- Sex after hysterectomy – Sexual health
- Vaginal dryness, sensation and orgasm
- Hysterectomy will ruin my sex life. Orgasm will never be the same!
- No One Warned Me About the Grief That Comes With a Hysterectomy
- Goodbye uterus, hello grief
- Overcoming the loss by reminding myself of all that makes me a woman
- 10 Things Your Doctor Won’t Tell You About Hysterectomy
- Your Sex Life and Sex Drive May Be Among the Topics Not Discussed Before Surgery
- 1. Your Sex Life Isn’t Over
- 2. Hysterectomy Is Never a Cure for Endometriosis
- 3. You Won’t Necessarily Go Into Menopause
- 4. Hysterectomy May Include Your Ovaries
- 5. Hormone Therapy Could Help With Physical Changes After Surgery
- 6. You May Be Able to Avoid a Hysterectomy
- 7. Less-Invasive Surgery May Be the Right Option for You
- 8. The Morcellation Technique Has Both Advantages and Risks
- 9. Hysterectomy May Prevent Certain Types of Cancer
- 10. Psychological Healing After Hysterectomy Can Take Time
- Subtotal vs total hysterectomy: Does the evidence support saving the cervix?
Sex after hysterectomy
Vaginal dryness, sensation and orgasm
Having a hysterectomy doesn’t mean you can’t have an orgasm. You still have your clitoris and labia, which are highly sensitive.
It’s not known what role the cervix plays in orgasm. Some experts have argued that removing the cervix can have an adverse effect, but others have found that it doesn’t.
A review of the evidence comparing subtotal with total hysterectomy in premenopausal women found both types offered similar results for sexual function.
In a study comparing different surgical methods of hysterectomy, some women noticed reduced sexual sensation. This included reduced feeling when their partner penetrated their vagina, a dry vagina and less intense orgasms. If, before hysterectomy, you had noticeable uterine contractions during orgasm you may find you do not experience these anymore.
If your hysterectomy has made your vagina feel drier than it used to be, try using a sexual lubricant. You can buy these over the counter at a pharmacy.
Your surgeon will have advised you to do pelvic floor exercises to help your recovery. These exercises can also tone up the muscles of your vagina and help improve sexual sensation. Read more about pelvic floor exercises.
Other women report their hysterectomy removed their pre-surgery symptoms (such as pain), and they had a greater sense of wellbeing and happiness.
The Royal College of Obstetricians & Gynaecologists has leaflets about recovering after hysterectomy:
Recovering well after abdominal hysterectomy
Recovering well after vaginal hysterectomy
Recovering well after a laparoscopic hysterectomy
Hysterectomy will ruin my sex life. Orgasm will never be the same!
How would a male gynecologist begin to know anything about a woman’s orgasm? Easy. In my pre-operative counseling for hysterectomy I discuss sexuality, orgasm, and hysterectomy. And I tell my patient that a year later I’m going to ask her about it. But this is not a controlled scientific study, so before telling you what I am hearing, let’s look at some real data. Again, don’t take my word for it. Go to the sources listed in the references. And if you like, check out their references. First, I was amazed when I reviewed some of the early publications. Retrospective studies, with no control groups. Honestly, they proved about as much as did my “violin” example above: absolutely nothing. Dr. Carlson also reviewed a number of studies on sexual function after hysterectomy in the above referenced article. Most interesting, perhaps, was a well done, prospective study which she co-authored: The Maine Women’s Health Study (see references). In Part I a number of health related questions were evaluated before and after hysterectomy. In Part II, a comparable group of women with similar problems treated without hysterectomy were evaluated. The results are interesting. After hysterectomy 7% of woman experienced “lack of interest in sex”. Of those treated without hysterectomy 6% of women had the same complaint. This is not a significant difference. “Lack of enjoyment of sex” was reported in 1% of women having hysterectomy and in no women without hysterectomy. Another study, by L. Helstrum (see references), concluded that the most predictive factor in postoperative sexuality was preoperative sexual activity. What women tell me after hysterectomy: The most frequent response to the question of how sex and orgasm are a year after hysterectomy is a laugh and a big smile. Most women tell me that there is no change in the way they feel orgasm, and they are able to enjoy sex more since they don’t have their original problem to interfere with sex. Many others report no change. Some women tell me orgasm is better and more intense after their hysterectomy (don’t ask my why). A small number of women tell me they have less interest in sex, but rarely do they consider this a problem. I have heard once that orgasm was different than before. Not “bad,” just different. And some women who had sexual dysfunctions before hysterectomy had sexual dysfunctions after hysterectomy. My impression regarding depression is that infertile women who desired children, and had a hysterectomy because of a problem that caused infertility such as endometriosis, may have a hard time coping with the finality of the realization that they would never carry a child. And certainly women who have a problem with depression before surgery often still have the problem afterwards. At times however, the resolution of a problem that interfered with a woman’s health and was a major focus in her life often improved emotional well-being. Supracervical hysterectomy – should I keep my cervix?
Before surgeons learned how to safely remove the cervix (which is really the lower portion of the uterus), it was left in place during a hysterectomy. In the 1950’s improvements in surgical technique and the desire to prevent cervical cancer resulted in the adoption of the routine removal of the cervix with the rest of the uterus at the time of hysterectomy. Currently there is a resurgence of interest in leaving the cervix at the time of hysterectomy. The short version: there are many arguments in favor of leaving the cervix, but very little data to support or to disprove these arguments. What are some of the arguments? Statement: There is less risk of vaginal vault prolapse with subtotal hysterectomy (the vagina falling out). It is argued that the supports of the vagina are damaged by removal of the cervix.
Counterpoint: Uterine prolapse (the uterus falling out) is a common indication for hysterectomy. The supporting structures are frequently damaged by childbirth, and can be repaired during hysterectomy.
Fact: There are no good studies comparing vaginal prolapse with and without removing the cervix. Lot’s of arguing, but no data. Statement: Orgasm is better with the cervix left in. In 1983 Kilkku published a study showing more frequent orgasms after supracervical hysterectomy than after total hysterectomy. It is argued that the nerves in the cervix are important for orgasm.
Counterpoint: Much of this argument comes from Kilkku’s 1983 study (see references). The flaws in this study were numerous. This was a retrospective study in which there was not even a baseline assessment of the subjects. It is impossible to draw any meaningful conclusions from this study.
Fact: In order to study this, it would be necessary to evaluate a group of woman planning hysterectomy, randomly leave the cervix in half of them, and then reacess orgasm at a given time after surgery. Once again, strong opinions, little information. Statement: If the cervix is normal then leave it in.
Counterpoint: It is easier to leave in the cervix if the uterus is removed through the abdomen, but the reverse is true for a vaginal hysterectomy. Although we have good screening methods for cervical cancer, adenocarcinoma (cancer of the glands inside of the cervix) is increasing in frequency, and can be fatal. In addition, there are now reports of having to go back and remove the cervix after a supracervical hysterectomy because of bleeding or other problems.
Fact: There is a small but definite risk of cancer in a remaining cervix, and of needing to have surgery to remove the cervix at a later time if it causes problems. The arguments about pelvic support and sexual functions have not been tested, so their validity is unknown. Hopefully there will be good prospective studies to better determine whether or not it is best to remove the cervix. Sounds like you’re for hysterectomy after all… I’m not for or against hysterectomy. If less invasive alternatives have a reasonable chance of solving a problem, then in most cases that would be preferable. That is why I am so aggressive about promoting hysteroscopy, hysteroscopic procedures, and laparoscopic procedures when they are medically appropriate. On the other hand, I don’t want any woman to be to be afraid of hysterectomy because of myths and misinformation. Most women who have a hysterectomy do very well. On the other hand, if a less invasive alternative is available, give it serious consideration! REFERENCES References
Clinical Obstetrics and Gynecology, Volume 40, No. 4, Dec. 1997. An excellent collection of recent articles review the literature and knowledge about hysterectomy. Highly recommended if you are seriously interested in researching this topic. Published by Lippincott-Raven at 1-800-638-3030. Included are the two following manuscripts referenced in the text:
Carleson, Karen J: Outcomes of Hysterectomy, Clinical Obstetrics and Gynecology, Volume 40, No. 4, Dec. 1997.
Johns, Alan: Supracervical Versus Total Hysterectomy, Clinical Obstetrics and Gynecology, Volume 40, No. 4, Dec. 1997.
What is a hysterectomy?
Hysterectomy is the surgical removal of the uterus. It ends menstruation and the ability to become pregnant. Depending on the reason for the surgery, a hysterectomy may also involve the removal of other organs and tissues, such as the ovaries and/or fallopian tubes.
- A supracervical hysterectomy is the removal of the upper part of the uterus leaving the cervix behind.
- A total hysterectomy is the removal of the uterus and cervix.
- A total hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes (salpingo) and ovaries (oophor). If you haven’t experienced menopause, removing the ovaries will usually start it since your body can no longer produce as much estrogen.
- A radical hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes, ovaries, the upper portion of the vagina and some surrounding tissue, and lymph nodes. A radical hysterectomy may be performed to treat cervical or uterine cancer.
Top image: Pelvic organs before hysterectomy
Bottom image: Pelvic organs after hysterectomy
Why is hysterectomy performed?
A hysterectomy may be performed to treat:
- Abnormal vaginal bleeding that is not controlled by other treatment methods
- Severe endometriosis (uterine tissue that grows outside the uterus)
- Leiomyomas or uterine fibroids (not cancerous tumors) that have increased in size, are painful or are causing bleeding
- Increased pelvic pain related to the uterus but not controlled by other treatment
- Uterine prolapse (uterus that has “dropped” into the vaginal canal due to weakened support muscles) that can lead to urinary incontinence or difficulty with bowel movements
- Cervical or uterine cancer or abnormalities that may lead to cancer for cancer prevention
Are there alternatives to hysterectomy?
Yes. A hysterectomy is only one way to treat problems affecting the uterus. For certain conditions, however, hysterectomy may be the best choice. Please ask your healthcare provider to discuss what alternatives are available to treat your specific condition.
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No One Warned Me About the Grief That Comes With a Hysterectomy
Health and wellness touch each of us differently. This is one person’s story.
The day I decided to get a hysterectomy at age 41, I felt relieved.
Finally, after living with the pain of a uterine fibroid and many months spent attempting nonsurgical options, I told my doctor to sign me up for the surgery that would end all the anguish.
My tangerine-sized fibroid was a benign growth in my uterus but it was greatly impacting my quality of life.
My periods were so frequent they were almost constant, and the minor intermittent pelvic and back discomfort had crossed into the category of constant nagging pain.
While I had options, I ultimately chose the surgical route.
I’d fought against the idea of a hysterectomy for months. It seemed so drastic, so final.
But other than my fear of the recovery, I couldn’t come up with a concrete reason not to go through with it.
After all, I already had two children and wasn’t planning on having more, and the fibroid was too large to simply remove by laparoscopy. I had no desire to live like that for an unknown number of years until the all-natural fibroid shrinker called menopause kicked in.
Plus, every woman I talked to who had undergone a hysterectomy proclaimed it one of the best things they’d ever done for their health.
I walked into the hospital on surgery day prepped with items I was told to pack and advice from other women who’d gotten a hysterectomy. They warned me to stay ahead of my pain medication, to rest and ask for help during my four- to six-week recovery, to listen to my body’s cues, and to ease back into normal life gradually.
But there was something my sisterhood didn’t warn me about.
They told me all about what would happen to me physically. What they neglected to mention was the emotional aftermath.
Goodbye uterus, hello grief
I’m not sure exactly what triggered a sense of loss after the surgery. Maybe it was because I was recovering on a maternity ward. I was surrounded by babies and happy new parents as I faced my own expulsion from the club of fertile women.
When strangers started congratulating me because they assumed I had just delivered a baby, it was a harsh reminder that I was on day one of my new status as an infertile woman.
Although I’d made the decision to have the surgery, I still experienced a kind of mourning for those parts of me that had been removed, a part of my womanhood that left me with a pervasive feeling of emptiness.
And while I’d said my goodbyes to my uterus before the surgery, thanking it for its service and the beautiful children it gave me, I was hoping for a couple of days to get used to the idea of it being gone without having to talk about it.
I thought I would snap out of my sorrow once I left the hospital. But I didn’t.
Was I less of a woman because my body was no longer capable of doing what a woman’s body was evolutionarily made to do?
I struggled at home with pain, night sweats, bad reactions to my medicine, and extreme fatigue. Still, the sense of emptiness remained so visceral it was as if I could feel that part of my womanhood was missing, almost like I imagine an amputee feels phantom limb pain.
I kept telling myself I was done having children. The kids I had with my ex-husband were 10 and 14, and although I had discussed expanding our family numerous times with my live-in boyfriend, I couldn’t imagine waking up for midnight feedings while worrying about my teenage boy doing teenage things like having sex and doing drugs. My parenting mindset had long surpassed the baby stage and the thought of backtracking to diapers exhausted me.
On the other hand, I couldn’t help but think: I’m only 41. I’m not too old to have another baby, but thanks to the hysterectomy, I relinquished my option to try.
Before the surgery I said I wouldn’t have any more children. Now I had to say I couldn’t have any more children.
Social media and the time on my hands as I took medical leave from work didn’t help my frame of mind.
One friend tweeted that she hated her uterus because of her cramps, and I flinched with an odd jealousy because she had a uterus and I didn’t.
Another friend shared a picture of her pregnant belly on Facebook, and I thought about how I’ll never again feel the kicks of a life inside me.
It seemed like fertile women were everywhere and I couldn’t help but compare them to my new infertility. A deeper fear became clear: Was I less of a woman because my body was no longer capable of doing what a woman’s body was evolutionarily made to do?
Overcoming the loss by reminding myself of all that makes me a woman
A month into my recovery, pangs of grief for my perceived womanhood were still hitting me regularly. I tried tough love on myself.
Some days I stared in the bathroom mirror and said firmly aloud, “You do not have a uterus. You will never have another baby. Get over it.”
My response, as the mirror showed me a woman who wasn’t sleeping and could barely walk to the mailbox, was hope that eventually the emptiness would fade.
Then one day, when my recovery had reached the point where I was off all medication and I felt almost ready to return to work, a friend checked in on me and asked, “Isn’t it fantastic not having periods?”
Well, yes, it was fantastic not having periods.
With that chunk of positivity, I decided to revisit that collection of advice from my friends with hysterectomies, those women who claimed it was the best decision they had ever made, and my thoughts took a different turn.
When I feel like I’m less of a woman, I remind myself that my uterus was only a piece of what makes me a woman, not everything that makes me a woman. And that piece was making me miserable so it was time for it to go.
“You don’t have a uterus. You will never have another baby,” I said to my reflection. But instead of feeling deflated, I thought of why I chose to have a hysterectomy to begin with.
I will never again endure the pain of a fibroid. I will never again curl up in bed with a heating pad because of debilitating cramps. I will never again have to pack half a pharmacy when I go on vacation. I will never again have to deal with birth control. And I will never again have an uncomfortable or inconvenient period.
I still occasionally have twinges of loss similar to those that plagued me right after my surgery. But I acknowledge those feelings and counter them with my list of positives.
When I feel like I’m less of a woman, I remind myself that my uterus was only a piece of what makes me a woman, not everything that makes me a woman. And that piece was making me miserable so it was time for it to go.
My womanhood is evident with one look at my children, both of whom look so much like me that there’s no mistaking that my body was, at one point in time, capable of creating them.
My womanhood showed up in the mirror the first time I got dressed up after the surgery to go on a long-awaited date with my boyfriend, and he kissed me and told me I was beautiful.
My womanhood is all around me in forms both big and small, from my perspective as a writer to the middle-of-the-night wake-ups from a sick child who doesn’t want to be consoled by anyone but mom.
Being a woman means so much more than having certain feminine body parts.
I chose to have a hysterectomy so I could be healthy. It may have been difficult to believe those long-term benefits were coming, but as my recovery neared its end and I began resuming normal activities, I realized how much that fibroid had affected my daily life.
And I now know I can handle whatever feelings of loss and what-ifs come my way, because my wellness is worth it.
Heather Sweeney is a freelance writer and blogger, an associate editor at Military.com, a mother of two, an avid runner, and a former military spouse. She has a master’s degree in elementary education and blogs about her life after divorce on her website. You can also find her on Twitter.
10 Things Your Doctor Won’t Tell You About Hysterectomy
Get the facts about hysterectomy. Laura Apostoli/Alamy
Your Sex Life and Sex Drive May Be Among the Topics Not Discussed Before Surgery
Although hysterectomy is one of the most common surgeries for women living in the United States, myths about removal of the uterus abound.
As many as 600,000 American women have hysterectomies each year, according to the U.S. Centers for Disease Control and Prevention (CDC). If you are about to be one of them, a frank discussion with your gynecologist is an essential first step.
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Dating back more than 4,000 years, hysterectomy was used as a treatment for women with “hysteria” — a broad diagnosis that covered symptoms like anxiety and depression.
Now hysterectomy is one of many options if you have fibroids (noncancerous tumors), excessively heavy periods, or uterine prolapse (a dropped uterus). Hysterectomy may be a real medical necessity, not simply another option, if you have invasive cancer of the reproductive organs — the uterus, cervix, vagina, fallopian tubes, or ovaries.
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A partial hysterectomy is surgical removal of the uterus alone, and a myomectomy is removal of only fibroids. A total hysterectomy removes the cervix as well as the uterus. In certain cancer cases, the upper vagina is also taken out. This surgery is called radical hysterectomy, and is extremely rare.
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Unless you ask, certain crucial and highly sensitive topics may not come up when you discuss hysterectomy pros and cons with your doctor.
“The majority of hysterectomies performed in this country are elective and in some cases medically unnecessary,” says Cindy Pearson, the executive director of the National Women’s Health Network, a Washington, DC–based women’s health advocacy organization. “Unnecessary hysterectomies put women at risk needlessly. While hysterectomy is the right choice for some women, for others, less-invasive alternatives may be the right choice,” she says.
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“It’s also important for women to be aware of the alternative options before an office visit, so they can know the right questions to ask when they see their gynecologist,” says, Nora W. Coffey, the president of HERS, a women’s health organization based in Bala Cynwyd, Pennsylvania, which has counseled close to 2 million women since 1982.
“For example, often uterine prolapse responds to Kegel exercises, and endometrial hyperplasia and early endometrial cancer can be treated conservatively with a strong progesterone, Megace , or the Mirena IUD,” explains Coffey.
So speak up and get specific. Find out what a hysterectomy could mean for your sex life, your hormones, and your future.
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Here are 10 things your doctor may skip, but that you need to know.
1. Your Sex Life Isn’t Over
While the surgery can have lasting effects on your body, and you’ll need time to heal, this does not mean that you’ll never have sex again. How soon you can have sex after a hysterectomy really depends on the type of hysterectomy: partial, total, or radical. Waiting two to four weeks to get back to sex is generally okay, with your doctor’s go-ahead, if your cervix was not removed along with your uterus, says Lauren Streicher, MD, an Everyday Health columnist, an associate clinical professor of obstetrics and gynecology at Northwestern University in Chicago, and the author of Sex Rx: Hormones, Health, and Your Best Sex Ever. But if your cervix was removed, it takes about six weeks for the back of the vagina to heal.
“Ask your doctor to define what they mean by sex,” advises Dr. Streicher. What doctors usually mean is vaginal intercourse. Orgasm may be fine, oral sex too, and vibrator use as well — your questions need to be specific.
2. Hysterectomy Is Never a Cure for Endometriosis
“Not a day goes by in which I don’t wish, with every fiber of my being, that my doctor had stressed to me the vital fact that having a hysterectomy is absolutely not a cure for endometriosis,” says Rachel Cohen, 33, of Woodmere, New York, about her total hysterectomy.
In fact, endometriosis — a condition that can be marked by severe menstrual cramps, chronic pain, and painful intercourse — is not cured by removal of the uterus, according to the Office on Women’s Health at the U.S. Department of Health and Human Services. And of the many treatment options (which include pain medications and hormone therapies), hysterectomy with removal of the ovaries is not a first-line treatment. Conservative surgery using a minimally invasive method may be one option, and will preserve the uterus. Cohen’s hysterectomy at age 28, recommended by her gynecologist, did not even diminish her endometriosis symptoms.
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3. You Won’t Necessarily Go Into Menopause
“I expected to have crazy hot flashes, mood swings, and night sweats all the time, and was pleasantly surprised to find out that I barely had any of those symptoms,” Cohen says about her experience after hysterectomy.
The myth about hysterectomy Streicher hears most often in her medical practice is that a woman will go into menopause afterward. You won’t have periods, and can’t get pregnant after your uterus is removed. But that doesn’t necessarily mean menopause. Streicher explains: “The only one who will have menopause is a woman who has her ovaries removed during the procedure and who was not in menopause already.” If surgery is limited to the uterus, timing of natural menopause may not be affected.
4. Hysterectomy May Include Your Ovaries
During surgery, your doctor may remove one or both ovaries and your fallopian tubes, as well as your uterus. Ovaries are the source of the female hormones estrogen and progesterone. These are critical for both sexual health and bone health. Losing both ovaries means these hormones are also lost abruptly, a condition known as surgical menopause. This sudden loss of female hormones can cause stronger symptoms of menopause, including hot flashes and loss of sex drive.
The emotional trauma of hysterectomy may take much longer to heal than the physical effects.
5. Hormone Therapy Could Help With Physical Changes After Surgery
If you have a hysterectomy that removes your ovaries, then you should talk about the pros and cons of estrogen therapy with your doctor, Streicher says. After the ovaries are removed, estrogen therapy can help relieve uncomfortable symptoms of menopause. However, oral hormone therapy carries increased risks of stroke, blood clots like deep vein thrombosis, and heart disease, which you should also discuss with your doctor.
6. You May Be Able to Avoid a Hysterectomy
Depending on the condition you are facing, you may be able to keep your uterus intact. Alternatives are out there for about 90 percent of hysterectomies surgeons do, according to Streicher in her book The Essential Guide to Hysterectomy. Fibroids, for example, may be treated using a nonsurgical procedure called uterine artery embolization that cuts off the fibroids’ blood supply. Another option is myomectomy, which removes fibroids but spares the uterus. For heavy bleeding, an ablation procedure — which freezes or burns the uterine lining — may be a treatment option. Before scheduling a hysterectomy, have a discussion with your doctor about the alternative treatments for your condition.
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7. Less-Invasive Surgery May Be the Right Option for You
Ask your doctor about minimally invasive surgery, also called laparoscopic or robotic-assisted hysterectomy. This newer type of surgery requires general anesthesia but only uses tiny incisions, causes less blood loss, and comes with shorter hospital stays. Laparoscopic surgery is used about 45 percent of the time now for hysterectomy, according to Streicher. However, not all gynecologic surgeons offer it. Recovery is quicker, with fewer complications, she says. If your doctor indicates that you are not a candidate for this type of surgery, then ask, “Do you do a lot of minimally invasive surgery?” If she doesn’t, Streicher notes, it could be that she, not you, isn’t right for one of the newer procedures.
8. The Morcellation Technique Has Both Advantages and Risks
To be able to remove the uterus during a minimally invasive surgery, surgeons cut it into small sections and may use a process called morcellation. In the past, the practice was criticized because of evidence that it could potentially increase the risk of spreading cancerous cells.
In response to these concerns, researchers developed new approaches to the procedure including contained and in-bag morcellation methods.
Streicher believes that many women undergo unnecessary open procedures, when morcellation is a better option. “It’s a real disservice to women,” she says.
“Morcellation doesn’t cause cancer,” adds Streicher, “but if the person had a specific kind of cancer, you could potentially spread the cancer by morcellation.” This type of cancer is extremely rare, Streicher adds. Informed consent is a must before going ahead with this procedure, says Streicher.
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9. Hysterectomy May Prevent Certain Types of Cancer
For women who have BRCA1 or BRCA2 gene defects, the risk of developing ovarian cancer are much higher, according to the National Cancer Institute. Only about 1 percent of women in the general population will develop ovarian cancer over their lifetime compared with about 44 percent of women who have inherited the BRCA1 mutation and about 17 percent of women who have inherited the BRCA2 mutation. In some cases, after genetic testing, women with BRCA1 or BRCA2 choose to have a preventive surgery. This removes both ovaries, called prophylactic oophorectomy, and can be done either alone or at the time of hysterectomy. Studies show having the surgery lowers risk of dying from ovarian cancer by 80 percent.
10. Psychological Healing After Hysterectomy Can Take Time
For some, the emotional trauma of hysterectomy may take much longer to heal than the physical effects. Feeling a little down or having a sense of loss after a surgery is normal. But be on the lookout for postoperative depression, and get professional help if you need it to deal with insomnia, loss of appetite, or hopeless feelings, if you have them.
“I have to struggle with the heartbreaking reality that I can no longer menstruate or have children,” says Cohen. For her, the hysterectomy was an emotionally painful experience. “Each woman who undergoes one deals with it in a way that is uniquely hers,” she says.
Additional reporting by Barbara Kean.
Subtotal vs total hysterectomy: Does the evidence support saving the cervix?
- Sexual function is not improved more with supracervical than with total hysterectomy.
- Operative morbidity for supracervical and total hysterectomy are similar.
- Pelvic-floor support and urinary incontinence do not seem to be improved with the supracervical approach.
- Cyclic bleeding occurs in 5% to 20% of women after supracervical hysterectomy.
- Reoperation rates for symptoms related to the retained cervix are significant—over 20% in the hands of highly skilled surgeons.
Thanks to the advent of minimally invasive, organ-preserving treatments such as endometrial ablation, progesterone-containing intrauterine delivery systems, and uterine fibroid embolization, today’s patients suffer less morbidity and enjoy better outcomes for a number of procedures. To take advantage of the potential for improved patient care, we try to use every new technology for every suitable candidate.
Hysterectomy is an obvious target. The number of hysterectomies performed has not declined substantially since these technologies were introduced, and persists at more than 550,000 per year in the United States. It is still the most widely performed major gynecological procedure.
Technological advances have made possible the use of laparoscopy to facilitate removal of the uterus without a major abdominal incision, with its inherent hazards. Many surgeons, seeking to make the most of new technology, have revisited laparoscopic subtotal hysterectomy, advocating preservation of the cervix to reduce surgical complications, sexual dysfunction, and pelvic-floor defects after hysterectomy.
New data, however—much of it released only in the last 12 to 18 months—tell us there is no difference in sexual function, pelvic floor support, or return to normal activities when the cervix is retained. What’s more, leaving the cervix in place puts the patient at greater risk of reoperation related to hysterectomy.
Improved sexual function
Recent prospective analyses using validated measures of female sexual function have failed to demonstrate any advantage for supracervical hysterectomy.
Scientific study of sexual function is difficult at best. Many factors influence sexual behavior, and all must be considered when analyzing the effects of hysterectomy. To clearly understand the impact of hysterectomy on female sexual function, prospective studies in which women serve as their own controls provide the best quality evidence. That said, the contention that supracervical hysterectomy results in better sexual function than total hysterectomy stems from the research of a single group, which in 1983 retrospectively compared coital frequency, dyspareunia, libido, and orgasm after “supravaginal uterine amputation” with total hysterectomy.1,2
Simple hysterectomy causes minimal disruption of Frankenhauser’s plexus of autonomic nerves.
They theorized that supracervical operation preserves Frankenhauser’s plexus of autonomic nerves, resulting in better sexual function. However, careful anatomic assessment of the nerve content in the ligaments supporting the uterus has since demonstrated that the rich nerve supply to the uterosacral and cardinal ligaments occurs in the lateral two thirds of these structures. Simple hysterectomy causes minimal disruption of these autonomic nerves, ganglia, and extensions of the inferior hypogastric plexus.3
Thakar et al,4 in a pivotal multicenter, double-blind, randomized trial conducted in the United Kingdom, randomized 279 patients with benign disease to supracervical or total hysterectomy and followed them for 12 months. Surgical technique was standardized and the endocervix was coagulated in all patients.
The 2 groups were similar in measures of sexual function, including frequency of intercourse, orgasm, and rating of relationship with partner.
The Danish Hysterectomy Group5 randomized 319 patients with benign disease to total abdominal hysterectomy or subtotal abdominal hysterectomy, of whom 276 completed validated mailed questionnaires preoperatively, and at 2, 6, and 12 months postoperatively.
There was no change in sexual satisfaction in either group from their prehysterectomy levels. Overall quality of life improved significantly in both groups, in both mental and physical measures.
Roovers et al,6 in a multicenter, nonrandomized trial—powered well to detect 20% differences—compared vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy (technique chosen by the surgeon).
Of the 379 patients recruited (from 13 teaching and nonteaching hospitals in the Netherlands) who had a male partner, 93% completed a validated questionnaire before and 6 months after surgery.
The questionnaire—used to assess sexual pleasure, activity, and problems—specifically addressed lubrication, orgasm, pain, and arousal on a 5-point scale (“not bothered” to “severely bothered”). Their findings:
- Sexual pleasure increased significantly in all groups regardless of type of hysterectomy.
- There was no difference in the incidence of bothersome sexual problems, but a significant number were reported: 43% after vaginal, 41% after subtotal, and 39% after total abdominal hysterectomy (P =.88).
- New sexual problems were reported in 9 patients (23%) after vaginal hysterectomy, 8 patients (24%) after subtotal hysterectomy, and 12 patients (19%) after total abdominal hysterectomy.
- There was a nonsignificant trend toward higher prevalence of arousal and lubrication problems after subtotal hysterectomy and total abdominal hysterectomy, compared with vaginal hysterectomy.