The Effects of Hysterectomy on the Subjective and Physiological Sexual Function of Women with Benign Uterine Fibroids
Copyright ©2004. Archives of Sexual Behavior, February 2004 Vol. 33, No. 1 , pp 31-42. Plenum Publishing Corporation.
Cindy Meston, Ph.D.
The first Athena Institute Research Grant Recipient, Dr. Cindy Meston, publishes study which concludes, "the findings from this study suggest potential impairment of physiological sexual arousal with hysterectomy surgery."
The goal of Athena Institute's Research Advisory Group and Dr. Cutler, in awarding this research grant in 2000, was to promote the collection of physiological data for women’s sex research among well women and those after hysterectomy who experience new deficits in sexual functioning. This goal was inspired by many personal letters from men and women surprised by sexual deficits after post hysterectomy healing was complete.
A message to women from Dr. Cutler:
"This study is important because it provides physiological data (not just an opinion survey of the volunteers) accepted for publication in a prestigious scientific journal after passing rigorous peer review. During sexual intercourse, vaginal blood flow is necessary for lubrication. Dr. Meston's study reveals that hysterectomy can disrupt the normal physical mechanisms by which blood flows to the vagina during sexual arousal in healthy women. And that absence of blood flow can disturb sexual relations between men and women. "
-- Winnifred Cutler, Ph.D.
Received January, 3, 2003; accepted August 14, 2003
Research indicates hysterectomy surgery may adversely affect the pelvic autonomic nerves and autonomic mechanisms which are integral to the sexual arousal response in women. This study explored the possibility that women who undergo hysterectomy may experience an impaired vasocongestive response to erotic stimulation.
Thirty-two women with a history of benign uterine fibroids who had (n=15) or had not (n=17) undergone hysterectomy participated in two experimental sessions in which self-report and physiological (vaginal pulse amplitude; VPA) sexual responses were recorded during an erotic film presentation. In one of the sessions, the women exercised on a treadmill for 20 min prior to viewing the erotic films as a means of inducing autonomic arousal. Exercise significantly increased VPA but not subjective sexual responses in both groups of women. VPA responses were marginally higher among the fibroid than hysterectomy group in the no-exercise condition. The hypothesis that physiological sexual arousal may be impaired with hysterectomy surgery was only partially supported.
Hysterectomy is the most common nonpregnancy-related surgery performed among American women. About 600,000 women undergo this procedure each year in the United States, and by the age of 60 nearly one out of every three American women will have undergone hysterectomy (Easterday & Grimes, 1983; Lepine et al., 1997; Wilcox et al., 1994).
Approximately 90% of hysterectomies are conducted for benign conditions such as leiomyomas (fibroids), dysfunctional uterine bleeding, endometriosis, chronic pelvic pain, and prolapse (Pokras & Hufnagel, 1987). Reports of positive outcomes posthysterectomy include the cessation of abnormal uterine bleeding, relief from menstrual symptoms and pelvic pain, and decreases in depression and anxiety (for review, see Farquhar et al, 2002). A high proportion of women, however, develop new symptoms posthysterectomy which include depression, fatigue, urinary incontinence, constipation, early ovarian failure, and sexual dysfunction (e.g., Carlson, Miller, & Fowler, 1994; Thakar, Manyonda, Stanton, Clarkson, & Robinson, 1997)...
Thus, it is not surprising that concern has been raised regarding the appropriateness of this surgery for the treatment of nonmalignant conditions. Nerve-sparing surgical techniques and procedures, such as endometrial ablation and supracervical hysterectomy, are offered as alternatives to total hysterectomy for the treatment of benign conditions but, as of yet, they have not substantially impacted hysterectomy rates (Farquhar & Steiner, 2002).
The extent to which hysterectomy impacts sexual function is of debate in the literature....
Participants were obtained through referrals from the Renaissance Women’s Medical Clinic, via advertisements in the local and University of Texas newspapers, and via posters placed in women’s restrooms across the University of Texas campus. The advertisements called for women to participate in a study directed toward understanding the effects of hysterectomy and uterine fibroids on sexual function.
The final total sample size was 32: 15 women who had and 17 women who had not received hysterectomy surgery. Inclusion criteria for all participants were: over age 20, premenopausal (as determined by assays assessing FSH and estradiol), heterosexual, absence of vaginal disease, and currently involved in a sexually active relationship.
Further inclusion criteria for women who had undergone hysterectomy (experimental group) were: having undergone hysterectomy for the primary purpose of treating benign uterine fibroids no less than 1 year and no more than 10 years prior, and at least one intact ovary. This latter criterion was used because bilateral oophorectomy and the consequent decrease in ovarian hormones may adversely impact sexual function by for example, decreasing vaginal lubrication (e.g., Dennerstein et al., 1977) or compromising a women’s sexual attractiveness via destruction of axillary pheromonal secretions (Cutler, 1996.) ...
Further inclusion criteria for women who had not undergone hysterectomy (fibroid group) were: diagnosis of benign uterine fibroids as per ultrasonography screening, and not scheduled or planning for hysterectomy surgery. This latter criterion was used because it may be expected that upcoming gynecological surgery would create a certain degree of anxiety, fear, and concern for the women involved, and subsequently might adversely impact sexual function. ...
Thirty-four premenopausal women with a history of benign uterine fibroids met initial inclusion criteria and were scheduled for their medical screening visit at the Renaissance Women’s Medical Clinic. Seventeen of these women had undergone hysterectomy for the treatment of benign uterine fibroids; 17 had not undergone hysterectomy.
Session 1 (Medical Screening)
During this session, the participants signed the informed consent document and were given a chance to ask any questions. A registered nurse then conducted a brief cardiovascular exam to ensure the women would not be at risk when exercising. None of the women were considered at risk. Blood samples were drawn so that analyses of FSH and estradiol could be made. Because menopause is likely to affect sexuality, information on these hormone levels allowed for the identification of women who were within this transitional period.
They were then given a complete physical exam, including pap. Those women who had not received hysterectomy surgery were also given a pelvic ultrasound to validate and further assess their degree of uterine fibroids. The gynecologists screened the women for vaginal atrophy, vaginal scarring or surgical damage, significant cervicitis, and cervical dysplasia.
Following the examination period, participants were given a 4-week supply of Daily Diary questionnaires along with four self-addressed, stamped envelopes. The diaries monitored the daily frequency of intimate contacts, masturbation, sexual intercourse, and sexual thoughts. They were instructed to fill out one from each day and mail in the forms at the end of each week.
Sessions 2 and 3 (Psychophysiology)
The second and third sessions were the two experimental conditions: no-exercise and exercise. Order of these conditions was counterbalanced across participants. For both of these sessions, the participants were asked to abstain from caffeine and alcohol, and to refrain from engaging in any strenuous physical activity for 24 hours prior to their visit.
During the no-exercise condition, participants entered the private, internally locked room together with the female experimenter. They were told that once the experimenter left the room, they were to sit in the chair and insert the vaginal photoplethysmograph using a placement device that standardizes the distance of probe insertion between women. To minimize potential movement artifacts, participants were asked to remain as still as possible throughout the session.
When participants notified the experimenter, via the intercom system, that they had finished inserting the plethysmograph, a 10-min adaptation recording was taken. After the adaptation period, participants viewed either videotaped sequence A or B. Each sequence consisted of the word “relax” (1 min), a neutral travelogue (3 min), and an erotic film (5 min). The films depicted a heterosexual couple engaging in foreplay and intercourse and were matched on the number and type of sexual activities. Immediately after the erotic film, participants were asked to fill out a subjective sexual arousal rating scale.
During the exercise condition, participants entered the room with the female experimenter and were informed of the experimental procedures as in the no-exercise condition. They were then asked to run for 20 min on a treadmill, during which time their HR was monitored continuously. Respondents were given continual visual feedback on their HR levels, and were asked to run faster or slower if their HR indicated that they were below or above 70% of their Hrmax.
Immediately after watching the erotic film, participants were asked to fill out the subjective rating scale. With the exception of 20 min of running, all experimental procedures were identical to those of the no-exercise condition.
(listed without summaries)
Locke-Wallace Marital Adjustment Test
Beck Depression Inventory
Body Satisfaction Scale
Female Sexual Function Index
Index of Sexual Satisfaction
Subjective Film Scale
A vaginal photoplethysmograph (Sintchak & Geer, 1975) was used to measure VPA responses. Separate VPA difference scores were computed for each group and condition by subtracting the average VPA score during the neutral film from the average VPA score during the erotic film.
This study examined the effects of autonomic activation on sexual arousal responses in women with a history of uterine fibroids who had and had not undergone hysterectomy. The uterine supporting ligaments contain sympathetic, parasympahtetic, sensory, and sensory-motor nerve types and are considered a major pathway for autonomic nerves to the pelvic organs. ****
The finding that women who had undergone hysterectomy showed lower VPA responses during the no-exercise condition than women with uterine fibroids contrasts with prior research of this nature.****
Although speculative, a third interpretation of the finding that women in the hysterectomy group showed lower VPA responses during the no-exercise condition than did women in the fibroid group warrants mention. It is possible that hysterectomy did, in fact, sever autonomic fibers required for physiological sexual responding but under conditions of intense autonomic activation (i.e, exercise), the existing fibers helped compensate for those damaged with surgery and allowed for a substantial vaginal response to erotic stimulation ***
The higher level of VPA responses to erotic stimuli during the exercise versus no-exercise condition were not accompanied by substantially higher reports of mental or physical sexual arousal, and correlations between subjective and physiological measures of sexual arousal were not significant. Numerous studies of this nature have noted a desynchrony between subjective and physiological measures of sexual arousal in women (for review, see Meston, 2000).
One explanation for this desynchrony is the contrived nature of the laboratory setting used in this type of research, which may limit the extent to which a woman can “feel” sexually aroused. Or, it may be the case that women estimate their degree of sexual arousal using standards other than genital cues. For women, external stimulus information such as relationship satisfaction, mood state, and sexual scenarios may play a more important role in assessing feelings of sexual arousal than do internal physiological cues.
According to the FSFI scores, women who had undergone hysterectomy reported below normal levels of vaginal lubrication with sexual activity. This finding is consistent with the low levels of VPA responses to erotic films also noted among hysterectomy women in the no exercise condition.
To summarize, the findings from this study suggest potential impairment of physiological sexual arousal with hysterectomy surgery.
The hypothesis that this impairment is due to severed autonomic input was not supported. These conclusions are based on comparisons between women who have undergone surgery for benign uterine fibroids and women who currently are diagnosed with benign uterine fibroids. Whether women with benign fibroids differ in their sexual arousal responses to increased autonomic activation from women without fibroids is worthy of further investigation.
This study was supported by an Athena Institute for Women’s Wellness Research grant to Cindy M. Meston. The author would like to thank Annie Bradford and Katie McCall for their assistance in data collection.
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