Besides direct trauma to adjacent organs, hysterectomy also can cause neural damage to the visceral pelvic nerves surrounding the cervix and the autonomic nerves and ganglia in the uterine ligaments.5 Although total hysterectomy disrupts these neural tracts to a greater extent than subtotal hysterectomy, some degree of injury occurs even with the less extensive procedure. This disruption is thought to be the culprit of postoperative urinary, sphincteric, and sexual dysfunction.
For women whose sexual response includes an “internal orgasm”—thought to be linked to sensory input from the cervix—removal of the cervix may have marked negative effects on sexual satisfaction. Therefore, proponents of the subtotal hysterectomy claim that the more limited resection preserves the neural pathways and, thus, physiologic function. However, Grimes argues that the presence of neural tissue in and around the cervix does not necessarily mean that it is functional.2
Other potential deleterious effects of complete cervical excision include the development of scar or granulation tissue at the vaginal apex and the possible shortening of the vagina. It is not clear from the current literature whether complete cervical excision increases the risk of vaginal-vault or pelvic-floor prolapse.6
Effects on sexuality
Using data from the Maine Women’s Health Study, Carlson and colleagues found marked improvements in symptomatology, including reduced rates of sexual dysfunction, when hysterectomy was performed for fibroids, bleeding, or pain.7 They concluded that hysterectomy was associated with an overall improvement in the quality of life. New problems were limited, with only 7% of patients reporting a loss of interest in sex following surgery.
A report from the Maryland Women’s Health Study noted that rates of dyspareunia decreased following hysterectomy and that measures of sexual activity, libido, and orgasmic function increased.1 These improvements were thought to result from removal of the offending pathology and freedom from conception concerns.
Unfortunately, neither the Maine nor the Maryland studies assessed the effects of the type of hysterectomy on outcomes. However, a prospective study from Finland did. The result? Measures of sexual function, libido, and coital frequency did not differ statistically between women in the 2 groups—either preoperatively or 1 year postoperatively.8
However, the percentages of women reporting reduced orgasmic function did increase significantly over the year following surgery among women who had a total hysterectomy but did not change appreciably in the subtotal cohort. Dyspareunia occurred less often in both groups but to a greater extent in women who had a subtotal hysterectomy.
When Helström and colleagues from Sweden reported their evaluation of the sexual lives of women prior to and following subtotal hysterectomy, they found varied results.9 Approximately half the women surveyed reported improved sexuality after surgery, nearly one-third reported little change, and one-fifth noted deterioration. Researchers concluded that the best predictor of postoperative functioning was preoperative sexual activity: The more interested and active the woman was before surgery, the more likely she was to report satisfactory sexual function afterward. A recent decision analysis comparing the effects of total and subtotal hysterectomy echoes this finding: Sexuality before best predicts sexuality after surgery.10
The previously held belief that hysterectomy is strongly associated with depression does not appear to have been borne out. In the Finnish study, the percentage of women experiencing no postoperative symptoms of depression rose continuously during 3 years of follow-up.8 Women who reported depression before surgery also were likely to report the condition in the 2 years following surgery, although some improvement was noted 3 years after the total hysterectomy. In contrast, women with preoperative depression who underwent subtotal hysterectomy reported marked improvement in emotional well-being 6 weeks after surgery. This effect endured throughout the period of observation.8 Although it is difficult to determine the precise reason for these findings, they provide encouraging information for the patient and her physician.
Information is more limited on the effects of surgical menopause on postoperative sexual function. The impact of estrogen deficiency may be direct or indirect. Vaginal dryness and/or atrophy may make intercourse uncomfortable. Lubricants may not completely alleviate this problem, as they may be awkward and cumbersome.
Estrogen deficiency also may induce sleep disturbances, mood changes, and other factors that impair a woman’s libido and affect her enjoyment of sexual relations. And some women may experience a feeling of loss associated with organs so closely identified with femininity, resulting in an altered sense of self and sexuality.
Patient selection
Subtotal hysterectomy. Women who have benign disease, e.g., fibroids, endometriosis, and ovarian cysts, but do not have a history of abnormal Pap smears. Rule out the presence of malignancies in the uterus or cervix prior to surgery.
Total hysterectomy. Women who have malignant disease, including cervical, uterine, and ovarian cancers. (Note, however, if a total hysterectomy is planned and the surgeon encounters severe endometriosis or extensive cul-de-sac adhesions, switch to a subtotal hysterectomy.)