To evaluate sexual functioning and expected changes in sexual functioning in women with planned total versus subtotal laparoscopic hysterectomy.
A total of 120 women undergoing laparoscopic hysterectomy were preoperatively enrolled in this study with a cross-sectional design. Full data sets were available for 112 patients, so that 56 patients with planned total laparoscopic hysterectomy (TLH) and 56 women with planned laparoscopic supracervical hysterectomy (LASH) were preoperatively assessed. Sexual functioning was evaluated using the female sexual function index (FSFI). Additionally, participants filled in a standardised questionnaire concerning expected changes on sexual function after the procedure. Demographic parameters, expectations concerning postoperative sexuality and FSFI scores were analysed and compared in women undergoing TLH and LASH.
There were no significant differences concerning demographic parameters and FSFI scores comparing collectives. Sexuality in general was considered more important in women undergoing LASH (2.88 ± 0.83 vs. 2.48 ± 0.89; p = 0.011). Also, in 29 patients (52%) opting for LASH and 8 (14%) patients undergoing TLH a potential change in postoperative sexuality had an impact on their choice for a subtotal/total hysterectomy, respectively (p < 0.001).
Patients’ expectations concerning preservation of the cervix and postoperative sexuality appear to have the potential to bias investigations comparing total with subtotal hysterectomy. Hence, future research focusing on this issue should be accomplished incorporating patients’ expectations stratified by mode of intervention.
As hysterectomy constitutes the most frequent major gynaecological surgery, it is inevitable to continuously optimise surgical strategies, focusing on patient-related outcome.
In general, vaginal (VH) and laparoscopic hysterectomy (LH) are associated with proven advantages over abdominal hysterectomy . These are primarily less perioperative complications, shorter length of hospital stay, improved short-term quality of life and faster return to normal activities . Hence, VH and LH have to be considered treatment of choice, apart from few exceptions (e.g. large uterine size, expected difficulties regarding exposure).
Concerning LH for benign reasons, both subtotal as well as total extirpation of the uterus have evolved to standard surgical procedures. However, with an increase in laparoscopic hysterectomies throughout the last decades, a considerable increase in subtotal hysterectomies can be observed . As, to this point of time, there are no proven benefits comparing subtotal with total hysterectomy, the preservation of the cervix is matter of an ongoing scientific debate. While subtotal hysterectomy seems surgically less demanding, long-term prospective randomised trials showed no differences concerning pelvic organ prolapse, urinary, sexual or bowel function, so that the increase in subtotal hysterectomies has to be considered unwarranted [2,3,4].
Approximately, 85% of hysterectomies are elective surgeries due to benign pathologies in predominantly sexually active women [2, 5]. Theoretically, it appears plausible that a hysterectomy might have an impact on postoperative sexuality—especially if the uterus is totally removed. There exist multiple hypotheses dealing with this topic, such as dyspareunia due to shortening of the vaginal vault, alteration of the uterovaginal innervation, vaginal dryness due to missing cervical mucus, e.g. [6,7,8]. Considering these circumstances and the fact that sexuality can have a significant effect on quality of life, it does not surprise that almost one half of women undergoing hysterectomy fears postoperative changes in sexuality, constituting the most frequent preoperative anxiety in this context . Hence, sexual functioning might serve as a pivotal surrogate parameter to evaluate and compare clinical outcome of hysterectomy procedures due to benign uterine pathologies . Accordingly, research throughout recent years focused increasingly on post-hysterectomy sexuality, comparing the total with the subtotal laparoscopic route with heterogeneous results.
Furthermore, it is known that patients’ predictions of postsurgical outcomes have a major influence on the actual outcome [11, 12]. Patients’ expectations have been identified as prominent factors influencing postsurgical emotional functioning, pain, recovery, disability and functional status as well as return to work [12,13,14].
Consequently, an analysis of patients’ expectations concerning the influence of the preservation of the cervix on postoperative sexuality as the major perioperative anxiety in laparoscopic hysterectomy might elucidate current heterologous data. To our knowledge, this is the first investigation to address this issue.
Materials and methods
After approval by the Ethics Committee II of the University Medical Centre Mannheim, Heidelberg University, Germany (2012-602N-MA), a total of 112 women who underwent laparoscopic hysterectomy between 01/2014 and 12/2015 at the University Medical Centre Mannheim, Heidelberg University and the Day Clinic Altonaer Strasse, Hamburg, Germany were included in this study. The investigation is registered in the German Clinical Trial Register (DKRS) with the clinical trials registration number: DRKS00004677. The participant women received either total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LASH). The choice of the type of surgery was based on informed consent and shared decision making.
Preoperatively patients were informed in a standardised way (written “patient information” approved by the Ethics Committee and orally by more than one physician) that there exists no scientific evidence that either surgical approach was beneficial (in terms of pelvic organ prolapse, urinary, sexual or bowel function, e.g.). Given this information, patients had complete choice of surgical approach.
Sexual functioning was assessed using the validated Female Sexual Function Index (FSFI) . The FSFI provides scores in six domains (desire, arousal, lubrication, orgasm, satisfaction, pain) summing up in a total score. Furthermore, a standardised questionnaire addressing patients’ opinion and expectations concerning sexuality after the procedure and the role of preservation of the cervix undergoing hysterectomy was used. The questionnaires were filled in by patients at least 24 h preoperatively after written informed consent was obtained.
Demographic parameters as well as sexuality related items (stable sexual partner, marriage, e.g.) were assessed. The FSFI scores and expectations for possible changes in sexuality were analysed comparing collectives.
All data have been stored in an ms excel sheet. After careful check for false data entry, the data were imported into SPSS® (Version 22; SPSS Inc., USA). Data were presented as mean ± standard deviation, respectively, frequencies separately for each group. The FSFI scores and expectations for possible changes in sexuality were analysed comparing collectives using univariate significance test (t test and Chi square test). A p value below 0.05 was considered statistically significant.
Full data sets were available for 112 patients, so that 56 patients with planned TLH and 56 women with planned LASH were preoperatively enrolled. Comparing collectives, there were no significant differences concerning menopausal—(p = 0.274) and smoking status (p = 0.556), chronic diseases (p = 0.334) and drug use (p = 0.694) as well as prior abdominal surgeries (p = 0.842).
Demographic parameters and indication for surgery of women who underwent LASH compared to women who underwent TLH did not differ significantly, as shown in Table 1. The majority of patients suffered uterine fibroids [LASH: 44 (79%), TLH: 32 (57%)] or bleeding disorders [LASH: 5 (9%), TLH: 12 (21%)]. Sexuality in general (measured with a five point likert-scale [rating scores ranging from 0 (unimportant) to 4 (very important)] was significantly more important for women who underwent LASH (LASH: 2.88 ± 0.83, TLH: 2.48 ± 0.89; p = 0.011). In both groups (LASH/TLH), the way/s to reach an orgasm were comparable as 30 women (53%) in both groups reached orgasm clitorally, 20 (36%)/18 (32%) vaginally and clitorally, 5 (9%)/6 (11%) vaginally and only 1 (2%)/2 (4%) did not reach orgasm at all (p = 0.912).
Forty women undergoing LASH (71%) and 30 women of the TLH collective (54%) scrutinized whether a hysterectomy may influence postoperative sexuality (p = 0.051). In patients undergoing LASH, a potential change in sexuality after hysterectomy had significantly more often an impact on their choice on mode of surgery (LASH: 29 (52%) vs. TLH: 8 (14%); p < 0.001). There were no differences regarding complaints during sexual intercourse as a reason for hysterectomy, whereas the majority of both collectives expected that a hysterectomy results in an increased frequency of sexual intercourse (LASH: n = 37 (66%) vs. TLH: n = 46 (82%); p = 0.126). Results of the standardised questionnaires are depicted in detail in Table 2.
Regarding the frequency of sexual activity, 13 women (23%) undergoing LASH vs. 16 women (29%) undergoing TLH had sexual intercourse once a month or less, 32 (57%) vs. 25 (45%) had sex once a week up to once in a month and 11 (20%) vs. 15 (27%) had sex more than once a week (p = 0.410), respectively.
The results of the FSFI score including the sub-scores desire, arousal, lubrication, orgasm, satisfaction and pain showed no significant differences in both groups, as depicted in Table 3.
Reviewing literature focusing on post-hysterectomy sexual functioning comparing laparoscopic subtotal versus total hysterectomy reveals heterologous results. Generally, literature addressing this topic is scarce, with only few prospective investigations reporting on sexual outcome. To the best of our knowledge, there exists no investigation focusing on patients’ expectations on postoperative sexuality stratified by mode of hysterectomy.
A Cochrane review of total versus subtotal hysterectomy for benign gynaecological conditions revealed no differences concerning urinary, sexual or bowel function . As four of the six studies included in this analysis compared subtotal with total abdominal hysterectomy, authors state that the review was underpowered to detect differences concerning the lapaparoscopic route.
In a prospective randomised investigation, Flory et al. assessed postoperative sexual and psychological functions after laparoscopically assisted vaginal hysterectomy versus LASH in 63 premenopausal women with benign uterine pathologies . Authors found either way of hysterectomy to result in an improved sexuality without changes in psychological functioning.
Radosa et al. addressed the same topic in a similarly designed prospective but non-randomised investigation, focusing on sexual functioning and quality of life comparing VH, TLH and LASH in 237 women . After a follow-up of 6 months, all procedures led to an improved sexual functioning and quality of life, regardless of surgical the technique used.
Contrarily, comparing sexual health and psychological wellbeing in a prospective randomised trial, Ellström Engh et al. found that women undergoing subtotal hysterectomy (n = 66) reported greater positive changes in frequency of orgasm and sexual pleasure than women with total hysterectomy (n = 66) . Also, prospective investigations by Lieng and Lyons et al. found a comparable improved sexual functioning after subtotal hysterectomy [18, 19].
As stated above, patients’ expectations have been identified as prominent factors influencing postsurgical emotional functioning, pain, recovery, physical disability and functional status in other than gynaecologic procedures [12,13,14]. A prominent example is a prospective double-blind investigation by McRae et al. . Authors found that the patients’ expectancy concerning a surgery patients perceived (regardless of whether they perceived it or not) had a major influence on postinterventional outcome.
Concerning hysterectomy, it is known that almost one half of women undergoing hysterectomy fears postoperative changes in sexuality, constituting the most frequent preoperative anxiety in this context . In a cross-sectional survey of 115 women who had undergone hysterectomy, Pouwels et al. retrospectively assessed factors possibly influencing the decision-making process on the type of hysterectomy (total or supracervical) and the impact of surgery on subsequent sexual function . Patients reported that the main reason regarding decision to remove or retain the cervix (79%) was the physician’s recommendation, followed by concerns regarding future sex life (51%). Furthermore, almost half of the women reported that hysterectomy had no impact on sexual function as there were no statistically significant differences between collectives regarding satisfaction with sexual function or impact on sexual function, using a non-standardised questionnaire. Concerning patients’ expectations, the authors did not differentiate between collectives, neither did they validate if the expectations, that the type of surgery would have an impact on post-hysterectomy sexuality, had an effect or not. However, they did show that concerns about sexual health were important to women when considering the type of hysterectomy to undergo.
As stated above, to our knowledge this is the first investigation to analyse patients’ expectations concerning preservation of the cervix stratified by mode of intervention with a cross-sectional design. Like Pouwels and Dennerstein et al. before, we also found as a trend that women scrutinise if the removal of the cervix has an impact on postoperative sexuality: 40 (74%) patients of the LASH and 30 (54%) of the TLH collective dealt with this question before (p value =0.051). Sexuality was considered significantly more important in women choosing LASH (p = 0.0119). Additionally, an expected change in sexuality after hysterectomy had significantly more often an impact on women opting for LASH compared to patients of the TLH collective (p < 0.001) and this was true although both groups reported a comparable satisfaction with sexuality. In our opinion, these results underline the fact that patients’ expectations concerning mode of hysterectomy appear to have a high impact not only on the patients’ choice regarding the surgical procedure, but may also bias results if not taken into consideration.
To date, there is no evidence that the preservation of the cervix in hysterectomy has positive effects on postoperative sexuality, as existing data are heterologous. As we could show, women undergoing LASH attach more importance to sexuality, and the potential change in sexuality after hysterectomy has higher impact on the choice of mode of surgery in women preferring LASH compared to women undergoing TLH. This is the first investigation focusing on patients’ expectations in this context. Future research focusing on this issue is necessary and should be accomplished incorporating patients’ expectancies stratified by mode of intervention.
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Conflict of interest
All authors declare that they have no conflict of interest.
The study was approved by the Ethics Committee II of the Medical Faculty Mannheim, Heidelberg University (2012-602 N-MA). The study is registered in the German Clinical Trial Register (DKRS) with the clinical trials Registration Number: DRKS00004677.
Informed consent was obtained from all individual participants included in the study.
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Cite this article
Berlit, S., Lis, S., Jürgens, S. et al. Postoperative sexual functioning in total versus subtotal laparoscopic hysterectomy: what do women expect?. Arch Gynecol Obstet 296, 513–518 (2017). https://doi.org/10.1007/s00404-017-4452-3
- Laparoscopic hysterectomy
- Patient expectations