Sexual Dysfunction after Hysterectomy
Irwin Goldstein, MD
The sexual medicine information session was held the day after our troops went into battle, but people in attendance were totally focussed on Dr. Goldstein’s lecture “Sexual Dysfunction Following Hysterectomy”. The talk opened with a discussion of sexual medicine in general, and specifically women’s sexual health.
Facts about Hysterectomy
Indications for hysterectomy are cancer, bleeding with childbirth and severe infection with uterine damage, all of which make up about 10% of cases; the other 90% are made up of medical, non-surgical and other surgical reasons, such as for menstrual cramps, heavy bleeding and fibroids. There are 3 types of hysterectomy: partial, where the cervix is left intact, complete, where the cervix is removed (the most common procedure) and radical, for cancer, where the lymph nodes and supporting structures are also removed. The uterus can be removed abdominally, vaginally or by LAVH, laparascopically assisted vaginal hysterectomy. If necessary, the ovaries can be removed through the vagina unless there is cancer. Removing the ovaries causes surgical menopause, and women have traditionally been prescribed estrogen therapy, but now there is a fear of this. In the US 600,000 hysterectomies are performed annually, triple the rate of the rest of the world. ACOG (American College of Obstetrics and Gynecology) describes hysterectomy as a treatment of last resort. Before having a hysterectomy, you should find out the reason for it, treatment options, and long term side effects. Side effects of hysterectomy can include depression and loss of sexual response or desire. Most physicians do not think twice about the sexual side effects associated with hysterectomy. Desire, arousal, orgasm and pain disorders may all be seen post-hysterectomy. Despite this, of the 1200 women seen to date at the Center for Sexual Medicine, very few have presented after hysterectomy. Kilkku et al looked at post-hysterectomy patients, and found that among the women who kept their cervix there was no loss in function, but when the cervix was removed, patients complained of sexual dysfunction. Rhodes et al found that post-hysterectomy patients actually had better sexual function. Even if the woman maintains her ovaries, sometimes the blood supply to the uterus is cut off. Internal orgasms are often changed significantly after hysterectomy. This is observed in part due to the inability to have rhythmic contractions of uterine muscles without the uterus present. Also internal orgasms are changed after hysterectomy due to injury to the nerves which pass near the cervix. Surgeons should try to spare these nerves, but efforts to spare them are limited at the present. The result is that after hysterectomy, many women lose the ability to have an internal orgasm. Reports suggest that if the uterine cervical ganglia were spared during cervix-sparing hysterectomy, sexual function would be preserved.
History, Physical and Lab Findings
The evaluation process for women with sexual dysfunction includes identification of the dysfunction, patient education, modification of reversible factors and first line therapy. The history should include a sexual function history, medical history and psychosocial history. The examination should include both the vulvar region and an internal physical exam. A sexual medicine doctor is a vulvar specialist, whereas the gynecologist usually examines the region beyond the vulvar area. Dr. Goldstein showed some photographs of women with a normal vulvar region as well as some of pathology. Specialized sexual medicine tests include genital biothesiometry, thermal testing, and duplex doppler ultrasonography. A questionnaire gives the sense of orgasmic function, which can be compared with the results of sensation testing.
Women have limited amounts of sex steroid prior to puberty. Post-puberty if the specific zone of the adrenal gland – the zona reticularis – stops working, you will have sex steroid insufficiency hormonal problems. As women age the sex steroids stop being synthesized and hormone levels return to those found pre-puberty. Removing the ovaries in animals up regulates estrogen receptors and down regulates androgen receptors. Testosterone in sexually healthy women is higher than in sexually dysfunctional women—suggesting that in some women sexual dysfunction has a biologic basis, a result of enzyme abnormalities, and is not exclusively psychologic. Treatments include DHEA, which has resulted in better SDS (Sexual Dysfunction Score) and FSFI (Sexual Function) scores, androstenedione and testosterone. A study of testosterone treatment after oopherectomy (ovaries removed) showed that testosterone was beneficial for sexual function. Estrogen therapy or birth control pills send estrogen to the liver that then produces SHBG (sex hormone binding globulin) which binds with free testosterone. Without this free testosterone available, the woman has androgen insufficiency. Testosterone therapy also converts to estrogen so women in transition from peri-menopause to menopause who have vasomotor symptoms (hot flashes, night sweats) and low androgens don’t need to take additional estrogen – they can take androgens. The vagina and labia need estrogen to maintain their health, or they become atrophied. There are estrogen pills that can be put directly into the vagina where the estrogen does not go systemic. It has been shown in animals that Viagra in women increases vaginal blood flow if the hormones are functioning. In perimenopause you may not have enough progesterone, which causes excessive bleeding, and is a common reason why hysterectomy is performed. Progesterone cream is easy to use. Estrogen, androgen and/or progesterone therapy should be tailored to each person. With vacuum clitoris therapy the device suctions the clitoris which increases blood flow into the area. Vulvar surgical intervention may be indicated for pain. Dr. Goldstein showed photographs of some of these surgical procedures. Surgical therapy has been shown to be better than biofeedback or behavioral therapy alone, but since each has benefit, it is best to do all three therapies for women who have sexual pain.
Attention should be paid to this–research and funding are needed.