Hysterectomy
Chapter 2
Hysterectomy and Sexuality
Ester Illiano1*, Konstantinos Giannitsas2,
Elisabetta Costantini1
1
Urology and Andrology Clinic, Department of Surgical
and Biomedical Science, University of Perugia, Italy
2
Department of Urology, University Hospital of Patras,
Rio, Greece
*
Corresponding Author: Ester Illiano, Urology and An-
drology Clinic, Department of Surgical and Biomedi-
cal Science, University of Perugia, Piazzale Gambuli 1
CAP06151, Italy, Tel: +393283620614; Email: ester.il-
liano@inwind.it
First Published June 07, 2016
Copyright: © 2016 Ester Illiano, Konstantinos Giannitsas
and Elisabetta Costantini
This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which per-
mits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original
author(s) and the source.
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Hysterectomy
Introduction
“Hysterectomy” which means “surgical removal of the
uterus”, can be done by the vaginal, abdominal and laparo-
scopic or robotic route. The term “total hysterectomy” re-
fers to the surgical removal of the entire uterus with its cer-
vix, while the term “subtotal hysterectomy” to the surgical
removal of only the body of the uterus. In premenopausal
women the majority of hysterectomies are performed for
benign diseases (fibroids, heavy bleeding, endometriosis/
adenomyosis), while after the menopause most hysterec-
tomies are performed for pelvic organ prolapse. A small
percentage of these operations are performed for endo-
metrial and cervical cancer [1]. Indeed, in the USA about
600.000 hysterectomies are performed annually, of which
almost 90% are elective for benign conditions [2]. Hys-
terectomy is a particular type of surgery, which can influ-
ence the patients’ future life. In fact deciding to undergo
hysterectomy is a difficult process for every woman, es-
pecially psychologically. Women should be informed on
the surgical procedure, and carefully counselled on avail-
able options, in order to make a decision that is right for
them, taking into account their desires and expectations.
It is important that patients understand the implications
of this type of surgery on their reproductive system, so
that they are prepared for any side effect. Unfortunately,
the impact of hysterectomy on sexual function is un-
clear and the estimated prevalence of sexual dysfunction
in women after hysterectomy varies widely among stud-
ies, mainly due to methodological differences. Certainly
hysterectomy outcomes depend on many factors and
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Hysterectomy
this also explains variations in post-hysterectomy sexual
dysfunction incidence. For example pre-operative sexual
problems is a strong predictor of post-operative ones [3].
Rates of post- hysterectomy sexual dysfunction in women
preoperatively normal sexual function are estimated to be
only 5–11% for decreased sexual desire, 2–11% for low or-
gasm, 2–7% for dyspareunia and 9–21% for vaginal dry-
ness [3,4,5]. Nevertheless, the anatomical and hormonal
changes that take place with hysterectomy may explain the
occurrence of sexual dysfunctions even in preoperatively
normal women.
Anatomical Changes with
Hysterectomy
Hysterectomy can affect different phases of sexual
activity. One of the anatomic changes with hysterectomy
may be the absence of the cervix, in cases of total hyster-
ectomy. During penetration, for example, the cervix plays
an important role. In fact some women who had their cer-
vix removed with hysterectomy may have discomfort at
penetration. The benefits and disadvantages of cervix re-
moval or preservation during hysterectomy have been in-
vestigated in many studies. Learman [6], in a randomized
study, found no differences in bowel/bladder function,
quality of life or sexual dysfunction between abdominal
total hysterectomy and subtotal hysterectomy. Gorlero
[7] compared abdominal subtotal hysterectomy and total
hysterectomy, and found that in both groups there was an
improvement of sexual function, quality of life and body
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Hysterectomy
image; however, body image was significantly better in
subjects who underwent subtotal hysterectomy. These re-
sults were confirmed by Flory [8] in a study comparing
laparoscopically assisted total vaginal hysterectomy and
laparoscopic supracervical hysterectomy. In both groups,
sexual drive, arousal, and sexual behaviour significantly
improved postoperatively. Similarly Schiff [9], in a pro-
spective study, showed that women had high sexual sat-
isfaction after total or subtotal hysterectomy. Thakar et al.
[10] compared total to subtotal abdominal hysterectomy
and showed that at9 years of follow-up the frequency, de-
sire, initiation of intercourse and sexual function were not
significantly different between the groups. These results
were reproduced by Andersen [11] in even longer-term
follow-up (14 years) after hysterectomy for benign condi-
tions. In a prospective study [12] abdominal, vaginal, lap-
aroscopically- assisted vaginal, laparoscopic supracervical
or total hysterectomy were compared. Also in this case no
difference was observed between groups in the prevalence
of hypoactive sexual desire disorder. In contrast, Saccardi
[13], in a retrospective study, found that women after lap-
aroscopically assisted subtotal hysterectomy experienced
faster improvement in their sexual activity and had less
pain during intercourse at 3 months after surgery com-
pared to women who underwent total hysterectomy. An-
other prospective study [14], showed a higher sexual de-
sire or improvement in sexual life in women after subtotal
hysterectomy.
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Hysterectomy
Another important anatomical change with hysterec-
tomy is the reduction of total vaginal length. The effects of
different types of hysterectomy on total vaginal length and
sexual function remain unclear. Abdelmonem [15] in his
prospective study showed that after vaginal hysterectomy
total vaginal length is shorter than after abdominal hys-
terectomy and consequently dyspareunia was more com-
mon in the second group. De La Cruz [16] found that after
vaginal hysterectomy total vaginal length is shorter than
robotic hysterectomy, but the Pelvic Organ Prolapse/Uri-
nary Incontinence Sexual Function Questionnaire score
does not differ significantly. Conversely Tan [17] showed
that there aren’t any differences in postoperative total vag-
inal length between abdominal hysterectomy and vaginal
hysterectomy.
The uterus and cervix which both have contrac-
tile properties play an important role in the physiology
of orgasm and sexual arousal. During the first phase of
orgasm there are contractions of the smooth muscles
of the Fallopian tubes, uterus and paraurethral gland of
Skene. During the second phase there are also contrac-
tions of the striated muscles of pelvic floor, perineum, and
anal sphincter. Following these contractions, the sensory
stimuli reach the brain and they are translated in orgasmic
sensation [18,19]. No recent work has directly examined
this phenomenon.
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Hysterectomy
Hysterectomy appears to be responsible for altera-
tions invaginal lubrication during intercourse. The auto-
nomic nervous system (originating from the hypogastric
and sacral plexus) provides the innervation to the internal
genital organs and is critical to normal sexual function-
ing, while somatic sensory innervation is provided by the
pudendal nerve. These structures can be damaged during
hysterectomy, especially during the excision of the cervix
and separation of the uterus from its supportive ligaments
[20,21]. Apart from the innervation, vascular supply can
also be injured: trauma to the arterial branches supplying
the vagina and clitoris causes a reduction to blood flow,
further aggravating the loss of sexual sensation and sexual
arousal. This problem is particularly common with hyster-
ectomy for cancer, where tissue removal is wider [21] and
damage to the inferior hypogastric plexus, located at level
of cervix and lateral vaginal fornix, is more likely. Sexual
arousal results in increased vaginal lubrication, vaginal
wall engorgement and increased clitoris length and diam-
eter. Damage of sympathetic and parasympathetic nerves
as well as to blood vessels leads to reduced lubrication and
impaired vasocongestion. This explains why women, es-
pecially after radical hysterectomy, complain of decreased
vaginal lubrication and genital swelling (Figure 1).
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Hysterectomy
Figure 1: Anatomical changes with hysterectomy.
Hormonal Changes after
Hysterectomy
Surgical castration in premenopausal women is re-
sponsible for sexual dysfunction. Perimenopausal women
following hysterectomy with oophorectomy present men-
opausal symptoms like depression, anger, communication
disorder, and low self-esteem, which may aggravate the
impact of surgery on sexual functioning. With menopause
thinning and loss of elasticity of the vaginal mucosa oc-
cur, as well as shortening of vaginal fornix. These changes
cause pain and dryness that preclude sexual intercourse
[22]. Surgically induced menopause is characterized by
decreased estrogen and androgen levels. Decreased estro-
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Hysterectomy
gen levels lead to reduced vaginal lubrication and dyspare-
unia [21], and cause fibrosis of the clitoris which dimin-
ishes its sensitivity [22] (Figure 2). Androgen deficiency
can be responsible for reduced libido and sexual arousal
(Figure 2). The afore mentioned hormonal changes are
clinically evident after total hysterectomy in premenopau-
sal women, while in postmenopausal women hormonal
levels don’t change, because a physiological ovarian fail-
ure has already developed at menopause [21] Chen [23]
showed that patients at menopausal transition period with
benign diseases prefer ovary preservation. This is prob-
ably explained by the fact that ovaries can produce andro-
gens after menopause, allowing women to maintain libido
and reach orgasm [21]. Teplin et al [24] compared subto-
tal and total hysterectomy. There were differences in the
immediate postoperative period for those who underwent
bilateral salpingo-oophorectomy, but these differences ap-
peared to diminish with time.
Figure 2: Hormonal changes with hysterectomy.
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Hysterectomy Hysterectomy

Psychological Impact of would have the tools to participate in the decision of their
wives, to assist them after surgery, and help them face any
Hysterectomy sexual problems. For example, husbands should realize
The incidence of depression following hysterectomy
that in the immediate 6 to 8 week post-operative period,
depends on many factors, including desire for having
when sexual intercourse is not recommended, non-pen-
more children, mental health before the surgery,; degree of
etrative activity such as hugging and kissing, is absolutely
symptom relief and post-operative complications or side
necessary to keep the closeness and intimacy alive, and are
effects. Signs of depression are typical: prolonged feelings
advised to encourage it . The psychological impact of hys-
of sadness and hopelessness, significant appetite loss or
terectomy also depends on mental health before surgery.
gain, insomnia, fatigue and thoughts of death or suicide.
Several studies have shown that the presence of psychi-
The alteration of body image due to hysterectomy may in-
atric symptoms before surgery is associated with sexual
fluence sexual life. In fact removal of the uterus is asso-
problems after hysterectomy [3,26]. The psychological im-
ciated with loss of self-esteem and femininity (Figure 3).
pact of hysterectomy also explains why sometimes, despite
The negative impact of hysterectomy on body image is of-
the improvement of preoperative symptoms, women have
ten correlated with the presence of the abdominal surgical
no sexual satisfaction after hysterectomy. It is frequently
scar or hormonal changes [17]. In this situation the role of
observed that despite improvements in dyspareunia and
the husband is important. Women who had a difficult re-
vaginal pain, the overall satisfaction with the sexual re-
lationship with the partner before hysterectomy, are often
lationship does not change. Kuscu [27] Meston [28] and
less able to resume a healthy sexual activity. For example,
Anonymous [29] showed no changes in sexual satisfac-
Helstrom [25] showed that the most frequent reason for
tion after hysterectomy compared to before surgery. If
deterioration in sexual functioning after hysterectomy is a
psychological factors are also taken into account the re-
poor or absent relationship with the partner. Beside that,
sults change. Sözeri-Varma [30] and Tangjitgamol [31]
many women also fear also their partners will see them dif-
reported that patients’ sexual satisfaction decreased after
ferently following hysterectomy. Hoga [26] showed a wide
the surgery, and Badakhsh [32] found a decrease in the
variation in the experiences of the husbands. In general,
percentage of people with sexual satisfaction, caused by
the husbands are the wives’ main caregivers, and therefore
psychological changes following the operation as well as
they should be informed about hysterectomy, its compli-
increased vaginal dryness. It has to be mentioned though
cations and its impact on female sexuality. In this way they
that sexual satisfaction is subjective and difficult to define.

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Hysterectomy
The term ‘sexual satisfaction’ describes a person’s level of
satisfaction and pleasure in a sexual relationship [33]. In
the literature rates of sexual satisfaction vary widely, as
different methods are used to assess it (e.g. face-to-face
interviews, interviews over the telephone, follow-up stud-
ies), and define it based on levels of orgasm, sexual inter-
est and frequency of intercourse. Sexual satisfaction rates
are also influenced by other factors, like age, race, mental
status, relationship dynamics, and economic conditions
[34]. Sexual satisfaction after hysterectomy is also influ-
enced by levels of sexual satisfaction before surgery.
Figure 3: Psychological changes with hysterectomy.
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Hysterectomy
The Effect of Hysterectomy on
Frequency of Sexual Intercourse
Ewert [35] and Coppen [36] showed an increase in
frequency of sexual intercourse after hysterectomy. Simi-
larly Rhodes [3] found that the frequency of sexual en-
counters increased after surgery, from a mean of 2.3 per
month before hysterectomy, to 3.1 and 2.9 at 12 and 24
months, respectively. Kilkku [37] showed a non-signifi-
cant decrease in the frequency of sexual activity after hys-
terectomy. The frequency of sexual intercourse depends
on many anatomical and psychological factors, especially
the interactions among emotional well-being, intimacy
with the partner, quality of life and physical health.
The female sexual response cycle is a 3- phase model,
consisting of desire, arousal and orgasm. Hysterectomy
via anatomical and psychological factors can have effects
that vary from one phase of the cycle to the other and
from woman to woman leading to changes in sexual sat-
isfaction.
Results of Studies on the Effects of
Hysterectomy on Sexual Desire are
Contradictory
Rhodes et al [3], in a prospective study of a popula-
tion of 1101 women who underwent hysterectomy (vagi-
nal or abdominal) for benign conditions, showed that the
frequency of desire increased significantly post-surgery.
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Hysterectomy
Indeed more 70% of women with low sexual desire before
hysterectomy reported an improvement at 12 months af-
ter surgery. There was a significant decrease in the prev-
alence of low libido from 10.4% before hysterectomy to
6.3% and 6.2% at 12 and 24 months after surgery, respec-
tively. Similar findings were also reported by Gutl’s study
[38], in which low libido, significantly decreased after
the hysterectomy. On the contrary Dragisic [39] and Ra-
himzadeh [40] reported that most of the patients did not
experience any change in their libido after hysterectomy.
Similarly Meston [28] showed that there weren’t any dif-
ferences inlibido between a control group and a group of
women who underwent hysterectomy for benign disease.
On the other hand, Zafarghandi [41], Lonnée [42] and Ba-
yram [43] found that sexual desire decreased significantly.
Tangjitgamol et al. showed that sexual desire is affected
more than any other sexual aspect of sexual functioning
[31].
Figure 4: Effect of hysterectomy on sexual activity.
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Hysterectomy
The Effect of Hysterectomy on Sexual
Arousal
Goetsch [44] in his prospective study showed that
75% of women had higher sexual arousal after hysterec-
tomy (abdominal or vaginal). This report is contradicted
by findings of many other studies [29,31,41,44-45] which
have shown a decrease in sexual arousal after surgery
which they attribute to vaginal dryness and inadequate
vaginal lubrication. Maas [45] found that women after
radical hysterectomy had a significant decrease in maxi-
mum vaginal pulse amplitude during subjective sexual
arousal.
Also increasing age, depression and psychosocial fac-
tors are the most frequently reported predictors of arousal
dysfunction.
The Effect of Hysterectomy on
Orgasm
Some prospective studies have shown improvement
of orgasm after hysterectomy [3,32,46]. Rhodes et al [3],
for example, showed that the frequency and intensity of
orgasm 12 months after surgery are equal to or grated
than the preoperative in 83.3 % and 84.6%, respectively,
of women able to reach orgasm before hysterectomy. The
percentage of women unable to achieve orgasm decreased
significantly from 7.6% before surgery to 5.2% and 4.9% at
12 and 24 months after hysterectomy respectively [3]. Low
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Hysterectomy
orgasm at 12 months postoperatively was associated with
not experiencing orgasms before surgery [3]. Coppen and
Virtanen in their prospective study showed that the fre-
quency of orgasm doesn’t change after surgery [36,47].
Goetsch [44] conducted a study on 105 women who un-
derwent total hysterectomy (vaginal or abdominal), and
also found that the intensity of orgasm after surgery was
similar to or greater than that before hysterectomy, regard-
less of the route for hysterectomy. Dennerstein in a retro-
spective study found that 75% of women after hysterecto-
my showed an improvement or no change in their ability
to achieve orgasm [48]. In contrast to the aforementioned
studies Rahimzadeh [40] and Tangjitgamol [31] showed
that hysterectomy may cause a decrease in pleasure with
inter course and in the frequency of orgasm. Kilkku found
that one year after hysterectomy 46.7% of women had in-
frequent orgasm compared to 29.7% before surgery [37].
He also reported that the rate of difficulty in reaching or-
gasm was slightly higher, but not statistically significant,
in women who had transvaginal hysterectomy compared
to women who had abdominal hysterectomy [37]. Predic-
tors of decrease in frequency of orgasm include age [48,3],
vaginal dryness [29], depression [3], and bilateral oopho-
rectomy [31,3].
Hysterectomy, POP and Sexuality
The debate on the effect of uterus-preserving pelvic
organ prolapse (POP) repair on sexuality is still open.
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Hysterectomy
Costantini et al [49,50,51] in two studies showed that
uterus-sparing colposacropexy is feasible in women who
want to preserve vaginal function, and improves the sex-
ual functioning. Indeed there was an improvement in the
total Female Sexual Function Index score as well as in the
domains of desire, arousal and orgasm [52], in the uterus
sparing group compared to the non- uterus sparing group.
Siddiqui [53] showed that after anterior-posterior colpor-
rhaphy without hysterectomy vaginal length was shorter
and the frequency of dyspareunia is higher compared with
anterior–posterior colporrhaphy, with vaginal hysterecto-
my. However, no significant differences in resulting sexual
function were observed between two groups. De La Cruz
[16] in a retrospective study confirmed these results. In
this study vaginal length was shorter after vaginal hyster-
ectomy with uterosacral ligament suspension compared to
robotic-assisted hysterectomy with colpopexy, but sexual
function did not differ between the two groups. The afore-
mentioned results suggest that despite the fact that after
hysterectomy during POP repair vaginal length is shorter,
it doesn’t necessarily cause worsening of sexual activity.
This can be explained by the improvement in symptoms
of vaginal bulging with POP repair which are known to
negatively impact sexual activity.
Conclusion
In conclusion is uterus important for a sense of self? It
depends on how each woman livesherage, and self-image.
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Hysterectomy
Virtually every woman expresses concerns, if not
to her doctor, to her partner, or even her self about how
hysterectomy will affect her sexual function, desire, and
desirability. Unfortunately, studies have shown that only
half of gynecologists initiate a discussion of sex. A lot of
women who worry about their postoperative sexuality do
just that – worry!!We need to develop appropriate tools
to evaluate sexual function and body image perception in
women and we must speak with our women about their
sex life.
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