Female sexuality does not need a uterine cervix: no need for subtotal hysterectomy

Female sexuality has been, and still is, mythical. This is largely because it is nearly impossible to create other than observational data, not to mention the possibility of blinded studies. This also concerns the role of the uterine cervix in female sexual arousing and satisfaction. Hysterectomy is the most common gynecologic operation; for example, in Finland approximately one-fifth of women over 45 years undergo hysterectomy (1). Most (approximately 90%) hysterectomies are performed for diseases that affect only the uterine corpus, such as fibroids, menorrhagia and other bleeding disturbances, adenomyosis or prolapse 1-3). Thus, it can be asked if the innocent cervix should be removed concomitantly with the corpus. Leaving the cervix behind shortens the operation time and reduces the risk of operative complication (4). Subtotal hysterectomy has increased in popularity in recent years because it requires less mobilization of the bladder and minimizes the risk of injury to the ureter. It is also associated with lower rates of wound infection, hematoma and vaginal granulation (2, 4). Further support for subtotal hysterectomy can be found in the claims that the cervix plays a crucial part in female sexuality (5). Two observational studies suggested that the subtotal hysterectomy maintains female capacity to orgasm better than total hysterectomy (5, 6). The background of these studies lies in the fact that total abdominal hysterectomy damages the autonomous innervation of the cervix and proximal vagina more than subtotal hysterectomy does, but of course women's (subconscious) psychological reactions due to the total removal of the uterus might play a part. These studies and some other observations have led to the perception that subtotal hysterectomy and leaving the uterine cervix intact results in better sexual function than total removal of the uterus, although this has not been seen in more recent studies (4, 7). In this issue Vibeke Zobbe and coworkers report their multicenter 1-year follow-up trial of Sexuality after total versus subtotal hysterectomy (9). This is a large study consisting of 319 women who were carefully randomized to total (n = 158) or subtotal (n = 161) hysterectomy. The rules of clinical science were followed as carefully as possible. The authors also followed 185 other women who made their own choice between hysterectomy or subtotal hysterectomy. Both forms of hysterectomies decreased dyspareunia, but very similarly. Moreover, the mode of operation did not affect the female orgasm. And finally, the type of surgery was no determinant for women's desire for sex, frequency of intercourse, or general sexual satisfaction. The variables that did predict postoperative sexual satisfaction were preoperative satisfaction with sexual life, good relationship to partner, chronic disease and hormone replacement therapy. The findings, which are of course more convincing in the randomized part of the study, were similar in the observational study group. The new Danish study shows that total abdominal hysterectomy is as good as subtotal abdominal hysterectomy with regards to female sexuality. In this respect there is no sound indication for subtotal hysterectomy. It should be further noted that approximately 7% of patients report scanty cyclic bleedings after subtotal hysterectomy (4). Moreover, we should also keep in mind that the cervical stump still has a normal risk of cervical cancer; the cumulative incidence, that is the lifetime risk until 84 years of age, is 0.5%. This is a considerable concern especially in countries that do not screen for cervical cancer with organized pap-screening programs (8). Although previous data do not suggest any difference in bladder and/or bowel functions in women after either total or subtotal hysterectomy (4), it might be wise to call for long-term follow-up comparison between these women with regards to the risk of vaginal prolapse. The Danish randomized trial (9) would provide a good patient series for this kind of long-term study. Mervi Halttunen Dept of Obst and Gyn Helsinki University Central Hospital FI-00029 HUS Finland e-mail: [email protected]