported worsening.

CONCLUSIONS

There is very limited evidence on QoL after RRH. Whilst there are benefits, most adverse consequences arise from oophorectomy. Benign hysterectomy allows for some limited comparison; however, more research is needed for outcomes in the population of women at increased EC-risk.