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Rapid response to:


Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy

BMJ 2003; 327 doi: (Published 02 October 2003) Cite this as: BMJ 2003;327:774

Rapid Response:

Women's fears of sexual dysfunction after hysterectomy are justified

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

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


Fibroid Embolisation - Information, Support & Advice

An independent patient group


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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

Competing interests: No competing interests

08 October 2003
Ginette C Camps-Walsh
Member of voluntary patient group FEmISA
Oxford, England OX3 9TY