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.