Hysterectomy and sexual function: a systematic review and meta-analysis

BACKGROUND

Sexual function after hysterectomy can be a concern for patients, and research remains inconclusive about changes in sexual function associated with hysterectomy.

AIM

We meta-analyzed studies on change in sexual function from pre- to posthysterectomy and the role of total vs subtotal hysterectomy and concomitant bilateral salpingo-oophorectomy (BSO) in differences in such change.

METHODS

We searched PubMed, Embase, and Cochrane databases from inception to January 2022. Two reviewers screened and included studies if they were published in a peer-reviewed journal and reported on sexual function pre- and posthysterectomy for benign nonprolapse indication. Methodological quality was assessed with the STROBE checklist. We used random effects multilevel models to meta-analyze standardized mean differences in pre- to postoperative sexual function and the posthysterectomy Female Sexual Function Index mean across study groups in R (RStudio).

OUTCOMES

Outcomes included overall sexual function, dyspareunia, desire, arousal, lubrication, and orgasm.

RESULTS

Thirty-two articles were analyzed: 8 randomized controlled trials, 20 prospective studies, 2 retrospective studies, 1 cross-sectional study, and 1 secondary analysis, comprising a total of 4054 patients. Each study provided data for at least 1 outcome. Study quality was moderate, and effect sizes showed large between-study heterogeneity. Hysterectomy was not associated with significant change in overall sexual function irrespective of surgical route, with patients tending to report potentially remaining sexual dysfunction posthysterectomy. Cervix removal was not significantly associated with differences in magnitude of change. Hysterectomy without BSO was associated with significantly stronger improvement in lubrication and orgasm than hysterectomy with BSO, which was not the case for desire, arousal or overall sexual function. However, these significant differences were not replicated within studies that directly compared cases with and without BSO.

CLINICAL IMPLICATIONS

Clinicians should address remaining sexual dysfunction posthysterectomy, and BSO should not be considered if not medically required.

STRENGTHS AND LIMITATIONS

We analyzed a comprehensive number of trials and studied clinically relevant factors that might relate to differences in change in sexual function. Conclusions need to be interpreted with caution since many studies showed moderate methodological quality and large effect size heterogeneity.

CONCLUSION

Subtotal and total hysterectomy was not associated with significant change in overall sexual function irrespective of surgical route, with patients tending to report potentially remaining sexual dysfunction posthysterectomy. Hysterectomy without BSO was associated with significantly stronger improvement in lubrication and orgasm than hysterectomy with BSO. Future research on hysterectomy should analyze predictors of sexual function change trajectories, such as different indications.

Predictive factors of return to work after hysterectomy: a retrospective study

Purpose

Although hysterectomy is one of the most frequently performed gynaecological surgeries, there is a dearth of evidence on perioperative care. The aim of the current study was to identify sociodemographic, surgical-related and work-related predictors of recovery following different approaches of hysterectomy.

Methods

Eligible patients for this retrospective cohort study were women who underwent vaginal, abdominal or laparoscopic hysterectomy for both benign and malignant gynaecological disease in 2014 in Máxima Medical Centre in the Netherlands. The main outcome measure was full return to work (RTW). Data were collected using a patient survey. Potential prognostic factors for time to RTW were examined in univariate Cox regression analyses. The strongest prognostic factors were combined in a multivariable model.

Results

In total 83 women were included. Median time to full return to work was 8 weeks (interquartile range [IQR] 6–12). The multivariable analysis showed that higher age (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.012–1.095) and same day removal of indwelling catheter (HR 0.122, 95% CI 0.028–0.539) were predictors of shorter duration until full RTW after hysterectomy.

Conclusions

This study provided insight in the predictors of recovery after hysterectomy. By identifying patient specific factors, pre-operative counselling can be individualized, changes can be made in perioperative care and effective interventions can be designed to target those factors.

Hysterectomy and sexual (dys)function: An analysis of sexual dysfunction after hysterectomy and a search for predictive factors

OBJECTIVES

Research about sexual function after hysterectomy is inconclusive. Possible predictive factors for sexual (dys)function are yet to be identified. The aim of this study is to assess the effect of hysterectomy on sexual function in women 3 and 12 months after hysterectomy for benign indications. Furthermore hypothesized predictive factors will be evaluated.

STUDY DESIGN

A prospective multicentre cohort study with follow-up at 3 and 12 months after hysterectomy was performed. To assess sexual function a short-form FSFI was used, a score ≤ 19 means sexual dysfunction). Linear mixed model repeated measure analysis was used to assess changes in sexual function in women who were sexually active at all three measure points (N = 260). Linear mixed model analyses were also used for the predictor analyses.

RESULTS

The FSFI score increased from 20.94 at baseline to 23.81 at 12 months post hysterectomy. The number of women experiencing sexual dysfunction was 86 (33.1 %). Women without preoperative sexual dysfunction had a significantly higher FSFI score 4.5 (95 % CI 3.5-5.6) one year after the operation than women indicating sexual dysfunction before surgery. Women who were living alone had a significantly higher FSFI score of 2.31 (0.7-4.0) when compared to women who were married or living together.

CONCLUSION

FSFI score increases significantly after hysterectomy, which indicates a better sexual function after the operation. Sexual dysfunction before hysterectomy (FSFI score ≤ 19) and being married or living together are predictive factors for a lower FSFI score post hysterectomy.

POstLAparoscopic Reduction of pain By combining intraperitoneal normal salinE And the pulmonary Recruitment maneuver (POLAR BEAR trial). RCT to estimate reduction in pain after laparoscopic surgery when using a combination therapy of intraperitoneal normal saline and the pulmonary recruitment maneuver

Background

Shoulder pain and pain in the upper abdomen are common complaints after laparoscopy, sometimes surpassing the pain at incision sites. The incidence of shoulder pain ranges from 35 to 80%. Post-laparoscopic pain is caused by retention of carbon dioxide in the abdomen, which irritates the phrenic nerve and diaphragm, causing referred pain in the shoulder and in the upper abdomen. A promising strategy to reduce this post-laparoscopic pain is the pulmonary recruitment maneuver, which indirectly increases intraperitoneal pressure and thereby facilitates removal of residual carbon dioxide. An alternative strategy is the infusion of intraperitoneal normal saline. With normal saline infusion, carbon dioxide rises and escapes through the port sites. In addition, normal saline offers a physiologic buffer system to dissolve excess carbon dioxide.

Methods/Design

This multicenter randomized controlled trial is conducted in two teaching hospitals in the Netherlands. Women between 18 and 65 years of age, with an ASA classification of I-II who are scheduled to undergo an elective laparoscopic procedure with benign gynecologic indication can participate. Following informed consent, participants are randomly allocated into two groups at the end of the surgical procedure. In the intervention group, the upper abdomen is filled with normal saline infusion with the patient in the Trendelenburg position. Then the anesthesiologist performs a standardized pulmonary recruitment maneuver with a pressure of 40 cm H₂O. The trocar sleeve valves will be left open, so carbon dioxide can escape the abdominal cavity. With the patient in a neutral position the instruments are removed from the abdomen. In the control group, carbon dioxide is removed from the abdominal cavity at the end of surgery, with gentle abdominal pressure and passive exsufflation through the port sites, with open sleeve valves.

The primary outcomes are the incidence and intensity of post-laparoscopic pain in the shoulder, upper abdomen and at the operation sites, at 8, 24 and 48 h after surgery. Secondary outcomes are postoperative use of analgesics, nausea, vomiting and pulmonary complications.

Discussion

This study may reduce post-laparoscopic pain in women undergoing laparoscopy.

Trial registration

Dutch trial register, number NTR4812.