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Quality of Female Sexual Function After Conventional Abdominal Hysterectomy - Three Month' Observation

Quality of Female Sexual Function After Conventional Abdominal Hysterectomy - Three Month'... 10.2478/chilat-2014-0105 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) ORIGINAL ARTICLE Quality of Female Sexual Function after Conventional Abdominal Hysterectomy – Three Months’ Observation Ieva Briedite*,**, Gunta Ancane***, Irena Rogovska****, Nellija Lietuviete*,** *Riga East Clinical University Hospital ‘Gailezers’, Gynecology Clinic, Latvia **Riga Stradins University, Department of Obstetrics and Gynecology, Latvia ***Riga Stradins University, Department and Clinic of Psychosomatic Medicine and Psychotherapy, Latvia ****Riga Stradins University, Division of Doctoral Studies, Latvia SUMMARY Introduction. Many medical and conservative surgical treatment options are available but still hysterectomy remains the most common gynecological procedure performed worldwide. These procedures are performed because of actual and possible malignant diseases, and benign conditions including pelvic pain, dyspareunia, uterine myomas, adenomyosis, endometriosis, and menometrorrhagia. The impact of hysterectomy on sexual function has always been a great concern to women and is a major source of preoperative anxiety. Data regarding the impact of hysterectomy on women’s sexual functioning are not clear and consistent, many women report improvement of sexual functioning after hysterectomy, which may be due to relief of symptoms, while others complain of sexual dysfunction as a result of hysterectomy. Also discussion about advantages of cervix sparing operations is still controversial. Aim of the study. Aim was to assess and compare pre- and post-operative quality of sexual life of gynecological patients undergoing planned hysterectomy, and to find out opinions of patients and their partners about expected impact of operation and changes after surgery. Material and methods. Questionnaire method was used to survey gynecologic patients undergoing planned subtotal / total hysterectomy due to benign indication. Sexual Quality of Life Questionnaire – Female (SQoL-F) was used to assess quality of sexual life before and after surgery. Questions about other influencing factors and patients’ opinions before and after operation were added. 38 completed questionnaires were used for data analysis. Results. Only 55% of subtotal hysterectomy group and 38.9% of total hysterectomy group told their partners completely about planned surgery. Mean period of beginning sexual activities after operation was 5.15 weeks after surgery in subtotal hysterectomy and 5.78 weeks in total hysterectomy group. SQoL-F after three months post-operation period was 6.50 points less in total hysterectomy group, which was not statistically significant. There was a slight statistically insignificant decrease of SQoL-F points within each group after three months observation period: -0.44 points in subtotal hysterectomy group and -2.47 points in total hysterectomy group. Although patients of total hysterectomy more frequently (22.2% vs. 5%) indicated negative impact on sexual function after operation, differences were not statistically significant. There were no differences in co-morbidities, concomitant medications, hormone use history and post-operative complications between groups. Conclusions. Patients before hysterectomy are worried about possible negative impact of surgery on their sexual function, they do not talk to their partners candidly about planned surgery. There were no statistically significant changes of sexual quality of life found after subtotal and total abdominal hysterectomy operation after three months observation period. Key words: sexuality, female sexual function, hysterectomy, sexual quality of life, gynecological surgery INTRODUCTION to the bladder and nearby nerves, and may even allow Hysterectomy is one of the commonest major gyneco- a woman to enjoy a better long-term sex life, while logical operations (8). Most commonly it is performed others state that if a growth develops, removing the in women of reproductive age (21). 40% of women cervix alone carries higher risk (19). Subtotal abdominal all over the world will have hysterectomy by the age hysterectomy is easier to perform, with less risk of of 64 and indication for the majority will be to relieve ureteric damage, but requires that women have regular symptoms and improve quality of life (10). More than cervical smears, and may result in cyclical bleeding in a half of all hysterectomies are carried out because of small proportion of women (11). Hysterectomy involves abnormal uterine bleeding, which is associated with a several surgical approaches - traditional abdominal wide range of diagnoses that include uterine fibroids, laparotomy, vaginal or laparoscopic hysterectomy endometriosis, adenomyosis, and dysfunctional uterine (7). Type of hysterectomy performed depends on bleeding (4). The types of hysterectomy include total the disorder to be treated, the size of the uterus and (removal of cervix) and subtotal (supracervical removal the skills and preference of the surgeon (4). Use of of the uterus), with or without unilateral or bilateral laparoscopic hysterectomy has become more frequent oophorectomy (13). Some authors argues that leaving (6). Quality of life measures after surgery did not appear the cervix untouched reduces the risk of surgical damage 26 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) to vary according to type of hysterectomy, whether an clitoral sensation (via pudendal and genitofemoral abdominal or laparoscopic approach was used (16). nerves) should not be affected by hysterectomy (13). Although hysterectomy is usually done to improve Sexuality of women is conditioned by many cultural, patient’s quality of life yet it has its own morbidity and religious, physical, affective, emotional, marital and mortality (1). When women face the decision of whether socioeconomic factors. Sexuality is a dynamic process to have a hysterectomy, they should be provided with with a high degree of subjectivity and overlapping that information relating indications for surgery, surgical imposes difficulties when it comes to assessing each procedure, recovery, and sequel by their physicians factor involved in the sexual response (18). Long-term (9). Hysterectomy related psychological morbidity controlled studies need to be conducted to properly typically includes depression, anxiety, and stress-related determine the psychological effects of hysterectomy (7). symptoms, it could be triggered by negative perceptions However, the decision remains up to the women and about body image, femininity, youth, energy and should be driven by their health needs (9). activity levels, as well as loss of child-bearing capacity. Physical co-morbidity typically includes increased risk of AIM OF THE STUDY developing pelvic floor prolapse, urinary incontinence Aim of this study was to assess pre-operative quality of and sexual dysfunction (7). The data regarding the impact sexual life of gynecological patients undergoing planned of hysterectomy on women’s sexual functioning are not total and subtotal hysterectomy without oophorectomy, clear and consistent, and many practitioners are not to compare it with post-operative quality of sexual life well-informed about the possible sexual consequences after three months within the groups and between of hysterectomies. (17). Women who are candidates for groups of total and subtotal hysterectomy, and to find hysterectomy are always concerned about the potential out patients’ and their partners’ opinions about expected negative effect on their sexual function and the possible impact of operation and actual changes after surgery. negative effect on their relations with their partner’s. (9). Female sexual dysfunction (FSD) is defined as a MATERIAL AND METHODS disorder of sexual desire, arousal, orgasm or sexual pain Study population was selected to analyze impact only that results in significant personal distress (12). Sexual of total and subtotal hysterectomy, excluding potential difficulties are very frequent among women and involve negative effects of hormone loss after oophorectomy. 20%–50% of the female population worldwide (5). Study group consisted of gynecological patients from Factors such as age, menopause, previous pathological Gynecology Department of Riga East Clinical University conditions and gynecological surgery may adversely Hospital ‘Gailezers’ undergoing planned hysterectomy affect sexual response (18). The most common due to benign indications. Inclusion criteria were: age independent clinical predictor of recent and lifelong FSD 18-50 years, patients who were sexually active and diagnosis was relationship dissatisfaction (2). Despite planned sexual activities within at least six months after the importance of sexuality in women’s lives, physicians surgery, patients who voluntary agreed to participate in ask about it reluctantly. (3). Women still remain to have study and were able to fill the questionnaire. Exclusion poor understanding of the physiology of the genital tract criteria were: age under 18 years, age above 50 years, (14). Reproductive, menstrual, and sexual functions of patients who were no sure about sexual activity after the uterus must be considered. Direct sexual function operation, patients who did not agree to participate involves uterine contractions during orgasm, while in study, patients who had different surgery extent indirect functions include: feeling less feminine after during operation – had unplanned unilateral or hysterectomy, concern about sexual difficulties, or bilateral oophorectomy, patients who did not proceed changes in the attitude of her partner (9). Gynecological with sexual activity within observation period after surgery may influence the sexuality in terms of self- operation. Study was performed in time period from image, sexual pain and orgasm difficulty (18). The August 2013 till February 2014. Participation in study prevailing view in the literature is that hysterectomy was offered to all patients of appropriate age and improves the overall quality of life, however, at least planned operation until 50 patients were recruited some deleterious effects of hysterectomy were reported and signed agreement form. 25 patients were planned in almost all of the articles (13). The expected changes in each study group – subtotal and total hysterectomy. can affect both partners, which is considered as a Questionnaire method was used to survey patients on fundamental issue in the relationship (9). The primary the day before operation. Standardized and validated medical conditions causing FSD can be hormonal, Sexual Quality of Life Questionnaire – Female (SQoL-F) anatomical, vascular and neural (12). The uterus and (20) was used to assess quality of sexual life before and cervix may be important factors in the physiology of after surgery. The 18-item SQoL-F was developed to sensation and orgasm, which is effected by sensory assess the sexual quality of life of women, specifically stimuli from contractions of the uterus, cervix, and to assess sexual confidence, emotional well-being and vagina. Hysterectomy may have a negative influence relationship issues. The instrument has been validated on this feedback system in the brain (15). Changes for use in broad range of women, it is self-administered depend not only on which nerves were severed by the in approximately 7 minutes, recall period is the previous surgery, but also the genital regions whose stimulation four weeks, each item is rated on a 5-point Likert scale, the woman enjoys for eliciting sexual response. Because designed for use among women who are 18+ in age. 27 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) SQoL-F does not provide cut-scores of sexual function in Group2 using concomitant medications at the time levels, result can be analyzed as primary endpoint. Nine of operation. Differences between the groups were not questions were added to find out age, co-morbidities, statistically significant. Standardized SQoL-F points (to concomitant medications, history of hormone a 0-100 scale) before surgery were 71.61 in Group1 (estrogen / progestin) use in period of last six month and 68.03 in Group2. Analysis of subjective satisfaction before operation, opinion about expected impact of in main domains of sexual function before operation operation, awareness and women’s view about opinion showed comparatively lower rates of satisfaction in of their partners (partners were not asked separately), domain of pain – 35% (n=7) in Group1 and 27.8% emotional well-being with partner, self-assessment (n=5) in Group2, but differences were not statistically of seven domains of sexual function (desire, arousal, significant (see Figure 1). Patients’ expectations about lubrication, orgasm, satisfaction, pain, partner). Each impact of planned operation on their sexuality are questionnaire got a code and no private data were used. described in Table 1. Although patients of Group2 Prior to participation, patients were not screened to rule were worried about possible negative impact more out any particular medical conditions as an indication frequently, differences were not statistically significant for operation because of the extensive overlap of (p=0.12). Only 55% (n=11) of Group1and 38.9% gynecological indications for each patient. Patients were (n=7) of Group2 told their partners completely about divided in two groups: subtotal hysterectomy (Group1) planned surgery, 30% (n=6) of Group1and 50% (n=9) and total hysterectomy (Group2). Initially there were of Group2 told their partners partly about planned 50 patients - 25 patients in each group. There were five surgery, but 15% (n=3) of Group1and 11.1% (n=2) of patients excluded from the Group1: one patient refused Group2 did not tell their partners at all about planned to continue participation during observation period, surgery. 30% (n=6) of partners of Group1patients and one patient divorced from partner after operation, 38.9% (n=7) of partners of Group2 patients thought three patients had unplanned oophorectomy during that nothing will change about woman’s sexuality after operation, one patient had changed partner after operation, 15% (n=3) of partners of Group1patients and operation. There were seven patients excluded from the 5.6% (n=1) of partners of Group2 patients thought that Group2: one patient refused to continue participation woman’s sexual function will improve after operation, after reading the questionnaire, five patients had no one of partners of Group1patients and 11.1% (n=2) unplanned oophorectomy during operation, one patient of partners of Group2 patients thought that woman’s did not proceed with sexual activities within three sexual function will decline after operation, 55% months because of suture complications (gynecologist (n=11) patients of Group1and 44.4% (n=8) patients recommendation). In total 38 (20 in Group1 and 18 in of Group2 could not answer about their partner’s Group2) fully and correctly completed questionnaires opinion concerning expected impact of operation on were used for data analysis. Study was approved by their sexual function. Mean period of beginning sexual the Ethics Committee of Riga Stradins University. activities after operation was 5.15 weeks after surgery SQoL-F calculation was performed in compliance with in Group1 and 5.78 weeks in Group2, all patients standardized scoring system. Distribution of variables from both groups proceeded with sexual activities within and between groups was assessed using rxc after operation. Patients from Group1 proceeded with or 2x2 frequency tables. Statistical significance of sexual activities more often after 6 weeks (35%, n=7), differences was tested by Pearson chi2 test or Fisher’s patients from Group2 proceeded with sexual activities exact test. SQoL-F mean scores and standardized more often after 4 weeks (27.8%, n=5) and 8 weeks parameters before surgery and 3 months after surgery (27.8%, n=5). Differences were statistically significant were calculated for both groups. Statistical significance (p=0.03). Five patients from Group1 (25%) proceeded of differences between groups and between different with sexual activities 2 weeks after surgery, which time points within one group was tested by means of is before recommended post-operative abstinence paired t test, two sample t test and by means of Mann- period (4 weeks). There were no statistically significant Whitney test. P value less than 0.05 was chosen as a differences in postoperative complications in Group1 level of statistical significance. (10%, n=2) and Group2 (16.7%, n=3). No one of the study group patients had any new co-morbidity during RESULTS three month period after operation. There was a slight Minimal age of patients was 32 years, maximal age statistically insignificant decrease of SQoL-F points was 50 years. Mean age of Group1 (n=20) was 45.2 ± within each group after three months observation 2.92 years, mean age of Group2 (n=18) was 44.5 ± 4.78 period: -0.44 points in Group1 (p=0.92) and -2.47 points years. There were 35% (n=7) patients in Group1 and in Group2 (p=0.67). Comparing mean standardized 22.2% (n=4) patients in Group2 who had hormone SQoL-F points between groups after three months post- using history in last six months before operation, operation period, there was a difference 6.50 points less differences were not statistically significant (p=0.07). in Group2, which is not statistically significant (p=0.43). There were 45% (n=9) patients in Group1 and 38.9% 65% (n=13) patients of Group1and 55.6% (n=10) of (n=7) patients in Group2 having other co-morbidity Group2 three months after surgery confirmed that they except gynecological condition. There were 50% feel emotionally comfortable with their partners, 5% (n=10) patients in Group1 and 27.8% (n=5) patients (n=1) of Group1and 5.6% (n=1) of Group2 did not feel 28 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) emotionally comfortable, but it was difficult to answer technique are major but not the only essential factors for 30% (n=6) of Group1and 38.9% (n=7) of Group2. from summary impact on sexual function after surgery. Subjective reported changes of the main domains of Data showed the same level of emotional partnership sexual function in both groups are depicted on Figure 2 well-being before and after operation (women’s view). and Figure 3. Worsening of sexual function seems to be In this study there were no further post-operation more frequent in Group2, however differences are not interviews and relationship analysis performed about statistically significant. Patients’ self-assessment about future partnership attitudes and relationship changes in impact of hysterectomy operation on their sexuality case of telling and not telling partner about operation. is described in Table 2. Although patients of Group2 There was one patient in subtotal hysterectomy group more frequently indicated negative impact, differences who divorced from her partner in three months period were not statistically significant (p=0.30). 55% (n=11) after operation. Her questionnaire data showed that of partners of Group1patients and 38.9% (n=7) of she did not tell her partner about planned operation, in partners of Group2 patients thought that nothing has this case it was impossible to analyze potential reasons changed about their partner’s sexuality after operation, for divorce without deeper interview of both partners. 20% (n=4) of partners of Group1 patients and 27.8% Asking woman about their partner’s opinions regarding (n=5) of partners of Group2 patients thought that their planned operation and post-operative changes brings partner’s sexual function has improved after operation, some risk of misinformation, because partners can 10% (n=2) of partners of Group1 patients and 27.8% have different opinions if asked directly, but according (n=5) of partners of Group2 patients thought that their to the protocol, partners were not directly involved in partner’s sexual function has declined after operation, the study. Also telling partner incomplete information 15% (n=3) of Group1 patients and 5.6% (n=1) of about planned operation can change his opinion about Group2 patients could not answer about their partner’s expected impact of surgery. opinion concerning impact of operation on their sexual Since there were no statistically significant differences function. Although partners of patients of Group2 more in co-morbidities, concomitant medications, hormone frequently indicated negative impact, differences were use history and post-operative complications between not statistically significant (p=0.40). groups, authors consider both study groups comparable. Wide interpretation of study results and generalization DISCUSSION to all population of gynecological patients is restricted by Data from this study prove that sexual health and future relatively small study group, but it gives an opportunity sexual function is important issue for gynecological to see and analyze tendencies and actualize the problem. patients. Usually people undergoing surgical procedures Disadvantage of questionnaire method is a subjective anticipate emotional support from their family. conception of questions, remembrance failures, as well This study demonstrates that in case of planned as impossible verification or particularization of answers. hysterectomy there are many patients who did not tell Women should be provided with as much information their partners about operation at all (13.16%) or told as possible and invited to participate in the decision only partly (39.47%). If the partners are not aware of making about the type of hysterectomy. Such planned surgery and possible difficulties, patients lose empowerment may well improve satisfaction rates after opportunity of wholesome support. Although previous surgery (11). Continuous research is necessary to obtain study data support viewpoint that most probably women more information about many possible factors that may will neither lose their sexual desire after hysterectomy, have an impact on sexual function after hysterectomy. nor they will lose their feminine shape or style (9), All patients from this study group are continuing sexuality after hysterectomy is still cause of great participation in study for further observation period anxiety of patients and continuous ambiguity for health to assess quality of sexual life after six months post- care providers. Women require more information and operation period. evidence based data about possible impact of operation to be fully informed about all aspects before consent of CONCLUSIONS scheduled surgery. Gynecological patients before scheduled hysterectomy This study did not prove statistically significant changes are worried about possible negative impact of surgery of quality of sexual life after operation not within each on their sexual function. Many patients do not tell their study group, nor between two groups of different surgical partners about operation or tell only partly, thereby extent – subtotal and total hysterectomy, which can be depriving themselves full emotional support from explained with relatively small initial number of recruited partner. There is no statistically significant impact of patients and loss of 12 excluded patients in the study hysterectomy on sexual quality of life. There are no process, however in some positions there was tendency statistically significant differences in sexual quality of of more frequent expected negative effects and reported life between total and subtotal hysterectomy. negative changes among patients of total hysterectomy group. Analyzing each questionnaire separately, there Conflict of interest: None were examples of marked worsening and examples of marked improvement of sexual function in both study groups. It seems that hysterectomy itself and its surgical 29 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) REFERENCES 13. Komisurak BR, Frangos E, Whiple B. Hysterectomy 1. Amin A, Ali A, Amin Z, Sani FN. Justification for Improves Sexual Response? Addressing a Crucial hysterectomies and frequency of histopathological Omission in the Literature // J Minim Invasive lesions of hysterectomy at a Teaching Hospital Gynecol, 2011; 18(3):288-295 in Peshawar, Pakistan // Pak J Med Sci, 2013; 14. Lekovic J, Pangasa M, Reiss J, Chan M, Prasad 29(1):170-172 L, Taubel DA. Does prior hysterectomy improve 2. Burri A, Spector T. Recent and Lifelong Sexual patients’ understanding of the anatomy and Dysfunction in a Female UK Population Sample: physiology of female reproductive organs? – A Prevalence and Risk Factors // J Sex Med, 2011; survey // ASRM Abstracts, 2013; 100(3):S406 8:2420-2430 15. Lermann J, Haberle L, Merk S, Henglein K, 3. Buster JE. Managing female sexual dysfunction // Beckmann MW, Mueller A, Mehlhorn G. Fertil Steril, 2013; 100(4): 905-915 Comparison of prevalence of hypoactive sexual 4. Butt JL, Jeffery ST, Van der Spuy ZM. An audit desire disorder (HSDD) in women after five of indications and complications associated with different hysterectomy procedures // Eur J Obstet elective hysterectomy at a public service hospital Gynaecol Reprod Biol, 2013; 167:210-214 in South Africa // Int J Gynaecol Obstet, 2012; 16. Lethaby A, Mukhopadhyay A, Naik R. Total versus 116:112-116 subtotal hysterectomy for benign gynaecological 5. Cabral PUL, Canario ACG, Spyrides MHC, Uchoa conditions (Review) // The Cochrane Library, 2012; SAC, Eleuterio Jr.J, Goncalves AK. Determinants of 4:1-73 sexual dysfunction among middle-aged women // 17. Peterson ZD, Rothenberg JM, Bilbrey S, Heiman Int J Gynaecol Obstet, 2013; 120:271-274 JR. Sexual Functioning Following Elective 6. Chalermchockchareonkit A, Tekasakul P, Hysterectomy: The Roleof Surgical and Psychosocial Chaisilwattana P, Sirimai K, Wahab N. Laparoscopic Variables // J Sex Res, 2010; 47(6):513-527 hysterectomy versus abdominal hysterectomy 18. Rodriguez MC, Chedraui P, Schwager G, Hidalgo for severe pelvic endometriosis // Int J Gynaecol L, Perez-Lopez FR. Assessment of sexuality after Obstet, 2012; 116:109-111 hysterectomy using the Female Sexual Function 7. Darwish M, Atlantis E, Mohmed-Taysir T. Index // J Obstet Gynaecol, 2012; 32:180-184 Psychological outcomes after hysterectomy for 19. Sutton C. Past, Present, and Future of Hysterectomy // benign conditions: a systematic review and meta- J Minim Invasive Gynecol, 2010; 17(4):421-435 analysis // Eur J Obstet Gynaecol Reprod Biol, 20. Symonds T, Boolell M, Quirk F. Development of a 2014; 174:5-19 questionnaire on sexual quality of life in women // 8. Davies A, Hart R, Magos A, Hadad E, Morris R. J Sex Marital Ther, 2005;31(5):385-397 Hysterectomy: surgical route and complications // 21. Turner LC, Shepherd JP, Wang L, Bunker CH, Eur J Obstet Gynaecol Reprod Biol, 2002; 104:148- Lowder JL. Hysterectomy surgical trends: a more accurate depiction of the last decade? // Am J 9. Fram KM, Saleh SS, Sumrein IA. Sexuality after Obstet Gynecol, 2013; 208:277.e1-7 hysterectomy at University of Jordan Hospital: a teaching hospital experience // Arch Gynecol Obstet, 2013; 287:703-708 Address: 10. Gupta S, Manyonda I. Hysterectomy for benign Ieva Briedite, gynaecological disease // Elsevier review Obstetrics, Riga East Clinical University Hospital ‘Gailezers’, Gynaecology and Reproductive Medicine, 2014; Gynecology Clinic, Hipokrata street 2, 24(5):135-140 Riga, LV-1038, 11. Gupta S, Manyonda I. Total and subtotal abdominal E-mail: dr.briedite@gmail.com hysterectomy for benign gynaecological disease // Elsevier review Obstetrics, Gynaecology and Reproductive Medicine, 2010; 21(2):36-40 12. Jha S, Thakar R. Female sexual dysfunction // Eur J Obstet Gynaecol Reprod Biol, 2010; 153:117-123 30 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) Partner 80.00 77.78 80 75.00 Pain 70.00 70.00 66.67 66.67 61.11 60.00 60.00 Sa sfa con 55.56 Beer 50.00 Org asm 50 No cha nges Group1 35.00 Worse Lubricaon Group2 27.78 Arous al Desire 0% 20% 40% 60% 80% 100% Desire Arous al Lubricaon Org asm Sa sfa con Pain Partner Fig. 1. Satisfaction rates of main domains of sexual Fig. 2.Changes of main domains of sexual function function before operation (%) after operation in Group1 (%) Partner Pain Sa sfa con Beer Org asm No cha nges Worse Lubricaon Arous al Desire 0% 20% 40% 60% 80% 100% Fig. 3. Changes of main domains of sexual function after operation in Group2 (%) Table 1. Patients’ expectations about impact of Table 2. Patients’ self-assessment about impact of planned operation on their sexuality hysterectomy operation on their sexuality Expected impact Group1 Group2 Reported impact Group1 Group2 n / total (%) n / total (%) n / total (%) n / total (%) Improve 4/20 (20) 1/18 (5.6) Improved 7/20 (35) 5/18 (27.8) Decline 1/20 (5) 6/18 (33.3) Declined 1/20 (5) 4/18 (22.2) Nothing will change 8/20 (40) 7/18 (38.9) Nothing has changed 10/20 (50) 9/18 (50) Do not know 7/20 (35) 4/18 (22.2) Do not know 2/20 (10) 0/18 (0) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Chirurgica Latviensis de Gruyter

Quality of Female Sexual Function After Conventional Abdominal Hysterectomy - Three Month' Observation

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10.2478/chilat-2014-0105 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) ORIGINAL ARTICLE Quality of Female Sexual Function after Conventional Abdominal Hysterectomy – Three Months’ Observation Ieva Briedite*,**, Gunta Ancane***, Irena Rogovska****, Nellija Lietuviete*,** *Riga East Clinical University Hospital ‘Gailezers’, Gynecology Clinic, Latvia **Riga Stradins University, Department of Obstetrics and Gynecology, Latvia ***Riga Stradins University, Department and Clinic of Psychosomatic Medicine and Psychotherapy, Latvia ****Riga Stradins University, Division of Doctoral Studies, Latvia SUMMARY Introduction. Many medical and conservative surgical treatment options are available but still hysterectomy remains the most common gynecological procedure performed worldwide. These procedures are performed because of actual and possible malignant diseases, and benign conditions including pelvic pain, dyspareunia, uterine myomas, adenomyosis, endometriosis, and menometrorrhagia. The impact of hysterectomy on sexual function has always been a great concern to women and is a major source of preoperative anxiety. Data regarding the impact of hysterectomy on women’s sexual functioning are not clear and consistent, many women report improvement of sexual functioning after hysterectomy, which may be due to relief of symptoms, while others complain of sexual dysfunction as a result of hysterectomy. Also discussion about advantages of cervix sparing operations is still controversial. Aim of the study. Aim was to assess and compare pre- and post-operative quality of sexual life of gynecological patients undergoing planned hysterectomy, and to find out opinions of patients and their partners about expected impact of operation and changes after surgery. Material and methods. Questionnaire method was used to survey gynecologic patients undergoing planned subtotal / total hysterectomy due to benign indication. Sexual Quality of Life Questionnaire – Female (SQoL-F) was used to assess quality of sexual life before and after surgery. Questions about other influencing factors and patients’ opinions before and after operation were added. 38 completed questionnaires were used for data analysis. Results. Only 55% of subtotal hysterectomy group and 38.9% of total hysterectomy group told their partners completely about planned surgery. Mean period of beginning sexual activities after operation was 5.15 weeks after surgery in subtotal hysterectomy and 5.78 weeks in total hysterectomy group. SQoL-F after three months post-operation period was 6.50 points less in total hysterectomy group, which was not statistically significant. There was a slight statistically insignificant decrease of SQoL-F points within each group after three months observation period: -0.44 points in subtotal hysterectomy group and -2.47 points in total hysterectomy group. Although patients of total hysterectomy more frequently (22.2% vs. 5%) indicated negative impact on sexual function after operation, differences were not statistically significant. There were no differences in co-morbidities, concomitant medications, hormone use history and post-operative complications between groups. Conclusions. Patients before hysterectomy are worried about possible negative impact of surgery on their sexual function, they do not talk to their partners candidly about planned surgery. There were no statistically significant changes of sexual quality of life found after subtotal and total abdominal hysterectomy operation after three months observation period. Key words: sexuality, female sexual function, hysterectomy, sexual quality of life, gynecological surgery INTRODUCTION to the bladder and nearby nerves, and may even allow Hysterectomy is one of the commonest major gyneco- a woman to enjoy a better long-term sex life, while logical operations (8). Most commonly it is performed others state that if a growth develops, removing the in women of reproductive age (21). 40% of women cervix alone carries higher risk (19). Subtotal abdominal all over the world will have hysterectomy by the age hysterectomy is easier to perform, with less risk of of 64 and indication for the majority will be to relieve ureteric damage, but requires that women have regular symptoms and improve quality of life (10). More than cervical smears, and may result in cyclical bleeding in a half of all hysterectomies are carried out because of small proportion of women (11). Hysterectomy involves abnormal uterine bleeding, which is associated with a several surgical approaches - traditional abdominal wide range of diagnoses that include uterine fibroids, laparotomy, vaginal or laparoscopic hysterectomy endometriosis, adenomyosis, and dysfunctional uterine (7). Type of hysterectomy performed depends on bleeding (4). The types of hysterectomy include total the disorder to be treated, the size of the uterus and (removal of cervix) and subtotal (supracervical removal the skills and preference of the surgeon (4). Use of of the uterus), with or without unilateral or bilateral laparoscopic hysterectomy has become more frequent oophorectomy (13). Some authors argues that leaving (6). Quality of life measures after surgery did not appear the cervix untouched reduces the risk of surgical damage 26 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) to vary according to type of hysterectomy, whether an clitoral sensation (via pudendal and genitofemoral abdominal or laparoscopic approach was used (16). nerves) should not be affected by hysterectomy (13). Although hysterectomy is usually done to improve Sexuality of women is conditioned by many cultural, patient’s quality of life yet it has its own morbidity and religious, physical, affective, emotional, marital and mortality (1). When women face the decision of whether socioeconomic factors. Sexuality is a dynamic process to have a hysterectomy, they should be provided with with a high degree of subjectivity and overlapping that information relating indications for surgery, surgical imposes difficulties when it comes to assessing each procedure, recovery, and sequel by their physicians factor involved in the sexual response (18). Long-term (9). Hysterectomy related psychological morbidity controlled studies need to be conducted to properly typically includes depression, anxiety, and stress-related determine the psychological effects of hysterectomy (7). symptoms, it could be triggered by negative perceptions However, the decision remains up to the women and about body image, femininity, youth, energy and should be driven by their health needs (9). activity levels, as well as loss of child-bearing capacity. Physical co-morbidity typically includes increased risk of AIM OF THE STUDY developing pelvic floor prolapse, urinary incontinence Aim of this study was to assess pre-operative quality of and sexual dysfunction (7). The data regarding the impact sexual life of gynecological patients undergoing planned of hysterectomy on women’s sexual functioning are not total and subtotal hysterectomy without oophorectomy, clear and consistent, and many practitioners are not to compare it with post-operative quality of sexual life well-informed about the possible sexual consequences after three months within the groups and between of hysterectomies. (17). Women who are candidates for groups of total and subtotal hysterectomy, and to find hysterectomy are always concerned about the potential out patients’ and their partners’ opinions about expected negative effect on their sexual function and the possible impact of operation and actual changes after surgery. negative effect on their relations with their partner’s. (9). Female sexual dysfunction (FSD) is defined as a MATERIAL AND METHODS disorder of sexual desire, arousal, orgasm or sexual pain Study population was selected to analyze impact only that results in significant personal distress (12). Sexual of total and subtotal hysterectomy, excluding potential difficulties are very frequent among women and involve negative effects of hormone loss after oophorectomy. 20%–50% of the female population worldwide (5). Study group consisted of gynecological patients from Factors such as age, menopause, previous pathological Gynecology Department of Riga East Clinical University conditions and gynecological surgery may adversely Hospital ‘Gailezers’ undergoing planned hysterectomy affect sexual response (18). The most common due to benign indications. Inclusion criteria were: age independent clinical predictor of recent and lifelong FSD 18-50 years, patients who were sexually active and diagnosis was relationship dissatisfaction (2). Despite planned sexual activities within at least six months after the importance of sexuality in women’s lives, physicians surgery, patients who voluntary agreed to participate in ask about it reluctantly. (3). Women still remain to have study and were able to fill the questionnaire. Exclusion poor understanding of the physiology of the genital tract criteria were: age under 18 years, age above 50 years, (14). Reproductive, menstrual, and sexual functions of patients who were no sure about sexual activity after the uterus must be considered. Direct sexual function operation, patients who did not agree to participate involves uterine contractions during orgasm, while in study, patients who had different surgery extent indirect functions include: feeling less feminine after during operation – had unplanned unilateral or hysterectomy, concern about sexual difficulties, or bilateral oophorectomy, patients who did not proceed changes in the attitude of her partner (9). Gynecological with sexual activity within observation period after surgery may influence the sexuality in terms of self- operation. Study was performed in time period from image, sexual pain and orgasm difficulty (18). The August 2013 till February 2014. Participation in study prevailing view in the literature is that hysterectomy was offered to all patients of appropriate age and improves the overall quality of life, however, at least planned operation until 50 patients were recruited some deleterious effects of hysterectomy were reported and signed agreement form. 25 patients were planned in almost all of the articles (13). The expected changes in each study group – subtotal and total hysterectomy. can affect both partners, which is considered as a Questionnaire method was used to survey patients on fundamental issue in the relationship (9). The primary the day before operation. Standardized and validated medical conditions causing FSD can be hormonal, Sexual Quality of Life Questionnaire – Female (SQoL-F) anatomical, vascular and neural (12). The uterus and (20) was used to assess quality of sexual life before and cervix may be important factors in the physiology of after surgery. The 18-item SQoL-F was developed to sensation and orgasm, which is effected by sensory assess the sexual quality of life of women, specifically stimuli from contractions of the uterus, cervix, and to assess sexual confidence, emotional well-being and vagina. Hysterectomy may have a negative influence relationship issues. The instrument has been validated on this feedback system in the brain (15). Changes for use in broad range of women, it is self-administered depend not only on which nerves were severed by the in approximately 7 minutes, recall period is the previous surgery, but also the genital regions whose stimulation four weeks, each item is rated on a 5-point Likert scale, the woman enjoys for eliciting sexual response. Because designed for use among women who are 18+ in age. 27 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) SQoL-F does not provide cut-scores of sexual function in Group2 using concomitant medications at the time levels, result can be analyzed as primary endpoint. Nine of operation. Differences between the groups were not questions were added to find out age, co-morbidities, statistically significant. Standardized SQoL-F points (to concomitant medications, history of hormone a 0-100 scale) before surgery were 71.61 in Group1 (estrogen / progestin) use in period of last six month and 68.03 in Group2. Analysis of subjective satisfaction before operation, opinion about expected impact of in main domains of sexual function before operation operation, awareness and women’s view about opinion showed comparatively lower rates of satisfaction in of their partners (partners were not asked separately), domain of pain – 35% (n=7) in Group1 and 27.8% emotional well-being with partner, self-assessment (n=5) in Group2, but differences were not statistically of seven domains of sexual function (desire, arousal, significant (see Figure 1). Patients’ expectations about lubrication, orgasm, satisfaction, pain, partner). Each impact of planned operation on their sexuality are questionnaire got a code and no private data were used. described in Table 1. Although patients of Group2 Prior to participation, patients were not screened to rule were worried about possible negative impact more out any particular medical conditions as an indication frequently, differences were not statistically significant for operation because of the extensive overlap of (p=0.12). Only 55% (n=11) of Group1and 38.9% gynecological indications for each patient. Patients were (n=7) of Group2 told their partners completely about divided in two groups: subtotal hysterectomy (Group1) planned surgery, 30% (n=6) of Group1and 50% (n=9) and total hysterectomy (Group2). Initially there were of Group2 told their partners partly about planned 50 patients - 25 patients in each group. There were five surgery, but 15% (n=3) of Group1and 11.1% (n=2) of patients excluded from the Group1: one patient refused Group2 did not tell their partners at all about planned to continue participation during observation period, surgery. 30% (n=6) of partners of Group1patients and one patient divorced from partner after operation, 38.9% (n=7) of partners of Group2 patients thought three patients had unplanned oophorectomy during that nothing will change about woman’s sexuality after operation, one patient had changed partner after operation, 15% (n=3) of partners of Group1patients and operation. There were seven patients excluded from the 5.6% (n=1) of partners of Group2 patients thought that Group2: one patient refused to continue participation woman’s sexual function will improve after operation, after reading the questionnaire, five patients had no one of partners of Group1patients and 11.1% (n=2) unplanned oophorectomy during operation, one patient of partners of Group2 patients thought that woman’s did not proceed with sexual activities within three sexual function will decline after operation, 55% months because of suture complications (gynecologist (n=11) patients of Group1and 44.4% (n=8) patients recommendation). In total 38 (20 in Group1 and 18 in of Group2 could not answer about their partner’s Group2) fully and correctly completed questionnaires opinion concerning expected impact of operation on were used for data analysis. Study was approved by their sexual function. Mean period of beginning sexual the Ethics Committee of Riga Stradins University. activities after operation was 5.15 weeks after surgery SQoL-F calculation was performed in compliance with in Group1 and 5.78 weeks in Group2, all patients standardized scoring system. Distribution of variables from both groups proceeded with sexual activities within and between groups was assessed using rxc after operation. Patients from Group1 proceeded with or 2x2 frequency tables. Statistical significance of sexual activities more often after 6 weeks (35%, n=7), differences was tested by Pearson chi2 test or Fisher’s patients from Group2 proceeded with sexual activities exact test. SQoL-F mean scores and standardized more often after 4 weeks (27.8%, n=5) and 8 weeks parameters before surgery and 3 months after surgery (27.8%, n=5). Differences were statistically significant were calculated for both groups. Statistical significance (p=0.03). Five patients from Group1 (25%) proceeded of differences between groups and between different with sexual activities 2 weeks after surgery, which time points within one group was tested by means of is before recommended post-operative abstinence paired t test, two sample t test and by means of Mann- period (4 weeks). There were no statistically significant Whitney test. P value less than 0.05 was chosen as a differences in postoperative complications in Group1 level of statistical significance. (10%, n=2) and Group2 (16.7%, n=3). No one of the study group patients had any new co-morbidity during RESULTS three month period after operation. There was a slight Minimal age of patients was 32 years, maximal age statistically insignificant decrease of SQoL-F points was 50 years. Mean age of Group1 (n=20) was 45.2 ± within each group after three months observation 2.92 years, mean age of Group2 (n=18) was 44.5 ± 4.78 period: -0.44 points in Group1 (p=0.92) and -2.47 points years. There were 35% (n=7) patients in Group1 and in Group2 (p=0.67). Comparing mean standardized 22.2% (n=4) patients in Group2 who had hormone SQoL-F points between groups after three months post- using history in last six months before operation, operation period, there was a difference 6.50 points less differences were not statistically significant (p=0.07). in Group2, which is not statistically significant (p=0.43). There were 45% (n=9) patients in Group1 and 38.9% 65% (n=13) patients of Group1and 55.6% (n=10) of (n=7) patients in Group2 having other co-morbidity Group2 three months after surgery confirmed that they except gynecological condition. There were 50% feel emotionally comfortable with their partners, 5% (n=10) patients in Group1 and 27.8% (n=5) patients (n=1) of Group1and 5.6% (n=1) of Group2 did not feel 28 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) emotionally comfortable, but it was difficult to answer technique are major but not the only essential factors for 30% (n=6) of Group1and 38.9% (n=7) of Group2. from summary impact on sexual function after surgery. Subjective reported changes of the main domains of Data showed the same level of emotional partnership sexual function in both groups are depicted on Figure 2 well-being before and after operation (women’s view). and Figure 3. Worsening of sexual function seems to be In this study there were no further post-operation more frequent in Group2, however differences are not interviews and relationship analysis performed about statistically significant. Patients’ self-assessment about future partnership attitudes and relationship changes in impact of hysterectomy operation on their sexuality case of telling and not telling partner about operation. is described in Table 2. Although patients of Group2 There was one patient in subtotal hysterectomy group more frequently indicated negative impact, differences who divorced from her partner in three months period were not statistically significant (p=0.30). 55% (n=11) after operation. Her questionnaire data showed that of partners of Group1patients and 38.9% (n=7) of she did not tell her partner about planned operation, in partners of Group2 patients thought that nothing has this case it was impossible to analyze potential reasons changed about their partner’s sexuality after operation, for divorce without deeper interview of both partners. 20% (n=4) of partners of Group1 patients and 27.8% Asking woman about their partner’s opinions regarding (n=5) of partners of Group2 patients thought that their planned operation and post-operative changes brings partner’s sexual function has improved after operation, some risk of misinformation, because partners can 10% (n=2) of partners of Group1 patients and 27.8% have different opinions if asked directly, but according (n=5) of partners of Group2 patients thought that their to the protocol, partners were not directly involved in partner’s sexual function has declined after operation, the study. Also telling partner incomplete information 15% (n=3) of Group1 patients and 5.6% (n=1) of about planned operation can change his opinion about Group2 patients could not answer about their partner’s expected impact of surgery. opinion concerning impact of operation on their sexual Since there were no statistically significant differences function. Although partners of patients of Group2 more in co-morbidities, concomitant medications, hormone frequently indicated negative impact, differences were use history and post-operative complications between not statistically significant (p=0.40). groups, authors consider both study groups comparable. Wide interpretation of study results and generalization DISCUSSION to all population of gynecological patients is restricted by Data from this study prove that sexual health and future relatively small study group, but it gives an opportunity sexual function is important issue for gynecological to see and analyze tendencies and actualize the problem. patients. Usually people undergoing surgical procedures Disadvantage of questionnaire method is a subjective anticipate emotional support from their family. conception of questions, remembrance failures, as well This study demonstrates that in case of planned as impossible verification or particularization of answers. hysterectomy there are many patients who did not tell Women should be provided with as much information their partners about operation at all (13.16%) or told as possible and invited to participate in the decision only partly (39.47%). If the partners are not aware of making about the type of hysterectomy. Such planned surgery and possible difficulties, patients lose empowerment may well improve satisfaction rates after opportunity of wholesome support. Although previous surgery (11). Continuous research is necessary to obtain study data support viewpoint that most probably women more information about many possible factors that may will neither lose their sexual desire after hysterectomy, have an impact on sexual function after hysterectomy. nor they will lose their feminine shape or style (9), All patients from this study group are continuing sexuality after hysterectomy is still cause of great participation in study for further observation period anxiety of patients and continuous ambiguity for health to assess quality of sexual life after six months post- care providers. Women require more information and operation period. evidence based data about possible impact of operation to be fully informed about all aspects before consent of CONCLUSIONS scheduled surgery. Gynecological patients before scheduled hysterectomy This study did not prove statistically significant changes are worried about possible negative impact of surgery of quality of sexual life after operation not within each on their sexual function. Many patients do not tell their study group, nor between two groups of different surgical partners about operation or tell only partly, thereby extent – subtotal and total hysterectomy, which can be depriving themselves full emotional support from explained with relatively small initial number of recruited partner. There is no statistically significant impact of patients and loss of 12 excluded patients in the study hysterectomy on sexual quality of life. There are no process, however in some positions there was tendency statistically significant differences in sexual quality of of more frequent expected negative effects and reported life between total and subtotal hysterectomy. negative changes among patients of total hysterectomy group. Analyzing each questionnaire separately, there Conflict of interest: None were examples of marked worsening and examples of marked improvement of sexual function in both study groups. It seems that hysterectomy itself and its surgical 29 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) REFERENCES 13. Komisurak BR, Frangos E, Whiple B. Hysterectomy 1. Amin A, Ali A, Amin Z, Sani FN. Justification for Improves Sexual Response? Addressing a Crucial hysterectomies and frequency of histopathological Omission in the Literature // J Minim Invasive lesions of hysterectomy at a Teaching Hospital Gynecol, 2011; 18(3):288-295 in Peshawar, Pakistan // Pak J Med Sci, 2013; 14. Lekovic J, Pangasa M, Reiss J, Chan M, Prasad 29(1):170-172 L, Taubel DA. Does prior hysterectomy improve 2. Burri A, Spector T. 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Satisfaction rates of main domains of sexual Fig. 2.Changes of main domains of sexual function function before operation (%) after operation in Group1 (%) Partner Pain Sa sfa con Beer Org asm No cha nges Worse Lubricaon Arous al Desire 0% 20% 40% 60% 80% 100% Fig. 3. Changes of main domains of sexual function after operation in Group2 (%) Table 1. Patients’ expectations about impact of Table 2. Patients’ self-assessment about impact of planned operation on their sexuality hysterectomy operation on their sexuality Expected impact Group1 Group2 Reported impact Group1 Group2 n / total (%) n / total (%) n / total (%) n / total (%) Improve 4/20 (20) 1/18 (5.6) Improved 7/20 (35) 5/18 (27.8) Decline 1/20 (5) 6/18 (33.3) Declined 1/20 (5) 4/18 (22.2) Nothing will change 8/20 (40) 7/18 (38.9) Nothing has changed 10/20 (50) 9/18 (50) Do not know 7/20 (35) 4/18 (22.2) Do not know 2/20 (10) 0/18 (0)

Journal

Acta Chirurgica Latviensisde Gruyter

Published: Nov 24, 2014

Keywords: Medicine; Clinical Medicine; Surgery; Surgery, other

References