Content written by Irwin Goldstein, MD

Hysterectomy, or surgical removal of the uterus, may be performed for treatment of cervical cancer. If the woman has cervical cancer, in addition to a total hysterectomy adjacent lymph nodes and surrounding tissues containing nerves may be removed for control of cancer. This kind of hysterectomy is called a radical hysterectomy. The uterus may be removed for treatment of non-cancerous growths called fibroids that cause heavy menstrual bleeding or severe menstrual cramps. If the entire uterus is removed, that is called a total hysterectomy. The uterus could be surgically removed sparing the cervix to preserve nerves in the region that pass to the vagina. This kind of hysterectomy is called a subtotal hysterectomy and is performed to maximize preservation of sexual function. Since important nerves that provide sensation pathways to and from the vagina pass near the cervix, it is postulated that nerve-sparing hysterectomy procedures be considered, especially in women who experience high sexual satisfaction with internal-based orgasms. During any procedure to remove the uterus, a decision is made to preserve or to remove the woman’s ovaries. The argument is that removal of the ovaries prevents the possibility of ovarian cancer. After any kind of hysterectomy with or without ovary removal, there may be changes in a woman’s sexual function.

What do the studies reveal? As it concerns radical hysterectomy, Jensen and colleagues reported the results of the sexual function of women who underwent radical hysterectomy for treatment of early cervical cancer. Compared to an age-matched control group, women who underwent radical hysterectomy experienced significantly less sexual interest and decreased vaginal lubrication that persisted over several years of follow-up. On the other hand, other surgically-related sexual and vaginal problems associated with the radical hysterectomy, such as uncomfortable sexual intercourse due to a reduced vaginal size, decreased with time.

Carlson reported that in women undergoing total hysterectomy for non-cancerous conditions (excessive bleeding, cramps, pain) there was a marked improvement in symptoms and quality of life during the early years after surgery. Rhodes and colleagues also examined measures of sexual function in women undergoing total hysterectomy. These authors showed that both sexual desire and frequency of sexual relations significantly increased after hysterectomy and throughout the follow-up period. Similarly, frequency of orgasm significantly increased and strength of orgasm rose dramatically after hysterectomy.

As it concerns the difference between total hysterectomy and subtotal hysterectomy in terms of sparing sexual function, Gimbel and colleagues examined the sexual satisfaction of women undergoing either procedure for benign uterine conditions such as fibroids. The authors reported that both groups had the same sexual satisfaction outcome. Zobbe and colleagues also studied the sexual outcome following total subtotal hysterectomy for benign uterine conditions. The authors found no significant differences between the two hysterectomy procedures at the 1-year follow-up with regard to women’s sexual desire, frequency of intercourse, frequency of orgasm, quality of orgasm, localization of orgasm, satisfaction with sexual life, and sexual pain. In both total and subtotal hysterectomy groups, there was a significant reduction in sexual pain.

As it concerns the hormone status of women after hysterectomy, Cutler and colleagues measured the post-operative hormonal impact on women’s sexual health and overall quality of life. The authors found that the combination of total hysterectomy and bilateral oophorectomy may worsen the clinical and quality of life picture. The authors stressed that the ovaries provide approximately half of a woman’s testosterone and, after surgery, many women report impaired sexual functioning, especially loss of sexual interest, despite estrogen treatment. Rako also reported on the important observation that the ovaries are a critical source of both estrogen and testosterone. Vaginal dryness, night sweat, and hot flashes are associated with the estrogen deficiency associated with bilateral oophorectomy (surgical menopause). Rako stated that, on removal of the uterus, even if the ovaries are spared, ovarian estrogen and testosterone function could be reduced. Rako noted that low testosterone values after a hysterectomy are associated with a decrease in sexual libido, sexual pleasure, and wellbeing.

In summary, it appears that for women with cervical cancer who undergo a radical hysterectomy, expectations are appropriate that changes in sexual function may result post-operatively. For women with severe clinical symptoms of fibroids, total or subtotal hysterectomy may actually result in improved sexual function. In women who undergo surgical menopause, the combination of a hysterectomy and bilateral ovary removal, hormone changes may occur and this may be a basis for changes in sexual function. Research is needed regarding the value of surgically-sparing pelvic autonomic nerves that pass to and from the vagina during total hysterectomy. This type of surgery deserves consideration in the effort to improve quality of life.