{"paper_id":"9581bba6-4079-45a9-8a30-605d226231d1","body_text":"Review began\n 08/27/2024 \nReview ended\n 09/04/2024 \nPublished\n 09/07/2024\n© Copyright \n2024\nFerhi et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.68876\nTo Preserve or Not To Preserve: A Prospective\nCohort Study on the Role of the Cervix in Post-\nHysterectomy Sexual Functioning\nMohamed Ferhi \n, \nNadia Marwen \n, \nAmeni Abdeljabbar \n, \nJihenne Mannai \n1.\n Psychiatry, Ibn El Jazzar University Hospital, Kairouan, TUN \n2.\n Obstetrics and Gynecology, Ibn El Jazzar University\nHospital, Kairouan, TUN\nCorresponding author: \nMohamed Ferhi, \nmohamed.ferhi@fmm.u-monastir.tn\nAbstract\nBackground\nHysterectomy remains the most commonly performed gynecologic procedure worldwide, undertaken\nprimarily for benign pathologies. The choice between total hysterectomy (TH) and subtotal hysterectomy\n(STH) has been debated, particularly with respect to its impact on sexual functioning (SF).\nObjective\nThis study aimed to assess the impact of TH versus STH on SF and to determine whether preservation of the\ncervix in STH offers advantages in terms of postoperative SF.\nMethods\nA prospective cohort study was conducted at Ibn El Jazzar University Hospital, Kairouan, Tunisia, involving\nwomen aged 40 to 65 years who underwent hysterectomy for benign conditions between January 2, 2020,\nand December 31, 2021. SF was evaluated using the Arizona Sexual Experiences Scale (ASEX) and the\nFemale Sexual Function Index (FSFI) before and six months after surgery. Statistical analyses were\nperformed using SPSS version 26.\nResults\nSixty women were included, with 30 undergoing TH and 30 undergoing STH. Postoperative evaluations\nrevealed improvements in SF in both groups without statistically significant differences between TH and\nSTH in terms of SF scores or the timeline for resuming sexual activity.\nConclusions\nHysterectomy, regardless of the technique used, appears to have a positive impact on SF, largely attributed\nto symptomatic relief. Therefore, the choice between TH and STH should consider factors beyond potential\ndifferences in SF outcomes. Women considering hysterectomy for benign indications should be informed of\nthese findings to aid in the decision-making process regarding their surgical options.\nCategories:\n Psychiatry, Obstetrics/Gynecology, Therapeutics\nKeywords:\n asex, female sexual health, female sexuality, fsfi, hysterectomy \n \n, orgasm, prospective cohort, psychiatric\neffects, sexual desire, total hysterectomy\nIntroduction\nHysterectomy, the surgical removal of the uterus, is the most frequently performed gynecological procedure\nworldwide \n[1]\n. Hysterectomies are classified into two types: those performed for carcinological diseases and\nthose performed for benign pathologies, which account for the majority of cases. The benign conditions that\nwarrant hysterectomy include uterine fibroids, persistent abnormal uterine bleeding that does not respond\nto medical treatment, endometriosis, adenomyosis, and uterine prolapse \n[2]\n. Total hysterectomy (TH)\nencompasses the surgical excision of both the uterus and the cervix, whereas subtotal hysterectomy (STH) is\ncharacterized by the excision of the uterus while preserving the cervical stump.\nAlthough the distinction between TH and STH is crucial for surgical planning, it is also imperative to\nconsider the broader spectrum of potential complications associated with hysterectomy. Hemorrhagic\ncomplications are the most common, occurring in approximately 4.7% of cases regardless of the surgical\napproach \n[3]\n. Other potential complications include vesicoureteral injuries, digestive complications, and\nstatic pelvic disorders \n[3]\n. A significant complication reported in the literature is the impact of hysterectomy\non sexual functioning (SF) \n[4]\n. The controversy surrounding the role of the uterus and cervix in the female\nsexual response stems from differences in innervation and brain projections between the cervix and clitoris.\n1\n2\n2\n1\n \nOpen Access Original Article\nHow to cite this article\nFerhi M, Marwen N, Abdeljabbar A, et al. (September 07, 2024) To Preserve or Not To Preserve: A Prospective Cohort Study on the Role of the\nCervix in Post-Hysterectomy Sexual Functioning. Cureus 16(9): e68876. \nDOI 10.7759/cureus.68876\n\nSome authors argue that the cervix is involved in female orgasm. Lopès P and Poudat F-X, in the Manual of\nSexology, proposed mechanisms explaining the potential involvement of the uterine cervix in the orgasmic\nresponse \n[5]\n. They suggested that the uterus likely plays a role in the female sexual response through the\nround ligaments, and mobilization of the cervix during penetration may stimulate the vulva by stretching\nthese ligaments. Similarly, Komisaruk BR and Whipple B \n[6]\n proposed the existence of three distinct entities\nthat contribute to female orgasms: cervical, vaginal, and clitoral orgasms. On the other hand, recent\nfunctional imaging studies have shed light on the crucial role of the brain in the orgasmic response \n[7]\n. This\nsuggests that orgasm is not merely a reflexive reaction but rather a complex process centered on the brain.\nConsequently, the brain, rather than the cervix, vagina, or clitoris, can be considered the center of desire and\npleasure \n[7]\n. Furthermore, any major pelvic surgery or injury has the potential to damage the nerves and\nblood vessels that supply the vagina and clitoris, which can affect SF after surgery. Despite these theoretical\nconsiderations, empirical studies directly comparing the sexual outcomes of TH versus STH are sparse and\ninconclusive \n[8-11]\n.\nGiven the nuanced debate surrounding the physiological and psychological roles of the cervix in sexual\nsatisfaction and response, the decision between TH and STH is of significant concern. This decision not only\nimpacts the surgical management of benign gynecological conditions but also has potential consequences\nfor postoperative SF. The preservation of the cervix in STH, as opposed to complete removal in TH, raises\npertinent questions about their respective impacts on sexual health outcomes. Therefore, this study aimed\nto fill the literature gap by providing a comprehensive comparison of outcomes of SF in patients undergoing\nTH versus STH for benign conditions.\nMaterials And Methods\nStudy design and setting\nThis study was carried out in the Department of Obstetrics and Gynecology at Ibn El Jazzar University\nHospital, Kairouan, Tunisia. Consecutive women between the ages of 40 and 65 years who had received a\nhysterectomy for a benign indication from January 2, 2020, to December 31, 2021, were selected for inclusion\nin this prospective cohort study.\nEligibility criteria\nThe exclusion criteria were defined to ensure minimized confounding factors that affect SF. Participants\nwere excluded if they had preexisting psychiatric conditions, including major depressive disorder, anxiety\ndisorders, bipolar disorder, schizophrenia, and sexual disorders diagnosed according to the Diagnostic and\nStatistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Verification of psychiatric conditions\nwas carried out through communication with treating psychiatrists for patients under psychiatric care.\nAdditionally, women were excluded if they had used, within the three months prior to the study, any\nmedications known to significantly alter SF. This included selective serotonin reuptake inhibitors (SSRIs),\ntricyclic antidepressants, antipsychotics, antiandrogens, specific antihypertensives (e.g., beta-blockers), and\nhormone replacement therapy. Other exclusion criteria included the need for concomitant surgical\ninterventions (e.g., prolapse repair), hysterectomies performed for hemostatic or carcinological reasons, and\nincidental discovery of malignancy in the hysterectomy sample postoperatively. Exclusion also applied to\nindividuals who reported no sexual activity within six months prior to surgery, with sexual activity defined\naccording to the WHO as encompassing any sexual acts undertaken for pleasure, whether with a partner or\nby masturbation. Further exclusion criteria included loss of a sexual partner during the study period,\nincomplete questionnaire responses, any medical condition that interferes with the understanding of the\nevaluation, and refusal to participate in the study.\nDetailed surgical procedures and perioperative protocols\nUpon admission to the study, a comprehensive initial assessment was performed for all participants to\ndocument their medical history and perform a thorough gynecological evaluation. This evaluation included\na gynecologic examination, transvaginal ultrasound, and the collection of samples for basic laboratory tests.\nTo standardize perioperative care and minimize variability in treatment outcomes, a uniform perioperative\nmanagement protocol was implemented across all participating hospitals. This protocol included the\nadministration of perioperative prophylaxis for deep vein thrombosis, using low molecular weight heparin\n(ENOXA 4000 UI ANTI-XA/0.4ML) administered subcutaneously. Analgesia was the same for all patients.\nAdditionally, to reduce the risk of infection at the surgical site, a single dose of prophylactic antibiotic was\nadministered intravenously during surgery.\nThe decision-making process regarding the surgical technique used for hysterectomy was primarily guided\nby the personal preference and technical expertise of the operating gynecologist. However, the indication for\nhysterectomy, determined by the specific medical condition of the patient, also influenced the choice of\nsurgical technique. The surgical procedures for all types of hysterectomy were discussed with each patient,\nand the suitable hysterectomy type was selected after the patient's informed consent.\nData collection\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n2\n of \n12\n\nData were collected through direct interviews with patients. An initial evaluation interview was conducted\nthe day before surgery, and a second interview was conducted 6 months after surgery during the outpatient\nvisit. The same interviewer asked questions in a calm and private setting, respecting the patient’s privacy.\nBoth groups were monitored in the same way throughout the study period. Medical and obstetric records\nwere used to collect data on the sociodemographic and clinical characteristics of the patients. For the data\nrelated to the operation, we consulted the operating reports and the monitoring sheets.\nAssessment measures\nSF was assessed using two questionnaires. The first questionnaire was the Arizona Sexual Experiences Scale\n(ASEX). It is a simple and brief questionnaire used to identify possible sexual dysfunction. It consists of five\nitems that assess sexual drive, sexual arousal, vaginal lubrication, orgasm, and satisfaction. Each item is\nrated on a scale of 1 to 6, ranging from hyperfunctioning to hypofunction. A total ASEX score greater than or\nequal to 18 is considered the cutoff point for sexual dysfunction. The ASEX scale has a high specificity of\n95.52%, a sensitivity of 70%, a positive predictive value (PPV) of 89.66%, and a negative predictive value\n(NPV) of 85.33%. It is also well-accepted by patients, making it suitable for assessing changes in SF over time\n[12,13]\n.\nThe second questionnaire was the Female Sexual Function Index (FSFI). The FSFI is a widely used\nmeasurement instrument in sexual medicine. It consists of 19 questions that assess six components: desire,\nsexual arousal, vaginal lubrication, orgasm, sexual satisfaction, and pain. Each item is scored on a scale from\n0 to 5 or from 1 to 5. The score for each domain is obtained by multiplying the score by a corresponding\nfactor for each element. The maximum score for all assessed domains is 6. A total score of 26.55 is the cutoff\nvalue for diagnosing sexual dysfunction. The FSFI has been extensively validated and used in research on\nsexual medicine \n[14,15]\n.\nEthical considerations\nThe ethics committee of Ibn El Jazzar University Hospital gave official approval for the study to be carried\nout (under approval number 4523). The women had been informed of the study's goal, procedure, benefits,\nnature, follow-up, and right to withdraw at any time without explanation and had given their written\nconsent. Through the coding of all the data and the protection of the acquired data, the confidentiality and\nanonymity of each woman was guaranteed.\nStatistical analysis\nStatistical analysis was performed using the SPSS, version 26 software. Qualitative variables were described\nusing observed numbers (n) and frequencies (%), while quantitative variables were examined for distribution\nusing skewness and kurtosis coefficients, along with normality tests such as the Shapiro-Wilk, Kolmogorov-\nSmirnov, and Anderson-Darling tests, depending on the sample size and distribution characteristics.\nVariables following a normal distribution were described using means and standard deviations, while\nmedians and interquartile ranges were used for variables not normally distributed. The association between\ntwo categorical variables was assessed using the Chi-square test, with Fisher's exact test applied when Chi-\nsquare test assumptions were not met. For comparing a qualitative variable with a quantitative one,\nStudent's t-test was used for normally distributed data, and the Mann-Whitney U test for two independent\nsamples was employed for data that did not follow a normal distribution. A significance level (p-value) of\n0.05 was established for all tests.\nResults\nSociodemographic and clinical characteristics\nA total of 84 patients were evaluated for eligibility, and 60 patients were included, with 30 women in each\ngroup, as shown in Figure \n1\n. Table \n1\n presents the sociodemographic characteristics of the patients. The\naverage age was slightly over 52 years. The mean duration of marriage was around 23 years. When\nexamining educational levels, a quarter of the participants had no formal education, slightly more than a\nquarter had completed primary education, another quarter had secondary education, and one-fifth had\nachieved higher education. Almost half of the group was classified as having a poor economic level. Lifestyle\nhabits revealed a low prevalence of tobacco use (less than 10%) and regular physical activity (slightly more\nthan 8%), and no participants reported alcohol consumption. BMI classification showed a small fraction\n(less than 2%) as underweight, more than half as having normal BMI, around one-fifth were overweight, and\nslightly less than a third were classified as obese.\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n3\n of \n12\n\nFIGURE\n 1: Flowchart of participant recruitment and selection.\nTH: Total hysterectomy; STH: Subtotal hysterectomy.\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n4\n of \n12\n\nCharacteristics\nTotal, n (%)\n b\n, \n \nn=60\nTH, n\n \n(%), n=30\nSTH, n (%), n=30\nMean age\n \n(SD)\na\n52.1 (7.3)\n55.87 (6.8)\n48.3 (5.6)\nAge intervals\na\n(40-49) \n24 (40.0)\n-\n-\n(50-59)\n22 (37.0)\n-\n-\n(60-69)\n14 (23.0)\n-\n-\nMarriage duration \na\nMean (range)\n23.5 (15.0-32.0)\n26.5 (19.7-32.0)\n20 (15.0-23.2)\n> 20\n31 (52.0)\n-\n-\n< 20\n29 (48.0)\n-\n-\nEducational level \nIlliterate\n15 (25.0)\n21 (70.0)\n11 (36.7)\nPrimary\n17 (28.0)\nSecondary\n16 (27.0)\n9 (30.0)\n19 (63.3)\nSuperior\n12 (20.0)\nPoor economic level\n27 (45.0)\n14 (46.7)\n13 (43.3)\nLifestyle habits\nTobacco use\n4 (6.7)\n1 (3.3)\n3 (10.0)\nRegular physical activity\n5 (8.3)\n1 (3.3)\n4 (13.3)\nAlcohol consumption\n0 (0.0)\n-\n-\nBody Mass Index\nUnderweight\n1 (1.7)\n19 (63.3)\n13 (43.3)\nNormal\n31 (51.7)\nOverweight\n11 (18.3)\n11 (36.7)\n17 (56.7)\nObese\n17 (28.3)\nTABLE\n 1: Sociodemographic characteristics of the study participants (n=60).\nTH: Total Hysterectomy; STH: Subtotal Hysterectomy; n: Frequencies; %: Percentages.\nNotes\n:\n a\n in years; \nb\n percentages are expressed out of the total number of participants.\nTable \n2\n displays the clinical and operative characteristics of the patients. Diabetes was prevalent in\napproximately one-fourth of the participants. Median gravidity and parity were reported as four pregnancies\nand two live births, respectively. In particular, more than 90% of the cohort had a history of childbirth, with\naround 14.5% undergoing cesarean sections and a predominant majority experiencing vaginal deliveries.\nThe onset of menopause occurred at a mean age of 46 years, affecting 70% of the participants.\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n5\n of \n12\n\nCharacteristics\nTotal, n (%)\na \n, n=60\nHT, n (%), n=30\nHT, n (%), n=30\nHistory of diabetes\n14 (23.3)\n12 (40.0)\n2 (6.7)\nGravidity, median (IQR)\n4 (3-6)\n6 (3-8)\n3 (3-4)\nNulligravid\n5 (8.3)\n3 (10.0)\n2 (6.7)\nParity, median (IQR)\n2 (3-5)\n5 (3-8)\n3 (3-4)\nNulliparous\n5 (8.3)\n3 (10.0)\n2 (6.7)\nHistory of childbirth\n55 (91.7)\n-\n-\nHistory of a cesarean section\n8 (14.5)\n-\n-\nHistory of a vaginal delivery\n47 (85.5)\n-\n-\nNumber of vaginal deliveries, median (IQR)\n3 (2-6)\n5 (3-8)\n3 (0-3)\nHistory of an instrumental extraction\n3 (6.4)\n1 (3.3)\n2 (6.7)\nMenopause\n42 (70.0)\n25 (83.3)\n17 (56.7)\nMenopause age of onset, mean (range)\n46 (39-55)\n-\n-\nPreoperative clinical symptoms\nChronic pelvic pain\n30 (50.0)\n10 (33.3)\n20 (66.7)\nAbnormal uterine bleeding\n18 (30.0)\n8 (26.7)\n10 (33.3)\nSensation of a ball in the vagina\n12 (20.0)\n12 (40.0)\n0 (0.0)\nSurgical indications\nUterine leiomyomas\n26 (43.3)\n10 (33.3)\n16 (53.3)\nUrogenital prolapses\n12 (20.0)\n12 (40.0)\n0 (0.0)\nAdenomyosis\n12 (20.0)\n3 (10.0)\n9 (30.0)\nAbnormal uterine bleeding\n10 (16.7)\n5 (16.7)\n5 (16.7)\nIntervention\nTotal hysterectomy\n30 (50.0)\n-\n-\nSubtotal hysterectomy \n30 (50.0)\n-\n-\nSurgical approach\nVaginal route\n14 (23.3)\n14 (46.7)\n0 (0.0)\nLaparotomy\n46 (76.6)\n16 (53.3)\n30 (100.0)\nBilateral adnexectomy\n43 (71.7)\n25 (83.3)\n18 (60.0)\nPost-operative complications\nBladder wounds\n3 (5.0)\n-\n-\nPostoperative peritonitis\n1 (1.7)\n-\n-\nSurgery site infection\n2 (3.4)\n-\n-\nTABLE\n 2: Clinical and operative characteristics of the study participants (n=60).\nTH: Total Hysterectomy; STH: Subtotal Hysterectomy; n: Frequencies; %: Percentages; IQR: Interquartile Range.\nNotes\n:\n \na\n Percentages are expressed out of the total number of participants.\nHalf of the participants reported chronic pelvic pain, while one-third and one-fifth of the study group noted\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n6\n of \n12\n\nabnormal uterine bleeding and sensation of a ball in the vagina, respectively. The surgical intervention\npredominantly involved laparotomy, chosen in 76.6% of cases. Postoperative complications were rare\n(10.0%), with bladder wounds, postoperative peritonitis, and surgical site infections observed in a minority\nof cases.\nSexual functioning results\nThe mean ASEX and FSFI scores showed improvement in SF from preoperative to postoperative evaluation in\nboth groups, as summarized in Table \n3\n and Figure \n2\n. Improvements were observed in all SF domains,\nincluding sexual desire, arousal, lubrication, orgasm, satisfaction, and pain.\n   \nTH (n=30)\nP-value\nSTH (n=30)\nP-value\nPre-op\n a\nPost-op\n b\nPre-op\n a\nPost-op\n b\nASEX domains, mean score\n±\nSD\nDesire\n5.0±1.0\n4.2±0.9\n.005\n4.9±0.8\n4.0±0.7\n< 0.001\nArousal\n5.0±0.9\n4.4±0.9\n.024\n4.8±0.6\n4.0±0.8\n< 0.001\nLubrication\n5.0±0.9\n4.3±0.8\n.007\n4.9±0.5\n3.9±0.8\n< 0.001\nOrgasm\n5.2±0.8\n4.5±0.8\n.002\n5.0±0.6\n4.1±0.9\n< 0.001\nSatisfaction\n5.3±0.9\n4.5±0.8\n.005\n5.0±0.8\n4.1±1.0\n0.001\nFSFI domains, mean score\n±\nSD\nDesire\n2.1±1.0\n3.0±0.9\n.004\n2.3±0.9\n3.1±1.0\n0.003\nArousal\n1.6±1.5\n2.7±1.1\n.001\n2.1±1.4\n3.2±1.0\n0.001\nLubrication\n1.7±1.7\n2.8±1.3\n.007\n2.0±1.4\n3.6±1.1\n< 0.001\nOrgasm\n1.6±1.6\n2.8±1.3\n.003\n2.1±1.5\n3.5±1.1\n0.001\nSatisfaction\n1.9±1.2\n2.9±1.2\n.005\n2.2±1.3\n3.4±1.1\n0.004\nPain\n1.7±1.7\n3.0±1.2\n.004\n2.3±1.6\n3.9±1.4\n0.002\nFSFI total score\n10.7±8.7\n17.5±6.7\n.003\n13.2±7.6\n21.1±6.3\n0.001\nTABLE\n 3: Mean ASEX and FSFI scores from preoperative to postoperative evaluation in the TH\nand STH groups.\nTH: Total hysterectomy; STH: Subtotal hysterectomy; n: Frequencies; ASEX: Arizona Sexual Experiences Scale; FSFI: Female Sexual Function Index.\nNotes\n:\n \na\n preoperative results; \nb\n postoperative results.\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n7\n of \n12\n\nFIGURE\n 2: Comparison of the ASEX and FSFI mean scores from\nbaseline to six months after surgery for the study participants (n=60).\nASEX: Arizona Sexual Experiences Scale; FSFI: Female Sexual Function Index.\nThe preoperative mean ASEX score was 25.1, suggesting compromised SF, particularly in the orgasm and\nsatisfaction domains. After hysterectomy, both groups exhibited a notable reduction in ASEX scores, with\nthe aggregate mean score declining to 21.1, reflecting an improvement in SF post-surgery.\nFor the FSFI, the preoperative results showed a score of 11.9, indicative of pronounced sexual dysfunction\nwithin both the TH and STH cohorts. Although the TH group showed marginally lower FSFI scores compared\nto the STH group, this difference did not reach statistical significance. In particular, only 6.7% of the\nindividuals in both cohorts achieved a preoperative FSFI score above the normative threshold of 26.55. After\nsurgical intervention, there was a notable improvement in SF evidenced by an increase in the mean FSFI\nscore to 19.3. Postoperative FSFI scores that exceeded the normal threshold of 26.55 were observed in 10%\nof the TH group and a significantly higher proportion of 26.7% in the STH group. Despite the observed\nimprovements in SF, the statistical analysis did not reveal significant differences in the magnitude of the\nchange in these scores before and after surgery between the TH and STH groups (Table \n4\n).\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n8\n of \n12\n\nScale\nChange in medians (range)\nP-value\nTH (n=30)\nSTH (n=30)\nASEX domains\nDesire\n-1.0 (-1.0 to 0.0)\n-1.0 (-2.0 to 0.0)\n0.791\nArousal\n-1.0 (-1.2 to 0.0)\n-1.0 (-2.0 to 0.0)\n0.59\nLubrication\n-1.0 (-1.0 to 0.0)\n-1.0 (-2.0 to 0.0)\n0.34\nOrgasm\n-1.0 (-1.0 to 0.0)\n-1.0 (-2.0 to 0.0)\n0.674\nSatisfaction\n-1.0 (-1.2 to 0.0)\n-1.0 (-2.0 to 0.0)\n0.554\nFSFI domains\nDesire\n1.2 (0.0-1.8)\n1.2 (0.0-1.8)\n0.922\nArousal\n1.3 (0.6-2.4)\n1.6 (0.1-2.1)\n0.881\nLubrication\n1.5 (0.8-1.8)\n1.8 (1.2-3.0)\n0.249\nOrgasm\n1.4 (0.6-2.1)\n2.0 (-0.1 to 2.7)\n0.521\nSatisfaction\n1.2 (0.4-2.4)\n1.6 (-0.9 to 2.4)\n0.667\nPain\n1.6 (0.6-3.2)\n1.8 (-0.6 to 3.8)\n0.772\nTotal score\n9.1 (4.3-11.5)\n9.8 (-0.5 to 15.8)\n0.544\nTABLE\n 4: Comparison of the change in median scores of the ASEX and FSFI from baseline to six\nmonths after surgery between the two interventions\nTH: Total hysterectomy; STH: Subtotal hysterectomy; n: Frequencies; ASEX: Arizona Sexual Experiences Scale; FSFI: Female Sexual Function Index.\nFurthermore, the duration until the resumption of sexual activity after surgery did not differ significantly\nbetween surgical types, with both TH and STH groups experiencing a median delay of 50 and 47.5 days,\nrespectively. Furthermore, comparative analysis of SF between the two surgical approaches, laparotomy\nversus the vaginal route, within the TH cohort did not produce statistically significant differences.\nDiscussion\nOur analysis did not reveal statistically significant differences in SF scores (ASEX and FSFI) before and after\nthe operation between the TH and STH groups, with p-values greater than 0.05. This lack of significant\ndifference extends to the timeline for resuming sexual activity after surgery. The postoperative evaluation\nfor both cohorts revealed a notable improvement in SF, which was quantitatively supported by the ASEX and\nFSFI results.\nThe impact of hysterectomy on sexuality has been a subject of interest for many researchers, as it is a\nsignificant concern for both patients and surgeons. The published literature presents conflicting results. A\nsubstantial review of the literature, comprising 34 studies \n[16]\n, predominantly indicated an improvement in\nSF after hysterectomy. This was particularly evident in patients who were sexually active before the\noperation, with many reporting sustained or enhanced sexual performance postoperatively. The\npredominant explanation for our findings lies in the relief of preoperative symptoms, which correlates with\na return to normal sexual activity and increased sexual satisfaction \n[17]\n. This observation is in alignment\nwith the findings of the Maine Women's Health Study, wherein Carlson KJ et al. \n[18]\n demonstrated the\nsignificant efficacy of hysterectomy in mitigating symptoms related to common benign gynecological\nconditions, resulting in a notable improvement in SF. The study underlines the proposition that the\nimprovement in SF after hysterectomy is primarily due to the relief of symptoms facilitated by surgical\nintervention \n[18]\n. Further supporting this argument, our study does not discern appreciable differences\nattributable to the surgical method used, indicating that the benefits in SF post-hysterectomy are\nfundamentally linked to symptom relief rather than the specifics of the surgical approach. While symptom\nrelief undoubtedly contributes to improved SF after hysterectomy, as supported by our findings, it is\nimperative to also consider psychological factors, the quality of partner relationships, and patient\nexpectations before and after surgery.\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n9\n of \n12\n\nOn the other hand, a systematic review and meta-analysis \n[11]\n found that hysterectomy was not associated\nwith significant changes in female SF. However, Dedden SJ et al. \n[11]\n stated that the studied population was\ntoo heterogeneous to determine the direction of changes in SF. The conclusion drawn from the meta-\nanalysis was tempered by the recognition that the absence of evidence is not synonymous with evidence of\nabsence. Furthermore, Lonnée-Hoffmann R and Pinas I \n[19]\n explored the potential negative impact of\nhysterectomy on SF, highlighting the risk of long-term health problems and sexual dysfunctions such as\ndiminished sexual pleasure, frequency, and comfort. These dysfunctions were attributed to hormonal\nimbalances, specifically reductions in androgen and estrogen, resulting from the surgery.\nA possible explanation for the observed heterogeneity in results across the literature may be attributed not\nto the hysterectomy procedure itself but rather to the underlying surgical indications, which can predict the\ndegree of alteration in SF after hysterectomy. It is possible that individuals who undergo hysterectomy for\nconditions such as fibroids or menorrhagia may report improvements in SF due to the resolution of these\nspecific complaints. On the contrary, individuals who undergo hysterectomy for chronic pelvic pain might\ncontinue to experience postoperative pain, resulting in negligible improvement in SF. Consequently, future\ninvestigations should focus on analyzing changes in SF after hysterectomy within homogeneous cohorts\ndelineated by surgical indications.\nIn evaluating the impact of the surgical approach on SF comparing TH with STH, our findings did not\nindicate significant superiority of one method over the other. This outcome is consistent with the prevailing\nbody of literature. A recent systematic review and meta-analysis \n[11]\n, along with previous clinical trials\n[8,20-22]\n, have suggested that TH does not demonstrate inferiority to STH in terms of SF variations observed\nfrom baseline to the postoperative phase. In addition, a comprehensive Cochrane review in 2012 \n[23]\nincorporated data from six randomized controlled trials (RCTs) conducted between 2002 and 2010, all of\nwhich reported on SF outcomes with follow-up periods extending up to two years. A meta-analysis \n[23]\nrevealed no statistically significant differences in terms of sexual satisfaction or patient-reported\ndyspareunia between subtotal and TH. Further emphasizing the robustness of these findings, one RCT \n[24]\nincluded in the Cochrane review, which extended its follow-up to five years, similarly reported no\ndifferences in sexual satisfaction between the two hysterectomy techniques.\nIt should be noted that any major pelvic surgery or injury carries the potential risk of damaging nerves and\nblood vessels essential for normal SF. Surgeons currently lack precise knowledge about the location of these\nvital anatomical structures in the female pelvis, highlighting the need for further research to prevent\nunintentional damage during surgery. By providing comprehensive information about the sexual effects of\nhysterectomies, healthcare providers can support patients in making informed decisions and addressing\ntheir concerns. Ultimately, optimizing patient satisfaction and overall quality of life should remain a key\nobjective in the management of benign gynecological conditions requiring hysterectomy.\nLimitations\nOur study has several limitations that warrant consideration. First and foremost, the modest cohort size\nlimits the statistical power to detect minor but potentially clinically relevant differences. This raises the\nquestion of the clinical importance of potential differences that remain undetected in a sample of 60\npatients. Furthermore, the absence of randomization in the allocation of patients to the specific type of\nhysterectomy performed introduces the possibility of confounding by baseline disparities in factors affecting\nsexual well-being. An ideal research design would have been a RCT; however, the recruitment of a sufficient\nnumber of gynecologists for such a study proved challenging, limiting our ability to conduct it. Another\nconstraint is the participation of multiple surgeons in the procedures, all within a single center setting. This\naspect may detract from the external validity of our findings, as the results may not be generalizable across\ndifferent surgical environments or physician expertise. Future research could benefit from a large\nmulticenter prospective cohort study to improve the generalizability of the findings. Lastly, we acknowledge\nthat the follow-up period did not allow an evaluation of longer-term outcomes of hysterectomy, such as the\npotential for early menopause onset and tissue-related complications, including pelvic prolapse and\nincontinence, which can manifest within 15 years after surgery \n[25]\n. Addressing these long-term effects in\nfuture research is crucial for a more comprehensive understanding of the impact of hysterectomy on sexual\nand overall health.\nConclusions\nThe findings of our study indicated that hysterectomy had a positive impact on overall SF, which might be\nexplained by symptomatic relief from conditions that warrant hysterectomy. Furthermore, there were no\nstatistically significant differences in SF between TH and STH. Therefore, preservation of the cervix with the\naim of improving overall sexual satisfaction cannot be recommended. Women who require hysterectomy\nshould be informed about the results of previous studies mentioned earlier, enabling them to make informed\ndecisions about the most suitable procedure.\nAdditional Information\nAuthor Contributions\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n10\n of \n12\n\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nAcquisition, analysis, or interpretation of data:\n  \nMohamed Ferhi\nDrafting of the manuscript:\n  \nMohamed Ferhi\nCritical review of the manuscript for important intellectual content:\n  \nMohamed Ferhi, Nadia Marwen,\nAmeni Abdeljabbar, Jihenne Mannai\nConcept and design:\n  \nNadia Marwen, Ameni Abdeljabbar, Jihenne Mannai\nSupervision:\n  \nNadia Marwen, Jihenne Mannai\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. The Ethics Committee of\nthe Ibn El Jazzar University Hospital issued approval 4523. \nAnimal subjects:\n All authors have confirmed\nthat this study did not involve animal subjects or tissue. \nConflicts of interest:\n In compliance with the\nICMJE uniform disclosure form, all authors declare the following: \nPayment/services info:\n All authors have\ndeclared that no financial support was received from any organization for the submitted work. \nFinancial\nrelationships:\n All authors have declared that they have no financial relationships at present or within the\nprevious three years with any organizations that might have an interest in the submitted work. \nOther\nrelationships:\n All authors have declared that there are no other relationships or activities that could appear\nto have influenced the submitted work.\nReferences\n1\n. \nHammer A, Rositch AF, Kahlert J, Gravitt PE, Blaakaer J, Søgaard M: \nGlobal epidemiology of hysterectomy:\npossible impact on gynecological cancer rates\n. Am J Obstet Gynecol. 2015, 213:23-29.\n10.1016/j.ajog.2015.02.019\n2\n. \nRamdhan RC, Loukas M, Tubbs RS: \nAnatomical complications of hysterectomy: a review\n. Clin Anat. 2017,\n30:946-952. \n10.1002/ca.22962\n3\n. \nChevrot A, Margueritte F, Fritel X, Serfaty A, Huchon C, Fauconnier A: \nHysterectomy: practices evolution\nbetween 2009 and 2019 in France\n. Gynecol Obstet Fertil Senol. 2021, 49:816-822. \n10.1016/j.gofs.2021.07.002\n4\n. \nMonterrosa-Castro A, Monterrosa-Blanco A, Beltrán-Barrios T: \nInsomnia and sexual dysfunction associated\nwith severe worsening of the quality of life in sexually active hysterectomized women\n. Sleep Sci. 2018,\n11:99-105. \n10.5935/1984-0063.20180019\n5\n. \nLopès P, Poudat F-X: \nManuel de sexologie\n. Elsevier-Masson, Amsterdam; 2022.\n6\n. \nKomisaruk BR, Whipple B: \nFunctional MRI of the brain during orgasm in women\n. Annu Rev Sex Res. 2005,\n16:62-86.\n7\n. \nCour F, Droupy S, Faix A, Methorst C, Giuliano F: \nAnatomy and physiology of sexuality\n. Prog Urol. 2013,\n23:547-561. \n10.1016/j.purol.2012.11.007\n8\n. \nKuppermann M, Summitt RL Jr, Varner RE, et al.: \nSexual functioning after total compared with supracervical\nhysterectomy: a randomized trial\n. Obstet Gynecol. 2005, 105:1309-1318.\n10.1097/01.AOG.0000160428.81371.be\n9\n. \nfederici francesca, Greta B, Teresa P, et al.: \nTotal versus subtotal hysterectomy for benign uterine disease:\nwhich advantages\n. Res Square. 2020, \n10.21203/rs.3.rs-45313/v1\n10\n. \nSaccardi C, Gizzo S, Noventa M, et al.: \nSubtotal versus total laparoscopic hysterectomy: could women sexual\nfunction recovery overcome the surgical outcomes in pre-operatory decision making?\n. Arch Gynecol Obstet.\n2015, 291:1321-1326. \n10.1007/s00404-014-3569-x\n11\n. \nDedden SJ, Werner MA, Steinweg J, Lissenberg-Witte BI, Huirne JA, Geomini PM, Maas JW: \nHysterectomy\nand sexual function: a systematic review and meta-analysis\n. J Sex Med. 2023, 20:447-466.\n10.1093/jsxmed/qdac051\n12\n. \nBriki M, Haffen E, Monnin J, Tio G, Nicolier M, Sechter D, Vandel P: \nSexual dysfunction and depression:\nvalidity of a French version of the ASEX scale\n. Encephale. 2014, 40:114-122. \n10.1016/j.encep.2012.10.008\n13\n. \nZakhour S, Sardinha A, Levitan M, Berger W, Nardi AE: \nInstruments for assessing sexual dysfunction in\nArabic: a systematic literature review\n. Transcult Psychiatry. 2022, 59:819-830. \n10.1177/13634615221105120\n14\n. \nHevesi K, Mészáros V, Kövi Z, Márki G, Szabó M: \nDifferent characteristics of the female sexual function\nindex in a sample of sexually active and inactive women\n. J Sex Med. 2017, 14:1133-1141.\n10.1016/j.jsxm.2017.07.008\n15\n. \nWylomanski S, Bouquin R, Philippe HJ, et al.: \nPsychometric properties of the French Female Sexual\nFunction Index (FSFI)\n. Qual Life Res. 2014, 23:2079-2087. \n10.1007/s11136-014-0652-5\n16\n. \nDanesh M, Hamzehgardeshi Z, Moosazadeh M, Shabani-Asrami F: \nThe effect of hysterectomy on women's\nsexual function: a narrative review\n. Med Arch. 2015, 69:387-392. \n10.5455/medarh.2015.69.387-392\n17\n. \nKazemi F, Alimoradi Z, Tavakolian S: \nEffect of hysterectomy due to benign diseases on female sexual\nfunction: a systematic review and meta-analysis\n. J Minim Invasive Gynecol. 2022, 29:476-488.\n10.1016/j.jmig.2021.10.012\n18\n. \nCarlson KJ, Miller BA, Fowler FJ Jr: \nThe Maine Women's Health Study: I. Outcomes of hysterectomy\n. Obstet\nGynecol. 1994, 83:556-565. \n10.1097/00006250-199404000-00012\n19\n. \nLonnée-Hoffmann R, Pinas I: \nEffects of hysterectomy on sexual function\n. Curr Sex Health Rep. 2014, 6:244-\n251. \n10.1007/s11930-014-0029-3\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n11\n of \n12\n\n20\n. \nLearman LA, Summitt RL, Varner RE, et al.: \nA randomized comparison of total or supracervical\nhysterectomy: surgical complications and clinical outcomes\n. Obstet Gynecol. 2003, 102:453-462.\n10.1016/s0029-7844(03)00664-1\n21\n. \nThakar R, Ayers S, Clarkson P, Stanton S, Manyonda I: \nOutcomes after total versus subtotal abdominal\nhysterectomy\n. N Engl J Med. 2002, 347:1318-1325. \n10.1056/NEJMoa013336\n22\n. \nEllström Engh MA, Jerhamre K, Junskog K: \nA randomized trial comparing changes in sexual health and\npsychological well-being after subtotal and total hysterectomies\n. Acta Obstet Gynecol Scand. 2010, 89:65-\n70. \n10.3109/00016340903353276\n23\n. \nLethaby A, Mukhopadhyay A, Naik R: \nTotal versus subtotal hysterectomy for benign gynaecological\nconditions\n. Cochrane Database Syst Rev. 2012, CD004993. \n10.1002/14651858.CD004993.pub3\n24\n. \nAndersen LL, Zobbe V, Ottesen B, Gluud C, Tabor A, Gimbel H: \nFive-year follow up of a randomised\ncontrolled trial comparing subtotal with total abdominal hysterectomy\n. BJOG. 2015, 122:851-857.\n10.1111/1471-0528.12914\n25\n. \nMadueke-Laveaux OS, Elsharoud A, Al-Hendy A: \nWhat we know about the long-term risks of hysterectomy\nfor benign indication-a systematic review\n. J Clin Med. 2021, 10:\n10.3390/jcm10225335\n \n2024 Ferhi et al. Cureus 16(9): e68876. DOI 10.7759/cureus.68876\n12\n of \n12","source_license":"CC0","license_restricted":false}