Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Sexual wellbeing after hystrectomy,The authors ignore other important factors?
- A.K Al-Sheikhli (4 October 2003)
-
98% of hysterectomies are recommended inappropriately
- Leilah McCracken (4 October 2003)
-
Self-report of Improved Sexual Life 6 months after Hysterectomy compared to what baseline?
- Winnifred B. Cutler, Elizabeth Genovese MD (4 October 2003)
-
University Medical Center of Utrecht compromises its integrity
- Victoria C. Norton (5 October 2003)
-
Total Histerectomy: Wise Decision.
- Michael Friedman, Haifa, Israel (5 October 2003)
-
Women's fears of sexual dysfunction after hysterectomy are justified
- Ginette C Camps-Walsh (8 October 2003)
-
A female sexual response primer
- Nora W. Coffey (8 October 2003)
-
Castration Ends Orgasms !
- Nan P. Luppert (8 October 2003)
-
A lie can travel half way around the world...
- Carla Dionne (8 October 2003)
-
Sexual Pleasure Improves After Hysterectomy
- Marsha V. (Van Fossen) Weaver (10 October 2003)
-
The uterus is a sex organ
- Nora W. Coffey (10 October 2003)
-
Misrepresentation of the Data Regarding Sexual Well-being
- William H. Parker, MD (13 October 2003)
-
Re: Misrepresentation of the Data Regarding Sexual Well-being
- Jan-Paul WR Roovers (13 October 2003)
-
Re: Re: Misrepresentation of the Data Regarding Sexual Well-being
- William H. Parker, MD (14 October 2003)
-
Re: Re: Re: Misrepresentation of the Data Regarding Sexual Well-being
- Jennifer L Martin (15 October 2003)
-
Re: Misrepresentation of the Data Regarding Sexual Well-being
- Carla Dionne (15 October 2003)
-
Re: Re: Misrepresentation of the Data Regarding Sexual Well-being
- Victoria C. Norton (17 October 2003)
-
Re: Re: Misrepresentation of the Data Regarding Sexual Well-being
- Jennifer L Martin (20 October 2003)
-
Re: Re: Re: Misrepresentation of the Data Regarding Sexual Well-being
- Carla Dionne (20 October 2003)
-
Respect for research
- Jan-Paul WR Roovers (22 October 2003)
-
Re: Respect for research
- Carla Dionne (23 October 2003)
-
More questions yet to be answered
- Andrea Bradford (24 October 2003)
-
Just a woman who wants to be heard
- Ann Semes Lynch (31 October 2003)
|
|
|||
|
A.K Al-Sheikhli, Loc.Consultant Psychiatrist Avenue clinic ,Nuneaton,England.
Send response to journal:
|
While it was interesting to read this article, I think that the authors ignored other factors that might affect the sexual wellbeing after hystrectomy, such as the age of the patient,whether she is involved in a stable relationship,or looking forward to become pregnant,any psychiatric illness,and about whether she already has children or not. Could it be that in the Netherlands these aren't important factors to look at? Competing interests: None declared |
|||
|
|
|||
|
Leilah McCracken, childbirth writer/researcher Vancouver, Canada
Send response to journal:
|
The authors say in this paper (Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy BMJ 2003; 327: 774-778) - "Hysterectomy is the most common major gynaecological operation in the United Kingdom and United States. In the Netherlands, 32% of women will need hysterectomy during their lifetime." Women don't "need" all those surgeries! The Hysterectomy Educational Resources and Services (HERS) say that 98 percent of women referred to board-certified gynecologists by HERS, after being told they needed hysterectomies, discover that they do not actually need hysterectomies. That is- 98% of hysterectomies are recommended inappropriately. Some of the difficulties associated with hysterectomy include: * heart disease * osteoporosis * bone, joint and muscle pain and immobility * loss of sexual desire, arousal, sensation * displacement of bladder, bowel and other pelvic organs * urinary tract infections, frequency, incontinence * loss of short-term memory See http://www.hysterectomyalternatives.net/ Uteruses are important, and should be preserved; it is outrageous that this even needs to be said. Your paper does nothing to protect women, it only serves as a platform for more pointless, cruel surgery. Leilah McCracken www.birthlove.com Competing interests: None declared |
|||
|
|
|||
|
Winnifred B. Cutler, President and Founder Athena Institute for Womens Wellness, Elizabeth Genovese MD
Send response to journal:
|
We are studying the paper and its conclusions and some missing information will help us all to better understand the meaning of these important data. What was your definition of "sexually active"? Penile/vaginal intercourse? hugging and kissing? What was the relationship status of these women; i.e. married? dating? steady live in partner? Can you tell your readers more about the baseline experience under which the women were questioned and compared to which the "Before" and "After" were tested? Were the questionnaires distributed in hospital before the surgery? If so, how were the women positioned when they were asked to complete questionnaires? In street clothing at a desk? In bed? In hospital gowns? Were they alone? How does this compare to the post op experience filling out the questionnaire? If the recruitment occurred outside the hospital, please describe timing and conditions, so that the continuity of the data can be assessed. Were these baseline sexual-life questions relating to a specific time period and time span? i.e. "now" or recollecting what their sex life had been like before they had the problem that brought them for a hysterectomy? Were the women who said they were sexually active at baseline actually having sexual intercourse during the immediate weeks before surgery? Or were they referring to a time before their dysfunctions became bothersome enough to schedule a hysterectomy? Competing interests: None declared |
|||
|
|
|||
|
Victoria C. Norton, Founder of Support Group for Fibroids Sufferers 28215 Bremen, Germany
Send response to journal:
|
Dear Sirs, As a sufferer from a benign disease of the uterus and founder of a German speaking internet-support group (www.smartgroups.com "gebaermuttermyome") for women with fibroids, I am concerned as to why these women were subjected to such an invasive treatment. There are a whole range of less invasive treatment options for these diseases. However, I am also extremely concerned about serious inconsistencies between the researcher's statement to the press that "an overwhelming positive response was given by 400 women" - and the actual study, according to which: - only 352 of the 379 participants who had a male partner responded at six months - Of these only 310 admitted being sexually active - 97 were still reporting sexual problems after six months - and new sexual problems were reported by 29 patients Now, I think it unlikely that Jan-Paul Roovers does not have the mathematical ability to interpret his own research. So I have to ask myself why he would risk compromising his own integrity and the reputation of the University Medical Center in Utrecht by issuing a press release containing blatant misinformation. Could it be to do with the fact that gynecologists faced with increasing competition from radiologists offering uterine fibroid embolisation, a minimally invasive treatment for the most common disease of the uterus, fear losing patients? I am also very surprised that a reputable medical journal like the BMJ should publish a report drawing such flawed conclusions. Regards, Victoria Norton Competing interests: None declared |
|||
|
|
|||
|
Michael Friedman, Director, Institution for Women's Health & Principle Gynecologist-in-Charge Maccabi Healthcare Services and Gyn. Dept. Rambam Med. Cntr., Haifa, Israel
Send response to journal:
|
At least three decades ago Western gynecologists came to the conclusion that no uterine cervix should be left behined while performing abdominal hysterectomy. One of the principle causes for such "innovation" was our desire to prevent cervical dysplasia and cervical invasive cancer. During the recent yeasr we became the witnesses that some gynecological surgens advocate the "supracervical hysterectomy renaissance". Thay argued the such a "new" approach might prevent posthysterectomy vaginal vault prolapse, urinary incontinence and could be beneficial for sexual life preserving the ability for patient's orgasm. Such a revival of an old surgical approach was rather wishful thinking than the triumph of the science. For me the main point of Roovers et al. paper is that supracervical uterine removal is NOT superior to panhysterectomy at least in sexual wellbeing. I belive that with the incontinence and prolapse we will get the same conclusion. Competing interests: None declared |
|||
|
|
|||
|
Ginette C Camps-Walsh, Member of voluntary patient group FEmISA Oxford, England OX3 9TY
Send response to journal:
|
The results of this paper state that 'sexual pleasure improved in all patients'. This is not borne out by the results. Of the 413 women taking part only 310 had results reported. Of these, 126 [40%] experienced sexual dysfunction after hysterectomy and 9% experienced these for the first time. This is hardly a glowing endorsement for hysterectomy. It surely confirms women's fears are justified. This study only lasted 6 months post-operatively. Hysterectomy is known to cause premature menopause and the adverse effects from this on sexual function will not show up in this trial.[1] Symptoms leading to hysterectomy are very likely to cause sexual dysfunction and did so in 55% of the 310 patients reported. Also general ill health may reduce libido. Women would expect sexual function to return to normal after hysterectomy and this is not shown. It is stated that 'in the Netherlands 32% of women will need hysterectomy during their lifetime'. This is untrue. 32% of women may need treatment for gynaecological conditions, but few of them will need hysterectomy. Looking at the patient characteristics in this study most of these women did not need hysterectomy [although the underlying pathology is not mentioned]. Women received hysterectomy for menorrhagia, metrorrhagia, abdominal pain and dysmenorrhea. All these conditions can be treated with much less invasive and non-surgical procedures such as endometrial ablation, hormone and drug treatments and uterine artery embolisation for fibroids. It is not explained why women with endometriosis and uterine prolapse were excluded. Arguably there might be more reason for these conditions to be treated by hysterectomy. It is interesting that the statistics for hysterectomy are higher than the UK, where it is estimated that 20% of women will have had a hysterectomy by the age of 55 [2]. 43% of these will also have oophorectomy [3], many without pathology, causing higher levels of sexual dysfunction. There are 6 main potential causes of sexual dysfunction from hysterectomy and some of these are not mentioned in this paper: - *The uterus and cervix have rhythmic muscle contractions during orgasm, which women can feel. This will be lost if they are removed and changes in pressure effects and orientation can result in a lessening of the sensation of an orgasm. *The nerves to the vagina are often damaged and cut, which will reduce sensation. *The vagina is likely to become narrower and shorter after hysterectomy. This can make sex painful and full penetration difficult *Urinary incontinence will adversely affect sexual function. 14-17% of women experience this for the first time after hysterectomy and 'hysterectomy increases the odds of urinary incontinence by 30%' [12, 13] *Menopause is 5 years earlier on average after hysterectomy. The effects of this would not be picked up by this study as it stopped at 6 months. *Psychological effects can cause sexual dysfunction due to clinical depression, early menopause, loss of femininity, loss of fertility, inability to conceive and continuing ill health. There have been few studies on female sexual function due to hysterectomy. Changes in climax have been noted in 33-35% of women post- hystetrectomy. [4,5,6,7] Many studies put any loss of libido down to depression, or the psychological loss of femininity [8,9,10] The reduction in testosterone levels after oophorectomy may lead to loss in frequency and desire for sex. 42% of women after hysterectomy but with conservation of at least one ovary had sexual intercourse less often, while 74% after removal of both their ovaries had less sex. [1,7] Reduction in other sex hormones and early or immediate menopause can also result in other sexual dysfunction symptoms such as reduced lubrication in 38% of women. [6,14] Rather than trying to prove, unsuccessfully, that very old-fashioned invasive surgery doesn't cause sexual dysfunction, it would be better to treat these women much less invasively, as advocated by Maresh et al. [3] This will help to reduce medical/iatrogenic sexual dysfunction and many other long-term symptoms from hysterectomy, including extended and early use of HRT.[15] Approximately 30% of hysterectomies are carried out for fibroids/leiomyomata and a significant number could be treated by uterine artery embolisation, which does not adversely affect sexual function. [11] Ginette Camps-Walsh
References 1. Siddle N et al - The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review - Fertil Steril 1987 Jan;47(1):94- 100 2. Vessey MP et al - The epidemiology of hysterectomy: findings in a large cohort study BJOG May '92 Vol 99 pp 402-7 3. Maresh MJA et al - The VALUE national hysterectomy study: description of the patients and their surgery - British J Obstet & Gynae March 2002 Vol. 109 302-312 4. Ennerstein L et al - Sexual response following hysterectomy and oophorecomy - Obstet Gynecol 1977 Jan;49(1):92-6 5. Dicker RC, Greenspan JR, Strauss LT - Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am.J.Obstet.Gynecol 1982; 144:841-848 6. Poad D, Arnold EP - Sexual Function After Pelvic Surgery - Aust NZ Obstet Gynaecol 1994; 34:4:471 7. Farquhar CM, Sadler L, et al - A prospective Study of the Short-Term Outcomes of Hysterectomy with and without Oophorectomy - Aust NZ J Obstet Gynaecol 2002 42:2:197 8. Bachmann GA - Psychosexual Aspects of Hysterectomy - Women's Health Issues 1990 Fall;1 (1): 41-49 9. Carlson K J et al - The Maine Women's Health Study: Outcomes of hysterectomy Obstet Gynecol 1994 Apr;83(4):556-65 10. Schofield M - Self-reported long-term outcomes of hysterectomy - Br J Obstet Gynaecol 1991 Nov;98 (11):1129-36 11. Watkinson AF Babar SA Robertson F Magos A Torrie EP Holt E - Impact of uterine artery embolisation on sexual function - Radiology 2001: 221(P):30 Presented at Radiological Society of North America Chicago 2001 12. Kjerulff KH, Langenberg PW et al - Urinary incontinence and hysterectomy in a large prospective cohort study in American women - J Urol 2002 May; 167(5):2088-92 13. Van der Vaart CH, van der Bom JG et al - The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms - BJOG 2002 feb; 109 (2): 149-54 14. Meston CM, Frohlich PF - Update on female sexual function - Current Opinion in Urology 2001 Nov,11,6,603-9 15. Patterns of use of hormone replacment therapy in one million women in Britain, 1996-2000 BJOG Dec 2002 Vol 109 pp 1319-1330 Competing interests: None declared |
|||
|
|
|||
|
Nora W. Coffey, President, Hysterectomy Educational Resources and Services Foundation HERS Foundation 422 Bryn Mawr Avenue Bala Cynwyd, PA 19004 USA
Send response to journal:
|
A female sexual response primer 1) The uterus is a sex organ. Women who experience uterine orgasm will experience a total loss of uterine orgasm if the uterus is removed. Women who never experienced uterine orgasm will not experience this loss. 2) The nerves that attach to the uterus innervate the vagina, labia, clitoris and nipples. These nerves are severed when a hysterectomy is performed. 3) In Victorian days hysterectomy was performed to cure women of unseemly sexual behavior, referred to as nymphomania. It worked. Nora W. Coffey, President Hysterectomy Educational Resources and Services (HERS) Foundation Competing interests: None declared |
|||
|
|
|||
|
Nan P. Luppert, Language Teacher Central Valley High Schol 99266
Send response to journal:
|
I find it absolutely incredible that any woman who has had a hysterectomy with oopherectomy and/or cervix removal could possibly say she has a good sex life. The traditional medical term for oopherectomy, which seems to be "standard procedure" with a hysterectomy, I found out after my surgery, is "castration," and the after effects are just as devastating as it would be if a male had his sex organs (penis and testicles) removed. I lost all sexual sensations in other erogenous zones besides the uterus and cervix (they are gone),such as the vagina and breasts, With work I can have a possible clitoral climax but pales dramatically compared to full orgasms). Perhaps these women in this study never had great, and/or multiple orgasms, so they have no clue as to what they have lost. What we women who had hysterectomies with oopherectomies find in reading the research that has been done in female anatomy and health connected with the functions of the ovaries is that the hyserecomois have taken away many aspects of our long term health --- so many that it takes books to describe them, such as "For Women Only" by Drs.Jennifer and Laura Berman, or "The Hysterectomy Hoax " by Stanley West, MD., or "Misinformed Consent" by Lise Cloutier-Steele, etc. (Many of these women are still devastated by their loss of a sex life after hysterectomy for six to fifteen years, not just six months.)The fact is that the uterine artery that supplies health to the vagina and clitoris is CUT. The communication between the ovaries and adrenals is GONE. The uterus which contributes contractions so that an orgasm is possible is GONE! This Dutch "researcher" should correspond with thousands of women around the world (many who who have met on the Sans Uteri Forum website or the other sites like it) who were not told of the inevitable loss of their sex drive, and their ability to have orgasms, but also how loss of the ovaries could affect their immune systems and other complex systems of their bodies negatively for the rest of their lives. (See reports onthe HERS (Hysterectomy Educational Resources) Foundation site. The only excuse for such biased, uniformed, so called "research" and reporting seems to be to get media attention to promote some (financial?) gain by certain organizations with purposes other than to portray full, factual, scientific information that would actually benefit women, not misinform them. I would like to talk personally to this "researcher" and have him talk directly to the other devasted thousands like me who will tell the whole truth, Competing interests: None declared |
|||
|
|
|||
|
Carla Dionne, Executive Director National Uterine Fibroids Foundation
Send response to journal:
|
***** all adj. Being or representing the entire or total number, amount, or quantity. Ex.: All the windows are open. Wash all the dishes. Sexual pleasure significantly improved in all patients, regardless of the type of hysterectomy. ***** Given the BMJ's press release on this paper (which was picked up by every major news source on the planet...or so it would seem...): http://bmj.bmjjournals.com/content/vol327/issue7418/press_release.shtml#3 as well Dr. Roover's very own comments and "Results" per the Abstract: "Sexual pleasure significantly improved in all patients," Dr. Jan- Paul Roovers, of the University Medical Centre in Utrecht in the Netherlands, said on Friday." http://www.msnbc.com/news/974932.asp?0cv=HB10 I can't help but wonder if such a simple, three letter word -- ALL -- has new connotations that have escaped the likes of myself, Websters, and the vast majority of linguists on this planet. ~99% (my own rough guestimate) of the news media sources receiving the BMJ press release promptly shared it intact with a completely unsuspecting public and, in doing so, the entire miraculous process of propaganda proliferation earned a whole new moniker (from me) for this excellent work: Mass dissemination of misinformation by the lazy media MD-MLM, for short. Use of the alpha MD and MLM -- as in medical doctor and multi-level marketing -- is no error here. Under the circumstances detailed above juxtaposed with the reality of the paper published, MD-MLM is quite apropos, in my view, for both the media who regurgitated the press release without reviewing the paper beyond the Abstract AND the individuals responsible for publishing this paper and touting it to the media. But enough chit chatting. Let's cut to the facts about this study, okay? 1. About those "...over 400 women...": -- 477 women were asked to join the study, 413 chose to do so. Out of those, 379 had a MALE partner, thereby eliminating 34 women from this study. Since no explanation was given for this heterosexual preference, one can only question whether or not the researchers had a bias or skewed perspective of the sexual lives of non-heterosexual women. -- 352 women completed the study questions both before and six months after their hysterectomy AND had a MALE partner. However, only 310 women indicated sexual activity BOTH before AND after their hysterectomy and final data analyzed was on these 310 women. -- What happened to the 42 women who were eliminated, dropping the total study to 310 women? Well, it turns out that 10 of them were sexually active pre-hysterectomy but NOT active post hysterectomy and 32 were not sexually active pre-hysterectomy but 17 became so post- hysterectomy. Great news for 17 of the 42 women and their MALE partners...not so great news for 15 women and totally crapper news for 10 of them. However, it would seem that ~3% (10) is of insignificant statistical value...and coincidentally messes up the potential for the use of the word "all" in the final study results...so anything less than 5% was eliminated. Basically, the 17 women who gained sexuality from hysterectomy cancelled out those lowly 10 women anyway. Right? (I want to be present when the docs explain this to those 10 women. Truly.) 2. About those 36 questions: -- "Slightly bothered" was viewed as the equivalent of "not to be bothersome." Huh? Did you explain that to the women before they answered the questions? Who validated these questions to determine this was an appropriate statistical placement of the answers? -- About that "validation".....with all the sexual function instruments currently validated for use in the study of female sexual function, which one was actually used? There doesn't seem to be any specific indication of this instrument or its method of validation. Why is that? References to this in the bibliography do not clarify the selection of questions used. -- What is the significance of referring to a paper on sexual function of adults with meningomyelocele in regard to this study? Your reference to this citation indicates relevance to the questionnaire used but given the multitude of papers published on the topic of female sexual function and the use of validated study questionnaires, I'm at a loss at to why this reference was chosen over hundreds of potentially more relevant papers. Please explain. 3. About those final results: -- Of 173 patients (out of 310) who reported one or more bothersome sexual problems before hysterectomy, 97 were still reporting problems after hysterectomy. ~56% of the (173) women! -- 29 patients (out of 310) reported the development of new sexual problems. That's equates to over 9%. -- By my {albeit rough} calculations of the data presented under "Results," 126 women (97 + 29) were not exactly showing the level of improvement necessary for the use of the word "all" as a descriptor here. In fact, ~40% (126) of the women in this study might be taking a bit of exception right about now to the news making it around the world this past week on this study. 4. A few other niggling little points.... -- Table 3. Am I interpreting this correctly to mean that, with the majority of sexual problems listed, less than 25% of the women actually responded to each of the After Surgery questions? For instance, under "Problems with lubrication", Before Surgery shows a total of 310 women responding but After Surgery shows only 68 doing so. If this interpretation is incorrect, could you please clarify? -- Ovaries. Not mentioned ANYwhere in this paper. Did these women keep their ovaries or ALL have them removed? Given the hormonal influence of the ovaries and the relationship of those ovaries to sexual problems such as lubrication and arousal, it would seem this is a gross oversight by these clinical investigators which severely cripples, dare I say "negates", even the anecdotal value of this paper. (Didn't the BMJ editors think to ask about this and kick it back for input/commentary from the investigators? If not, why not?) Based only upon the statistics presented in this paper, 100% (as in "all") of the women in this study did not show significant improvement in sexual pleasure. In fact, 29 women (out of 310 -- or, 39 women out of 342!) who indicated no problems prior to their hysterectomy, reported NEW problems after their hysterectomy. Doesn't this directly contradict the use of the word "all", Dr. Roovers? What do YOU think, BMJ editors and press staff? Here's what I think: you owe every woman who participated in this study and shared with you their sexual details pre and post hysterectomy an apology AND the truth. Publicly stated, just as the original press release was PUBLICLY stated. Frankly, I'm confused. What possible motive would the authors of this study or the BMJ editors or press staff have for sending out so much misinformation on this paper to the media? Apparently the last time y'all wiped your noses on your shirt sleeves you forgot to check for residues of bias. Which, in this case, is far uglier than any 5 year old with a nasty cold could have mustered up and left behind. Shame on ALL of you. Apparently the BMJ isn't interested in being a respectable and respected medical journal but instead seems to be actively choosing to compete in the land of tabloids, gossip, and pure propaganda. Too bad the mass media doesn't know this yet and still trusts press releases coming from the BMJ. Truly, a travesty for all unsuspecting women who will read the local press or watch the TV news but never see the actual BMJ paper. Carla Dionne Executive Director National Uterine Fibroids Foundation A lie can travel half way around the world while the truth is still putting on its shoes. Mark Twain Competing interests: None declared |
|||
|
|
|||
|
Marsha V. (Van Fossen) Weaver, Woman Patient-UFE for Uterine Leiomyoma Internet Research/32303
Send response to journal:
|
Dear Editors of BMJ and Roovers, et al "Study" I am severely bothered by the reliance upon such survey questions as the above in the Roovers, et al "Study". Given all the new technological advances, ie MRI for diagnostics, reliance upon survey questions and the overall statistics of the study simply convince me of the severe limitations of hysterectomy for removing the entire uterus for benign pathology. In the next "study", Roovers, et al I would suggest MRI be deployed to record and compare orgasm of both women with intact uteri and women post-hysterectomy. MRI has already been used to record copulation and the amazing discovery that a penis in the vagina assumes a "banana-like" shape and not a horizontal erection. Use real evidence-based medicine in Gynecology. Women expect evidence, not more anecdotal remarks 6 months post-hysterectomy and beyond. Cheers! Marsha Van Fossen Weaver
Competing interests: None declared |
|||
|
|
|||
|
Nora W. Coffey, none HERS Foundation 422 Bryn Mawr Avenue Bala Cynwyd PA 19004
Send response to journal:
|
Obscured by the discussion of flaws in methodology, errors in reporting, and numbers and statistics is the lives of the women who are subjects of this and other studies of the effects on women of removing their sex organs. The surgical removal of female sex organs is mutilating and barbaric. It has been done to women for well over a century. It is time to stop ruining the lives of millions of women and those who care about them. If you stop talking and listen you will hear the thunderous roar of the millions of women who have been irreparably damaged by the removal of their female organs that not only define their gender but are central to their health and well being. Nora W. Coffey
Competing interests: None declared |
|||
|
|
|||
|
William H. Parker, MD, Clinical Professor, Department of Obstetrics and Gynecology, UCLA School of Medicine Santa Monica, CA 90401
Send response to journal:
|
I read with interest, as I imagine many other gynecologists will do, the study by Roovers et al regarding hysterectomy and sexual wellbeing (1). This subject is of great concern to women who might need gynecologic surgery and, thus, the findings will be read by many with an interest in women's healthcare. Unfortunately, the conclusions of the study and, I might add, your press release regarding this study are not borne out by the data presented. First, my calculations show that 126/310 of the women had "any sexual problems" after surgery. Additionally, 29 (9%) women had new sexual problems after surgery, which I would suggest is not "scarce". Your conclusion that sexual pleasure improves after hysterectomy is, therefore, incorrect and unfounded. Second, it is interesting that the authors chose to include women who were "slightly bothered" in the "not bothered" group for the statistical analysis. It has been my experience, as well as that of others, that many women who suffer from chronic gynecologic problems such as pelvic pain or heavy bleeding, accommodate to the symptoms and do not perceive them as bothersome. In any event, "slightly bothered" should be bothersome enough to affect one's quality of life for an event that should be pleasurable. Third, it is interesting that the authors chose to only include women with male partners, as if that is the only type of sexual pleasure that counts. Thus, 34 women were summarily excluded from the analysis. Also excluded were 10 women who were not sexually active after surgery, perhaps because of symptoms induced by the surgery. Being acutely aware of these issues in clinical practice, I would suggest that self-pleasure and same- sex pleasure should have been included in the analysis. Fourth, and importantly, it is not clear from the study whether oophorectomy was always performed, never performed or sporadically performed. Use or non-use of estrogen following surgery is also not reported. These are clearly important issues, as the hormonal effects on sexuality (both estrogen and testosterone) have been well described. The one conclusion that has been shown here, that these three types of hysterectomy do not differ with respect to statistically significant changes in sexual pleasure, disappears among the other misstatements. Finally, it is important for women to know that statistics are just that, and do not guarantee a particular result for an individual woman. Sincerely, William H. Parker, MD
(1) Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. Roovers J. BMJ 2003;327:774-778 Competing interests: None declared |
|||
|
|
|||
|
Jan-Paul WR Roovers, registrar University Medical Center Utrecht, The Netherlands
Send response to journal:
|
With great interest I have read several reactions to our manuscript. From our data it can be concluded that in general sexual well-being improved following hysterectomy. This does not indicate at all that hysterectomy might be a treatment for sexual problems. The reason that we only included women with a male partner is that the number of women with a female partner or without partner was too low to allow a well-powered statistical analysis. So the results of our study are only applicable for women who have a male partner. Some of the women were sexually active before hysterectomy and not afterwards, and some of them who were not sexually active before hysterectomy appeared not to be afterwards. We did not study in detail if the change is sexual activity was related to the performed surgery of to other circumstances in life. As we did not study it, we do not feel for speculating about a possible relation to hysterectomy. With respect to bilateral oophorectomy: this procedure was only simultaneously performed in 3.8 % of the study group. All pre-menopausal women who underwent hysterectomy and bilateral ophorectomy were given hormone replacement therapy. I found some reactions suggesting that the results of this study may enhance the number of hysterectomies performed. I honestly hope this is not the case. All hysterectomies in our study were performed according to the recommendations of the Dutch College of Obstetricians and Gynaecologists. This indicates that hysterectomy was only performed in those in whom less invasive treatments had failed. The results of our study should not allow doctors to bypass less invasive treatment options. The symptoms that may lead to hysterectomy are bothersome. Based on fear for worsening of sexual well-being, patients may be afraid for a treatment that may be very effective. The study shows that doctors, when exposed to a patient with such fear, can tell their patients that on general sexual well-being improves. Of course they should emphasize that it is always dificult in the individual what will happen to the sexual well-being. Gynecologists who, based on previous studies, wonder whether technique of hysterectomy may influence sexual well-being following hysterectomy, can conclude from our study that it appears that this is not the case. On behalf of the authors, Jan-Paul Roovers
Competing interests: None declared |
|||
|
|
|||
|
William H. Parker, MD, Clinical Professor, Department of Obstetrics and Gynecology, UCLA School of Medicine Santa Monica, CA 90401
Send response to journal:
|
Well, no, you didn't say "in general" sexual well-being improved following hysterectomy. Your conclusion states "Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy", your discussion states "Sexual wellbeing improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy." and the press release, which I assume you approved, states " Sexual pleasure significantly improved in all patients, regardless of the type of hysterectomy." Perhaps a retraction of these misstatements of fact would be in order. With regards to your statement that you only included the women with a male partner for statistical analysis misses the point. The questionnaire does not have to be specific for male partner intercourse. The variables of frequency of sexual activity, discomfort, lubrication, orgasm, and arousal could have been used to evaluate other sexual activity before and after surgery. However, I will defer to experts in the field of female sexual response to comment on this further. In the new world of the internet, your assumption that the results of this study will not be misinterpreted is a bit naive. Many gynecologists around the world will read your conclusion and read no further. They will not be bound to the protocols of the Dutch College of Obstetricians and Gynaecologists. As a result, I believe the misstated conclusions of this paper do a disservice to women. Competing interests: None declared |
|||
|
|
|||
|
Jennifer L Martin, postdoc University of Wisconsin 53706
Send response to journal:
|
It would appear many of those who have submitted rapid responses have misunderstood the intention of the study, the measurements used, and the author's conclusions. "Sexual problems" and "sexual pleasure" are two SEPARATE measurements. From the article: "The first 16 questions concerned the general perception of the patient's own sexuality and frequency of sexual activity. The next 18 questions concerned different types of problems during sexual activity." Women had fewer sexual "problems" after the surgery. While some women had new sexual problems after the surgery, the results of the study do indeed indicate that "sexual PLEASURE significantly improved in all patients". This is not an incorrect or misleading conclusion. Physical sexual function (orgasm, lubrication, etc.), and experience of sexual PLEASURE or satisfaction, are two very different things, in women. For various reasons, being in a "monogamous, stable (at least one year) heterosexual relationship" is a common inclusion criterion in studies of female sexual dysfunction. This criterion is NOT meant to imply that women who are not in a monogamous relationship are any less worthy of study. Competing interests: None declared |
|||
|
|
|||
|
Carla Dionne, Executive Director National Uterine Fibroids Foundation
Send response to journal:
|
Mr. Roover, While you are busy touting the sexual improvement of ALL the patients (what few in number there actually were, once divided 3 ways and reduced to only 310 women in total) in this study, perhaps you could also share with us some of the additional findings from your doctoral thesis. The content from chapters 10 & 11 was MOST interesting in this regard, specifically the differences in micturition and defecation outcome for vaginal vs. abdominal hysterectomy patients. Furthermore, I couldn't help but wonder how the outcomes described for those patients may/may not have contributed to THEIR sexual function. http://www.library.uu.nl/digiarchief/dip/diss/1957893/inhoud.htm To remove simply the issue of sexual function and lift it out of context of your larger work on comparative hysterectomy outcomes seems, from my own personal perspective, quite wrong and deliberately sensationalistic of both you and the editors of BMJ. I believe this to be especially so now that I've had the opportunity to read the rest of the book -- hardly a glowing recommendation for ANY kind of hysterectomy no matter the questionable improvement you erroneously tout in the Results here. I am a wee bit confused by your reference list though, as I noted a few deletions and additions for your references in Chapter 12 -- the chapter published here in the BMJ. Could you explain how or why those references were chosen differently for the BMJ publication vs. your thesis? Carla Dionne p.s. What a pity your resources were spent on a body of work which will be used by gyns around the world to convince women to undergo hysterectomy when lower risk treatments are available which may well prevent some of the very outcomes you studied. How truly naive of you to not understand how the game of published outcomes on hysterectomy works in the real world of clinical practice and patient coercion. Competing interests: None declared |
|||
|
|
|||
|
Victoria C. Norton, Support Group Bremen, Germany
Send response to journal:
|
To quote the study "In the Netherlands, 32% of women will need hysterectomy during their lifetime." This is an incredibly high number of women about 1 in 3. I find it difficult to believe Roovers when he states that the women in his study were only hysterectomised after other treatments failed. Perhaps he should state exactly what diseases the women were suffering from and what treatments they tried. It would be interesting to see how many fibroid sufferers for example had previously been offered myomectomy, hysterescopic resection, endometrial ablation or uterine fibroid embolisation. Quite apart from anything else, these huge numbers of hysterectomies are costing tne Dutch Health System a lot of money. Dr Parker's comment about experts in the field of female sexuality is very interesting. It could be argued that gynecologists are not in fact experts in this field at all and should not be conducting this kind of study. I do not understand the comments about "problems" and "pleasure". There are complex psychological mechanisms involved here. It is very difficult for people to admit that they don't enjoy sex, it is like admitting failure given the messages sent by the media that we should all be having great sex lives. Also, for some women, admitting they don't enjoy sex would be tantamount to being disloyal to their spouses. Hysterectomy consent forms often contain the statment that the operation will not affect one's experience of sex. So women feel that they must be imagining it if they have problems. I am sure their "pleasure" would be even greater if they did not have the "problems". I looked at Roovers book about hysterectomy. I too find it sad that he has poured time and resources into studying hysterectomy instead of less invasive and less expensive ways of treating what are after all, benign diseases. It is probably a comment on Dutch gyaecologists in general. I note that no Dutch gynaecologists have commented here on the study. Victoria Norton Competing interests: None declared |
|||
|
|
|||
|
Jennifer L Martin, postdoc University of Wisconsin 53706
Send response to journal:
|
Ms. Dionne, I don't know how helpful your comments are to women, especially those who do choose to have a hysterectomy. As you surely must know, Roovers' findings are not unusual and similar results been reported previously (1,2). You should consider the Roovers study one of many studies on the subject, increasing our body of knowledge. You seem to want to censor information that may support a woman who, along with her physician, chooses to have a hysterectomy. While I commend your efforts at promoting alternate nonsurgical treatments for hysterectomies, your vitriolic criticism of hysterectomy in and of itself is unwarranted and does women a disservice. New treatments for fibroids and abnormal bleeding, two of the most common reasons for hysterectomy, should decrease the need for hysterectomy in the future. It is clear that, for now, most women benefit from having a hysterectomy. Many women have symptoms that, while not life- threatening, do affect their general physical and emotional health and their ability to perform normal activities. Yes, a minority of women develop new "sexual problems" after the surgery. Efforts should be concentrated on this group of women to determine what their sexual experience was before surgery (are these women who had deep internal orgasms? are these women for whom the uterus played a central role in their sexual function? etc.), what occurred during the surgery to disrupt their sexual functioning, and what techniques can be perfected in the future (nerve-sparing techniques, for example) to hopefully avoid the development of new sexual problems. With more research, women for whom it is discovered that a hysterectomy is likely to disrupt their sexual function would be better informed of the risk vs reward of the surgery. Women's sexual functioning for all intents and purposes, remains a mystery. Let's not throw the baby out with the bathwater. The Roovers study adds to our knowledge base, whether you like the findings or not. Let us encourage more research on the subject of women's sexual function, not less. (If anything, the major problem with the study as it is reported is the way it was reported. The verbiage is unclear, and tables are not presented in a readily understandable format.) 1. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: II. Outcomes of nonsurgical management of leiomyomas, abnormal bleeding, and chronic pelvic pain. Obstet Gynecol. 1994 Apr;83(4):566-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8134067&dopt=Abstract 2. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's Health Study: I. Outcomes of hysterectomy. Obstet Gynecol. 1994 Apr;83(4):556-65. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8134066&dopt=Abstract Competing interests: None declared |
|||
|
|
|||
|
Carla Dionne, Executive Director National Uterine Fibroids Foundation
Send response to journal:
|
Ms. Martin, The Roovers study was so seriously flawed, in my view, it added NOTHING to our current body of knowledge on hysterectomy and sexual function. Further, the "vitriolic" exception I take to this study has zero relationship to censorship and everything to do with the BMJ's publication of such a flawed piece of work AND the press release they subsequently disseminated on it to promote their journal. A press release, BTW, which was picked up by over 200 press sources at my last count. Considering my view of the unworthy nature of this paper, this mass media run generated expressly by the BMJ for sensationalistic- attention-grabbing purposes was indeed an element which caused great distress and tremendous anger by myself and a multitude of women's groups which our organization affiliates with and/or supports. Hysterectomy and sexual function studies performed using currently accepted validated sexual function instruments by professionals in the field of female sexual function are what I would ask for and expect from a publication such as the BMJ -- not miniscule studies done by doctoral students who do not have appropriate sexual function education, research knowledge (as clearly identified by the lack of an appropriate bibliography to support this paper--not to mention the fact that the paper seemed to have completely changed it's bibliography from the first time it was published as a thesis chapter in 2001 vs. here in the BMJ) and clinical experience. The simple fact there wasn't any mention of ovaries ANYWHERE in this paper was more than enough for me to find it incredulous that the BMJ would even consider publishing this nonsense. Roovers' subsequent Rapid Response indication of 3.8% oopherectomy does not clarify this in the least. 3.8%? Really? I find that statistic amazingly low and a bit unbelievable. In addition, the HRT these patients received was ????? Estrogen? Progesterone? Testosterone? Some combination therein? Puh-lease. Without specificity, the apples, oranges, and grapes thrown into the pot here have made it one big fruit salad of truly indiscernible results. If only 3.8% of the patients in this study underwent oophorectomy, why not eliminate them from the final numbers to simply clarify the muddy waters therein? The authors had little problem eliminating other participants at various stages of the study for a host of questionable reasons -- at least the elimination of these 3.8% wouldn't have been even remotely questionable, given the role of the ovaries in sexual function! More importantly, this oversight by the authors is clearly indicative of researchers treading into female sexual function waters they know little to nothing about and have made ill attempt to even comprehend the significance of the presence or lack thererof ovaries. I simply would have expected MORE from the BMJ in their choice of publication on this matter. Approximately 25% of all the women who contact our organization for information have chosen hysterectomy or already undergone hysterectomy as a treatment option. We support these women as we support ALL women who contact us for information on their medical condition and/or treatment options currently available. The information we provide is based in science (what little there is on women's reproductive disease/treatments!) and current medical publications appearing in peer reviewed journals. I would trust that information to be of sound quality. When it isn't, I feel it is my duty to speak out against it and demand higher quality in study, review, and publication. Accepting studies of questionable value as "adding to our body of knowledge" is, well, unacceptable to me. BTW, the Carlson studies you cite bear no relevance to comparative sexual function outcomes in hysterectomy type. Carla Dionne Competing interests: None declared |
|||
|
|
|||
|
Jan-Paul WR Roovers, registrat (resident) University Medical Center Utrecht, The Netherlands
Send response to journal:
|
When reading the 3rd rapid response of Mrs Dionne, I was wondering why someone is motivated so much to devalue our manuscript. We performed the first large prospective study, evaluating the effects of hysterectomy on sexual well-being using a validated questionnaire. I do not know whether Mrd Dionne ever published in the BMJ (a search in Pub Med regarding “Dionne and hysterectomy or sexuality” did not show one single publication!!) but I can reassure that editors and statistician acted very carefully. Each response of Mrs Dionne brings in new arguments why the study is seriously flawed. I am afraid that Mrs Dionne does not understand that she flaws her own criticism by using phrases like “miniscule studies done by doctoral students” and “unworthy nature of this paper”. First of all I am not a doctoral student (shortly I will finish my training as gynaecologist) and have spent four years of research to study the effects of hysterectomy on micturition, defecation and sexual well-being . The University Medical Center of Utrecht is a renowned institute. Together with the epidemiologists of the Julius Center for Health Sciences and Primary Care, many large multi-center prospective studies have been performed or started. I would like Mrs Dionne to perform a better designed study (I am interested to see the study protocol) and am looking forward to the results as I seriously believe that it is important to well inform patients who are candidate for hysterectomy about possible consequences. Finally, if you care for those women in whom less invasive treatment options failed, respect researchers who evaluate the effects of hysterectomy. In the end, this respect among researchers, will be more helpful to patients than your comments have been up till now. Jan-Paul Roovers
Competing interests: None declared |
|||
|
|
|||
|
Carla Dionne, Executive Director National Uterine Fibroids Foundation
Send response to journal:
|
Mr. Roovers, Perhaps I'm mistaken, but it's always been my understanding that one does not have to be a physician or clinical investigator to read and pick apart a poorly done study. It would seem a bit of an elitist attitude to presume that only those who are published may comment on your paper or have questions and concerns about it, Mr. Roovers. As a professional patient advocate who fields queries from women day in and day out on reproductive disease and treatment options, major press releases on research picked up by the mass media on a scale such as this study is a fully indescribable irritant. When the research is great, fielding these queries is easy and a joy. When the research is flawed, it makes my job 1000 times harder to sort it all out to create the proper response that explains the problems with the study appropriately. When the BMJ chose to publish this particular paper and its corresponding press release, a trickle down tidal wave was created with women worldwide that I sincerely find doubtful you understand even remotely, Mr. Roovers. Not even as a soon-to-be gynecologist. The National Uterine Fibroids Foundation and every other organization publicly supporting women by providing information on reproductive disease and treatment options know it only too well. Join me for a year of MY work, Mr. Roovers, and perhaps your perspective on this will be broadened to more fully and charitably comprehend the impact. A few questions: 1. Were you or were you not a doctoral student when this study was written and published as part of your thesis in 2001? 2. Table 3. How many women actually responded at 6 months? 100% of the 310 for every question? Please clarify the numbers associated with response at 6 months for each arm of the study and for each question. 3. Do you honestly think that a hysterectomy study of 310 women split three ways across a multitude of clinical facilities/surgeons and asked 36 questions is a large study of tremendous statistical value that can be seriously relied upon by women and physicians in the decision- making processes of making a treatment choice? Especially in light of some of the problems identified with this study, such as no control on ovary retention? Also, out of context with your other research work on micturition and defecation? 4. Are you of the belief that ovaries are of no consequence in considering a study on female sexual function outcomes and/or that HRT (of ANY sort) is a comparable substitute? If my questions/concerns raised on this issue are of no concern to you, why did you then review your work and subsequently post a 3.8% oophorectomy statistic? 5. In your pursuit of medical education, how many hours of classroom/field study were you required to complete on the topic of female sexual function? 6. As for research, can you share with me how much money the prestigious institutes you identifed spent on disease specific studies vs. hysterectomy treatment studies? In other words, how much money during the last decade -- year by year -- have those institutes spent on the following: - uterine fibroids - endometriosis - adenomyosis - ovarian cysts - prolapse (unrelated to the hysterectomy) For that matter, how much did your entire public health system allocate for study of these health issues? While I understand that the field of gynecology has been in triage mode for well over 100 years in utilizing the hysterectomy as a treatment for a wide variety of female reproductive disease, if you don't mind, Mr. Roovers, I would personally like to reserve the majority of my professional respect for researchers who choose to work on the expansion of our body of knowledge on reproductive disease and ALTERNATIVE treatment options that would allow a woman to retain her body parts fully intact while potentially avoiding the risks of major surgery. I've sent you private email which you've not chosen to answer. Hence, my public postings and queries. Carla Dionne Footnote: The following is offered to assist your search in determining "who" I am: 1. Go to any online search engine and type: "Carla Dionne" -- put my name in quotemarks to filter for best results. While not all "Carla Dionne" listings are about me, you'll know which ones are relevant. A metasearch can be done at: http://www.dogpile.com 2. http://www.uterinefibroids.com 3. http://www.NUFF.org 4. sex, lies, and the truth about uterine fibroids. c2001 Penguin Putnam/Avery. 5. A secret not well known to the public at large but well understand by physicians who publish: ghostwriters and medical students are the actual authors of a great many published medical papers. I am published in PubMed and also with a variety of additional book publishers- -but you won't find any of this work under my name. Running a relatively new nonprofit on a publicly funded shoestring isn't easy, Mr. Roovers. While I may not have a MD or PhD to place after my name, I have been a professionally paid technical researcher and writer for ~20 years. 6. I've been a woman my entire life, a woman diagnosed with reproductive disease for 18 years, and a woman who has suffered through post-procedural sexual dysfunction and the subsequent oft-humiliating scrutiny of poorly educated medical professionals (who know little to nothing about female sexual function) for 6 years. 7. I enjoy my sex life and have worked hard to regain it during the past 6 years. I wouldn't wish post-procedural sexual dysfunction on even a single woman, much less be even remotely dismissive of the numbers suffering at 6 months per your study. Competing interests: None declared |
|||
|
|
|||
|
Andrea Bradford, Doctoral student The University of Texas at Austin, U.S.A.
Send response to journal:
|
I applaud the authors of this study for taking subjective distress into account in their examination of sexual outcomes following hysterectomy. This is a much-needed aspect of the research on this topic. I am disappointed that, as we see so often in this research, the method does not include the use of a well-validated interview or self-report measure to assess sexual function. I am concerned with the interpretation of the results with regard to those women who developed new sexual symptoms after their surgeries. In your words, "New sexual problems developed in 9 (23%) patients after vaginal hysterectomy, 8 (24%) patients after subtotal abdominal hysterectomy, and 12 (19%) patients after total abdominal hysterectomy." For previously asymptomatic women undergoing hysterectomy, the rate of new sexual problems (about 1 out of 5) is troubling and do not suggest that sexual symptoms after hysterectomy are rare. Moreover, more women than not (again, according to your data, over 50%) continued to be troubled by existing sexual problems after hysterectomy. I hesitate to accept the authors' conclusion that sexual pleasure is enhanced following hysterectomy, particularly since they did not directly measure sexual enjoyment or satisfaction. Sexual pleasure cannot simply be inferred from the absence or presence of a few symptoms. Several elements are curiously absent from prospective studies of hysterectomy and sexual function, including a consideration of the incidence of sexual problems in the general population compared to that among women undergoing hysterectomy. We lack strong evidence either for or against the hypothesis that hysterectomy may negatively impact sexual function. I do not believe that the present study, nor other research to date, has successfully addressed this question. Competing interests: None declared |
|||
|
|
|||
|
Ann Semes Lynch, DES daughter exposed in Utero Home 15068
Send response to journal:
|
Friends, I saw this study on the DES Daughter List Serve. I'm a 49 year old female whose mother took DES while she was pregnant with me. I am thrilled to have one daughter (20 years old - she's got problems too) and I lost two babies due to miscarriage. Not tooting my own horn but I experienced severe pain, cramping, bleeding et al throughout my life. I begged my doctor to perform this surgery. I was thrilled when we finally had enough documentation and the option of a hysterectomy was put before me. I was convinced that this would be the one, the only thing in the world that would fix my problem. I had the best doctor and I'm so happy to say it worked! My sexual pleasure has definitely increased since the hysterectomy and I'm not afraid to say so. Yes, I'm 49 - almost 50 and I'm tired after working all day so I'm not "in the mood" constantly but I have to admit and my husband would probably admit this as well that this aspect of our life is much better. Quit fighting over this - hysterectomy is not the answer for everyone just like abortion is not the answer for everyone. You must not dictate what is good for some will be good for all. I am not a doctor, a researcher or a specialist of any kind - I'm just a woman who is glad that there are choices for everyone to make. Competing interests: None declared |
|||