Sexuality After Hysterectomy Anne Katz, RN, PhD

Transcription

1 IN REVIEW Sexuality After Hysterectomy Anne Katz, RN, PhD Objective: To review the literature regarding sexuality after hysterectomy and identify areas for future research. Data Sources: Articles published between 1970 and 2000 on sexuality and hysterectomy were located using MEDLINE, CINAHL, Psychlit, and Sociofile databases. Study selection: English language research dealing with the topic was reviewed. Data Extraction: Study findings were categorized and include studies of the effect of hysterectomy on sexuality, women s perspectives on hysterectomy, and information sharing with women prior to surgery. Data Synthesis: A number of studies have explored sexuality after hysterectomy. Many of these studies have methodologic flaws, including vague measures of sexual satisfaction and potential for recall bias. A major source of bias is that the first measure of sexual satisfaction/functioning was performed in the immediate preoperative period when symptoms are more likely to affect sexual functioning. Conclusions: There are a number of gaps in the knowledge base pertaining to this topic. Future research in this area is needed to provide direction for nurses in the clinical area. Topics for future research include what women and their partners want to know about sexuality following hysterectomy and the most efficient methods to provide them with this information. In addition, sexuality in premorbid women needs to be more fully described. JOGNN, 31, ; Keywords: Hysterectomy Sexual history taking Sexuality Sexuality counseling Accepted: November 2001 Hysterectomy, the second most frequent surgery performed on women, is exceeded in number only by cesareans. It is estimated that by age 64 years, 40% of women will have had this surgery (Ryan, 1997). Controversy exists about a woman s sexual functioning after this intervention, with some contradictory evidence as to the effects of the surgery on sexual functioning. This article will discuss the findings of these studies and make some suggestions for future research in the area of patient information and education before hysterectomy. Hysterectomy Hysterectomy refers to the removal of the uterus with or without associated structures. This operation may be performed through an abdominal incision or vaginally, in which all incisions are made internally through the vaginal vault (Thakar, Manyonda, Stanton, Clarkson, & Robinson, 1997). More recently, laparoscopic techniques have facilitated removal of the uterus through a number of small incisions in the abdomen and vagina (Ewert, Slangen, & van Herendael, 1995). The procedure may involve removal of the uterus and cervix, termed a total hysterectomy, or removal of the uterus with conservation of the cervix, a subtotal hysterectomy (Thakar et al., 1997). Removal of the ovaries is sometimes performed at the time of the hysterectomy; this is termed an oophorectomy. If this occurs before the woman has reached menopause, an immediate cessation of the production of all ovarian hormones occurs (North American Menopause Society, 2000). Removal of the uterus fundamentally affects the anatomical structures of the pelvic basin, including the bowel, bladder, and nerve supply to the area. Interruption in the nerve supply of the upper vagina is thought to interfere with lubrication and orgasm (Thakar et al., 1997). The surgery is also thought to 256 JOGNN Volume 31, Number 3

2 alter the mobility of the pelvic organs during coitus as well as limiting the ability of the upper vagina to expand during the arousal phase (Helstrom, Backstrom, Sorbom, & Lundberg, 1994). The relationship of the cervix to sexual functioning is thought to be of special importance; Masters and Johnson (1966, p. 117) observed that many women will certainly describe cervical sexual pressure as a trigger mechanism for coital responsivity. Many of the nerves to the pelvic area run through a structure called the uterovaginal plexus, and excision of the cervix may result in damage to this plexus. Changes in sexual arousal and orgasm may follow. Loss of the cervix also may decrease lubrication of the vagina through a lessening of mucous from the cervix. The reduced quantity of sensitive tissue in the area may lead to a decrease in arousal and a reduced probability of multiple orgasms (Naughton & McBee, 1997). For women who feel uterine contractions as a pleasurable part of orgasm, the absence of the organ may negatively affect the experience of orgasm (Allgeier & Allgeier, 1991). However, hysterectomy may increase sexual pleasure for some women as it means that the risk of pregnancy is permanently removed as well as curtailing undesirable symptoms related to menstruation (Anderson Darling & McKoy-Smith, 1993). Controversy exists related to sexuality after hysterectomy, with some contradictory evidence as to the effects of surgery on sexual functioning. The Effect of Hysterectomy on Sexuality When studies on sexuality after hysterectomy are being reviewed, it is important to bear in mind that the reason for the hysterectomy may play an important role in preand postoperative sexual functioning. For women experiencing heavy bleeding or pain due to the presence of uterine fibroids, removal of the cause of the problem will likely have a highly positive effect on sexuality postoperatively. If the reason for the surgery is the excision of cancer in part of the reproductive tract, postoperative sexuality is likely to be affected by both the psychologic effects of a cancer diagnosis as well as the ongoing effects of treatment for the cancer. Historically, the prevailing attitudes toward complaints about sexual functioning after hysterectomy resulted in a minimization of reported sexual changes, and any that were recognized were considered to be psychogenic in etiology. It was thought at the time that the reproductive organs had little connection with libido and sexual gratification. The Freudian view of the loss of sexual organs as a castration led to the belief that hysterectomy would inhibit sexual functioning due to psychologic stress rather than physiologic changes. A lack of understanding of the physiologic changes resulting from removal of parts of the reproductive tract was the basis for the erroneous belief that all women should exhibit the same symptoms after hysterectomy (Zussman, Zussman, Sunley, & Bjornson, 1981). It is now recognized that there is a real and welldescribed physiologic basis for the changes experienced by women after hysterectomy, that not all women experience these changes, and that the nature and extent of these changes are varied. One of the earliest studies of the effect of hysterectomy on libido was performed in South Africa in the 1970s (Utian, 1975). In a small prospective study of women attending an outpatient clinic, it was found that a decrease in libido followed hysterectomy irrespective of whether the ovaries had been removed or not. This decrease in libido was still evident 2 years after the surgery and was significantly different from that of women who had not undergone hysterectomy. Of interest from this early study was the observation that estrogen therapy did not improve libido. Researchers in Finland (Virtanen, Makinen, Tenho, Kiilholma, & Hirvonen, 1993) undertook a prospective study of 102 women who had abdominal hysterectomies for benign conditions. They found that women reported a significant increase in libido following the surgery and no difference in orgasms after the procedure. This study as well as others used relatively crude measures to describe aspects of sexual functioning. In this study, changes in libido and orgasm were rated as normal, increased, or decreased. Anderson Darling and McKoy-Smith (1993) studied the relationship between quality of life and hysterectomy by comparing women who had a hysterectomy with those who had not. Although the study did not show a difference in quality of life between the two groups, the women who had a hysterectomy reported greater sexual satisfaction. The limitations of this study include the use of only college-educated women as the population of interest and that for most of the women, the surgery had occurred on average 10 years before the survey. The major indications for the surgery were heavy menstrual bleeding, uterine fibroids, and other pelvic diseases. Women with cancer were also included in this group. Thus, the reported increase in sexual satisfaction after hysterectomy is likely related to alleviation of symptoms. Helstrom, Weiner, Sorbom, and Backstrom (1994) studied 104 premenopausal women to determine whether mental status affects sexuality both before and after hysterectomy. A secondary reason for the study was to determine if two of the most common reasons for hysterectomy, pelvic pain and heavy menstrual bleeding, had a negative effect on sexuality and if any sexual benefit was May/June 2002 JOGNN 257

3 derived from the surgery. Almost 50% of their sample had a history of psychiatric illness, and 25% were treated for this problem. They found that the only variable that influenced postoperative sexuality was the presence of painful periods. Removal of the uterus had a positive effect on sexuality for these women. This study used measures of sexual activity that were more sensitive, including frequency of sexual desire and coital frequency (less than or once a year, less than or once a month, two to four times a month, once or twice a week, or more than twice a week). In another report of this study, Helstrom (1994) suggested that the most important factor for postoperative sexuality is preoperative sexual functioning, including sexual enjoyment. Helstrom reported on three possible outcomes: those who reported improved sexual functioning postoperatively (n = 52), those who reported no change (n = 30), and those who reported a deterioration in their sexual functioning (n = 22). In the first group, preoperative frequency of sexual intercourse and masturbation was higher than in the other groups. Seventy-three percent of these women reported that for them, sex was more pleasurable, and 14 of this group (27%) stated that they had experienced improved partner relationships after the surgery. This had in turn improved their sexual experiences. Of those who reported no change in their sexual functioning, more than 50% described their preoperative functioning as satisfying and frequent and regarded no change in that as good. The rest of the group had poor preoperative sexual functioning but had experienced no deterioration after the surgery. The most frequent reason for deterioration after the surgery was a poor or absent partner relationship. This included lack of support from a partner and male sexual dysfunction. One of the strengths of this study is that much of the data were qualitative in nature. Recall bias may be a limitation in this study, however, because participants were interviewed 1 year after the surgery. These women all had the same type of surgery (subtotal hysterectomy), which did not involve removal of the cervix. This too may be an influential variable in the outcome, because this type of surgery may be less likely to cause damage to blood and nerve supply. In yet another report of the same study (Helstrom, Lundberg, Sorbom, & Backstrom, 1993), the frequency of the cyclicity of sexual desire was reduced and the frequency of coital activity was increased. The frequency of desire, orgasm, and the multiplicity of orgasm all remained the same for the women in this study. In another small study from Europe (Ewert et al., 1995), women undergoing laparoscopic-assisted vaginal hysterectomy were surveyed postoperatively about their sexual functioning. The vast majority of these women had experienced severe dysmenorrhea (70%) or bleeding (83%) and almost all considered menstruation to be disagreeable. Sexuality, as measured by questions regarding libido, sexual sensitivity, and frequency of sexual intercourse, generally increased or remained the same after the surgery. A limitation of this study is the small sample size (N = 58) and the threat of recall bias, because the questionnaire was mailed to potential respondents 6 to 24 months after the surgery. All the respondents had the same type of surgery. The investigators suggest that the less invasive nature of laparoscopic-assisted vaginal hysterectomy as well as the absence of disfiguring scars may have influenced the outcome. A study of 366 women who had undergone abdominal hysterectomy investigated short- and medium-term outcomes (Clarke, Black, Rowe, Mott, & Howle, 1995). These women reported that preoperatively, their health interfered with their sex life, and that 3 months after surgery, symptoms (pain, bleeding, lack of desire) were less common. Despite this and despite reports of enjoyment of sex 3 months postoperatively, the frequency of sexual activity remained unchanged. Frequency of intercourse is of course dependent on a number of factors independent of symptoms, including opportunity, available time, and the presence of a partner who is willing and able (Helstrom, Sorbom, & Backstrom, 1995). A limitation of this study was a low response rate (52%) and a drop-off over time in the number of those responding. The investigators Studies reviewed reveal a lack of comparison of sexuality in pre-morbid women compared with women who are symptomatic immediately prior to surgery. developed new scales for this study, and thus the validity and reliability of those measures are not well established. A nursing study attempted to describe women s perceived sense of well-being before and after hysterectomy for benign conditions (Lambden et al., 1997). The sample of 178 women completed questionnaires before the surgery and 11 months postoperatively. After the immediate recovery period, the respondents reported improved health status, including improved sexual functioning. Frequency of intercourse increased at 4 months after surgery, as did interest in sex. Of interest in this study is the observation by the authors that 118 of the 157 who reported being sexually active stated on the questionnaire that they experienced painful intercourse, although only 16 of these women had dyspareunia noted on their medical charts. Galyer, Conaglen, Hare, and Conaglen (1999) compared sexual desire effects of women who had undergone 258 JOGNN Volume 31, Number 3

4 hysterectomy (abdominal and vaginal; total n = 30) and a group of women who had nongynecologic surgery (n = 10). Participants completed questionnaires 6 to 18 months after the surgery and had blood drawn to measure their hormone levels. This study found no difference in sexual desire between the two groups of women as well as no difference between women who had abdominal or vaginal hysterectomy. The lack of statistical significance may be due to the very limited sample size. Of interest from this study is the observation that the majority of women reported engaging in sexual intercourse despite a lack of desire. The most recent research reported is that of a 2-year prospective study of hysterectomy, which included measures of sexual functioning (Rhodes, Kjerulff, Langenberg, & Guzinski, 1999). This large study (N = 1,101) measured sexual desire, frequency of coitus, orgasm, dyspareunia, and vaginal dryness as outcome measures 6, 12, 18, and 24 months after surgery. Significant differences noted after surgery included an increase in the percentage of women who were sexually active, from 70.5% of women before hysterectomy to 76.7% 2 years after the surgery. More women experienced orgasm after the surgery than before and low libido rates dropped from 10.4% before the surgery to 6.2% at the endpoint of the study. One of the limitations of this study is that the preoperative interview occurred shortly before the surgery, which introduces the possibility that anxiety may have affected the preoperative measures. The women were also experiencing severe gynecologic symptoms. This may have resulted in an overestimation of the positive effects of the intervention. As in other studies, measures of sexual functioning were crude, with respondents being asked to compare the strength of orgasms (very strong, strong, mild, or very mild). Increased frequency of sexual activity may not necessarily mean increased satisfaction. The increase may be related to alleviation of symptoms that interfered with coital activity. Farrell and Kieser (2000) conducted an extensive review of 18 studies related to this topic and found that overall, the methodologic quality of the studies was poor, with most being retrospective and with many confounding factors not taken into account in the analysis. However, the conclusions reached suggest that hysterectomy results in either an improvement or no change in sexuality for women who have had a hysterectomy. Women s Perspectives on Hysterectomy A small number of qualitative studies have been conducted to explore the experience of hysterectomy from the perspective of women. Bernhard (1992) studied the expectations of 63 low-income women before the surgery as well as at 4 weeks and 3 months after the hysterectomy. A questionnaire was mailed to the participants 2 years later. Of this sample, 16% had expectations before the surgery of a positive outcome; after the surgery, twice as many (35%) reported that the outcome was positive. This is a significant finding. In this study, the women reported that sexual consequences primarily involved their personal appearance, with some reporting that they were concerned about weight gain and the presence of a scar. At the 4-week interview, they expressed concerns about resuming sexual intercourse. Their major concerns related to the fear that intercourse would feel different for both the woman and her partner, that she would experience an injury as a result of intercourse, and that intercourse would be painful. Most of the women resumed intercourse about 6 weeks after the surgery. One third of the participants reported that intercourse was the same or better than before the surgery, and the remaining two thirds said that it was somewhat painful or not as good as usual because they were not relaxed. However, over time most of the women reported that intercourse returned to normal after a few attempts. In responses to the follow-up questionnaire 2 years after the surgery, there was some evidence of psychologic consequences, including feelings of depression and feeling empty, as well as somatic symptoms of menopause (hot flashes and night sweats). This part of the study was quantitative and so there was no opportunity for clarification of the responses. Questions about sexuality at this time elicited responses indicating some changes in sexual functioning, including decreased sex drive and changes in orgasm. This latter part of the study needs to be viewed with caution, because the questionnaire did not have reliability and validity data and only 35 of the original respondents returned data. In addition, the sample consisted only of women of low socioeconomic status and therefore the results may not be applied to a larger, more diverse population of women. An ethnographic study of six premenopausal women who had hysterectomies is described by Kinnick and Leners (1995). Interviews were conducted 3 months postoperatively, and the resulting analysis is reported as five domains and 15 themes. Three of the domains describe the women s experiences in anticipating the surgery, and the final two domains deal with the experience of the surgery itself and how the women coped with the resulting changes in their lives. The overarching theme of the study is that of moving from resourceful endurance to unexpected relief. In terms of sexuality, the women in this study stated that after the surgery, sex was the same as before or better. However, at the 3-month interval after surgery, many of the women were still somewhat anxious about having sex and were concerned about the physical healing that they were experiencing despite the fact that enjoyment of sex was better or the same as before. An Australian study (Ferroni & Deeble, 1996) of 656 women used questionnaires to elicit the subjective experience of this surgery. The sample comprised a healthy control group who had neither gynecologic problems nor sur- May/June 2002 JOGNN 259

5 gery (n = 358), a group of 191 women who were currently experiencing gynecologic problems, and a group of 107 women who had a hysterectomy for conditions other than cancer in the preceding 5 years. The response among those who had the surgery was overwhelmingly positive, and most reported no change in their satisfaction related to sexual activity. Those who did report a change were more likely to report that the change reflected increased satisfaction. Once again, it is difficult to interpret these results with a high degree of confidence. The major issue is that of the validity of measures of sexual satisfaction. This is highlighted by the results from the group of women with gynecologic problems. These women reported that their condition had adversely affected their sex life, although the frequency of sexual activity reported by this group was slightly higher than average. In summary, the few studies of women s experiences of this surgery support the findings of other studies. Methodologic weaknesses are also consistent with difficulties in measuring sexual satisfaction and in defining and describing important variables. Information Sharing With Women Before Surgery It is generally accepted that before surgery and other medical interventions, patients require information, both so that they can give informed consent for the procedure and to facilitate understanding. Women receive information about hysterectomy from a variety of sources including friends and family, the media, and nurses and physicians. Some of the studies discussed in the preceding pages also asked respondents about the quality and quantity of the information they received. Drummond and Field (1984) suggested that before hysterectomy, women may lack knowledge about the anatomy and physiology of the reproductive system. It may seem obvious that nurses and physicians should provide women with information in these areas, but this may not be the case. Coulter (1994) found in her study of hysterectomy patients that many were not given sufficient information. The research indicates that nurses do not routinely inquire about sexual practices and do not provide teaching or counseling in this area (Gamel, Davis, & Hengeveld, 1993). Nurses may be reluctant to ask questions about their patients sexual functioning because they are embarrassed, they may not believe that sexuality is part of the problem for which the patient seeks care, or they may feel that they are not trained adequately (Merrill & Thornby, 1990). Some nurses feel that asking about sexuality is an invasion of patients privacy and state that they do not know appropriate nursing interventions for identified problems (MacElveen-Hoehn, 1985). However, patients have said that a discussion of sexual concerns is appropriate (Waterhouse, 1996), but nurses are more likely to wait for the patient to initiate the discussion than to ask questions of the patient (Matocha & Waterhouse, 1993). Adequate preoperative education of women and their partners may be useful in preventing potential problems in the postoperative period. Once myths and erroneous information are incorporated into the patient s belief system, it may be more difficult to give them factual information (Bachmann, 1990). Some studies report that women are satisfied with the amount and quality of information from their health care providers. The women in Ewert et al. s study (1995) were mostly satisfied with what their physicians told them about the procedure. Of interest is that most of the Adequate preoperative education of women and their partners related to sexual activity may be useful in preventing potential problems in the postoperative period. women (79%) who stated that they obtained information from newspapers had a negative opinion of the surgery. This is supported by the findings of Kinnick and Leners (1995): Participants stated that information in the lay press focused on reasons why women should not have a hysterectomy. These women described pamphlets given to them by their physicians as too general. Participants in this study and in another study (Webb & Wilson-Barnett, 1983) stated that the information given to them by physicians should be realistic and should not be given in a humorous manner. However, Ferroni and Deeble (1996) reported that 94% of the women in their study were satisfied with the explanation they were given by their physicians. Two studies addressed the specific issue of the educational needs of women undergoing hysterectomy. Neefus and Taylor (1981) conducted an exploratory study of the educational needs of these women. They asked women what they wanted to know, when they wanted the information, and whether they obtained this information. They found that women most wanted to know about the physical effects of the surgery, but younger women (between the ages of 31 and 40 years) valued topics related to sexuality as most important. This information was needed before the surgery occurred. Twenty percent of those surveyed reported receiving no information at all about sexual problems. In a study by Kreuger and colleagues (1979), the physician was cited as the most valuable source of information. Almost 95% of the respondents, however, stated that they would prefer a nurse to provide them with information 260 JOGNN Volume 31, Number 3

6 regarding sexual adjustment after hysterectomy because they would prefer to talk about this with a woman rather than a man. This reflects the stereotype that nurses are more likely to be female and physicians male. Eight percent of the sample indicated that the nurse was the person with whom they felt most comfortable discussing questions about sexuality. Suggestions for information sharing before hysterectomy include one-on-one counseling accompanied by a pamphlet, with the opportunity for further discussion with a health care provider (Bachmann, 1990). It was also noted that health care providers should be more comfortable talking about sexual topics rather than only the mechanics of the surgery (Kreuger et al., 1979). Conclusion This article has described studies that investigated changes in sexual functioning after hysterectomy as well as the information given to women about the surgery. Gaps in knowledge in these areas are apparent. The most striking of these is the lack of research comparing sexual functioning in pre-morbid women. All the studies described asked women to answer questions about their sexual functioning immediately before surgery at a time when they were symptomatic. This leads to a positive bias in the results: Women are more likely to report improved sexual functioning after the surgery when their symptoms have been alleviated. Another gap in the knowledge base is a description of what women want to know about sexuality after hysterectomy and the most efficient methods to provide them with this information. It is hoped that these questions will be asked and answered in the years to come. REFERENCES Allgeier, E., & Allgeier, A. (1991). Sexual interactions (3rd ed.). Lexington, MA: D. C. Heath. Anderson Darling, C., & McKoy-Smith, Y. (1993). Understanding hysterectomies: Sexual satisfaction and quality of life. Journal of Sex Research, 30(4), Bachmann, G. (1990). 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7 Naughton, M., & McBee, W. (1997). Health-related quality of life after hysterectomy. Clinical Obstetrics and Gynecology, 40(4), Neefus, M., & Taylor, M. (1981). Educational needs of hysterectomy patients. Patient Counseling and Health Education, 3, North American Menopause Society. (2000). Menopause core curriculum study guide. Cleveland, OH: Author. Rhodes, J., Kjerulff, K., Langenberg, P., & Guzinski, G. (1999). Hysterectomy and sexual functioning. Journal of the American Medical Association, 282(20), Ryan, M. M. (1997). Hysterectomy: Social and psychological aspects. Balliere s Clinical Obstetrics and Gynecology, 11, Thakar, R., Manyonda, I., Stanton, S., Clarkson, P., & Robinson, G. (1997). Bladder, bowel and sexual function after hysterectomy for benign conditions. British Journal of Obstetrics and Gynaecology, 104, Utian, W. H. (1975). Effect of hysterectomy, oophorectomy and estrogen therapy on libido. International Journal of Gynaecology and Obstetrics, 13, Virtanen, H., Makinen, J., Tenho, T., Kiilholma, P., & Hirvonen, T. (1993). Effects of abdominal hysterectomy on urinary and sexual symptoms. British Journal of Urology, 72, Waterhouse, J. (1996). Nursing practice related to sexuality: A review and recommendations. NT Research, 1(6), Webb, C., & Wilson-Barnett, J. (1983). Self-concept, social support and hysterectomy. International Journal of Nursing Studies, 20, 97. Zussman, L., Zussman, S., Sunley, R., & Bjornson, E. (1981). Sexual response after hysterectomy-oophorectomy: Recent studies and reconsideration of psychogenesis. American Journal of Obstetrics and Gynecology, 140(7), Anne Katz is an assistant professor, Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada. Address for correspondence: Anne Katz, RN, PhD, Faculty of Nursing, 405 Helen Glass Centre for Nursing, University of Manitoba, Winnipeg MB R3T 2N2 Canada. anne_ katz@umanitoba.ca. 262 JOGNN Volume 31, Number 3