Comparison of the effects of total laparoscopic hysterectomy and total abdominal hysterectomy on ovarian reserve and sexual function: a non-randomised prospective study.

This study was conducted in two distinct phases. The first phase involved the development of a Sinhala version of the FSFI, which was translated and culturally adapted using standard forward-backward translation methods. The translated version was then validated in a sample of the normal population to ensure cultural appropriateness, content validity, reliability, and internal consistency before application in the patient cohort. FSFI is a self-administrated questionnaire with 19 questions assessing six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The score ranges from 1.2 to 36 and higher score indicate healthy sexual function. The second phase was designed as a prospective, non-randomised cohort study comparing women undergoing TAH and TLH at the Teaching Hospital Peradeniya, Sri Lanka, from 1st March 2024 to August 2025. Eligible participants were recruited preoperatively, and written informed consent was obtained from each patient. Ethical clearance for the study was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Peradeniya. Demographic characteristics, clinical and gynaecological details, assessment of ovarian reserve using biochemical markers and sexual function using the validated Sinhala FSFI were collected. Patient recruitment was carried out at the time of admission to the ward, where the surgical method (TLH or TAH) had already been decided at the clinic level, without any involvement of the investigators in this decision-making process. Eligible patients were initially assessed during their clinic visits, at which point pre-operative evaluations including blood investigations and ultrasound examination of the gynaecological condition were conducted. Because the surgical approach was predetermined at clinic level, allocation was non-randomised. Baseline characteristics (age, BMI, parity, marital status, education level, comorbidities, and pre-operative FSFI) were compared between groups to assess comparability. Although some variables, such as marital status showed imbalance, the main clinical variables were comparable. To account for these baseline differences and their potential influence on postoperative sexual function, variables that were imbalanced or clinically relevant (pre-operative FSFI score, parity, marital status, and education level) were adjusted for during multivariable analysis. allowed us to interpret group differences with appropriate caution. Women aged 35–45 years, premenopausal, sexually active, and scheduled to undergo hysterectomy by either TLH or TAH without oophorectomy for benign gynaecological conditions, with ASA physical status I or II, were included. Patients were excluded if they had medical comorbidities known to affect ovarian reserve, such as those with prior gonadotoxic treatment, polycystic ovarian disease, endometriosis, autoimmune disorders, insulin-dependent diabetes mellitus, or cardiovascular disease. Further exclusions included patients undergoing concomitant adnexal surgery, intraoperative conversion from laparoscopy to laparotomy, indications such as pelvic organ prolapse, bilateral ovarian cysts, or premalignant lesions, postmenopausal or sexually inactive women, and those unwilling to complete the FSFI questionnaire. A priori sample size calculation was performed based on a 95% confidence interval, 5% margin of error, and population proportion of 50%, suggesting a minimal sample size of 33 patients per group. To account for a 10% dropout rate, we aimed for 37 patients per group. Ultimately, 81 patients were recruited (TAH;37, TLH;44), exceeding the minimum requirement and ensuring sufficient power of the study analyses. Demographic details, clinical details, and gynaecological condition-related details were collected by a trained assistant. The patient was given a copy of the FSFI scoring questionnaire to assess the pre-operative sexual function. A pre-operative FSH and E2 levels were done after admission for the surgery. Post-surgical hormonal assessment was done 6 months after the surgery for each patient. Operative details were collected at the end of the surgery and each patient were reassessed for their quality of life and sexual function using the FSFI score after 6 months. Total abdominal hysterectomy and bilateral salpingectomy was performed by an expert gynaecologist who has more than 4 years of experience, according to the standard protocol that included ligation and cutting round and uretero-ovarian ligaments, separation of bladder, cutting uterine artery and cardinal ligament, and cutting and suturing vaginal cuff without using electro surgery techniques. Total laparoscopic hysterectomy and bilateral salpingectomy was also performed by the same gynaecologist for all cases. In this process, round and uretero-ovarian ligaments were sealed and cut by ligasure 10 (Covedian 1037) with blunt tip as a bipolar vessel sealing device, used with force trial generator to provide a permanent fusion for the vessels up to 7 mm diameter and heat spread was depended on the tip and the duration of activation, then uterine artery was sealed (cutting mode, power 40 W) and cut by bipolar cautery (Günter Bissinger Medizintechnik‘s Powergrip bipolar), and bladder was separated by sharp dissection. Finally, the vaginal cuff was cut by monopolar cautery at 30 W and sutured. The number of activations and exact duration of energy application were not recorded, but the use of standardised equipment and a single surgeon minimised variability in thermal exposure. During both procedures, adhesion of the bowel and omentum to the anterior wall of the abdomen, if present, would be released. Data were coded and entered into Microsoft Excel and analysed using SPSS version 21. Continuous variables were presented as mean ± standard deviation or median (IQR) and compared using either Independent t-test or Mann-Whitney U test for independent samples or the Wilcoxon Signed-Rank test for paired data, depending on the distribution of the data. Effect sizes for non-parametric tests were calculated using the formula r = Z/√N and interpreted according to Cohen’s guidelines. Changes in continuous outcomes (ΔFSFI, ΔFSH, ΔE2) were computed and compared between groups using the Mann-Whitney U test. ΔFSFI was analysed as a change score without covariate adjustment to assess whether the magnitude of change differed between groups. Categorical variables were evaluated using the chi-square test or Fisher’s exact test, as fitting. To account for baseline differences between surgical groups, analysis of covariance (ANCOVA) was performed to compare postoperative FSFI scores between groups, adjusted mean with 95% confidence intervals (CI) were reported. A p-value of less than 0.05 was deemed statistically significant.

A total 81 patients participated in this study, out of them 37 underwent TAH while 44 underwent TLH. Tests of normality were performed (Shapiro-Wilk, p  < 0.05) and all were statistically non- significant. The mean age of the cohort was 43.4 years (SD 3.28), and age distribution was similar between groups (TAH: 43.51 years, TLH: 43.30 years). Patients’ ages ranged from 36 to 50 years. The mean BMI was 23.34 kg/m² (SD 4.63), preoperative haemoglobin level was 11.1 g/dL (SD 1.65) and duration of pneumoperitoneum was 41.58 min (SD 9.16). The prevalence of comorbidities was similar in both groups, with hypertension being the most frequently observed (TAH: 13.5%, TLH: 15.9%). Table  1 compares other baseline characteristics of the two surgical groups. Values are expressed as N (%). Table 1 Baseline characteristics of the two surgical groups (TAH vs. TLH) Variable Sub variables TAH N (%) TLH N (%) P value Marital status Married 19 (51.4) 42 (95.5) < 0.001 Unmarried 1 (2.7) 2 (4.5) No of children 0 3 (8.1) 5 (11.9) 0.415 1 6 (16.2) 7 (16.7) 2 15 (40.5) 22 (52.4) 3 12 (32.4) 6 (14.3) 4 1 (2.7) 2 (4.8) Mode of delivery is Normal vaginal delivery 20 (74.1) 23 (60.5) 0.255 Mode of delivery is Cesarean section 9 (40.9) 17 (47.2) 0.639 Comorbidities HTN 5 (13.5) 7 (15.9) 0.762 DM 4 (10.8) 3 (6.8) 0.697 BA/COPD 1 (2.7) 3 (6.8) 0.621 hypothyroidism 0 (0) 3 (6.8) 0.246 DL 0 (0) 2 (4.5) 0.498 IHD/HF/Arrythmias 0 (0) 2 (4.5) 0.498 DVT 0 (0) 1 (2.3) 1.000 Previously treated for subfertility 2 (7.4) 4 (15.4) 0.420 Education level < grade 5 2 (5.4) 0(0) 0.447 O/L 4 (10.8) 9 (20.9) A/L 19 (51.4) 21 (48.8) Diploma 4 (10.8) 5 (11.6) Degree 8 (21.6) 8 (18.6) Employment Government 6 (23.1) 15 (34.1) 0.230 Private 3 (11.5) 10 (22.7) Self employed 0 (0) 1 (2.3) unemployed 17 (65.4) 18 (40.9) Presenting complaint dysmenorrhea 11 (29.7) 21 (47.7) 0.099 Menorrhagia 27 (73.0) 34 (77.3) 0.655 Abdominal pain: not related to menstruation 12 (32.4) 9 (20.5) 0.220 Dyspareunia 2 (5.4) 0 (0) 0.206 Back pain 6 (16.2) 0 (0) 0.007 other 3 (8.1) 3 (6.8) 1.000 Pre-op iron treatment Oral Fe 20 (54.1) 22 (50) 0.485 IV Fe 1 (2.7) 0 (0) Pre-op blood transfusion 4 (10.8) 3 (7) 0.698 Blood loss  250 ml 3 (8.8) 2 (4.7) Baseline characteristics of the two surgical groups (TAH vs. TLH) The indications for hysterectomy in this study were limited to benign gynaecological conditions. The most common indication in both groups was fibroid uterus, accounting for 43.7% of patients in the TAH group and 40.9% in the TLH group. Other benign indications included abnormal uterine bleeding, unresponsive to medical management and adenomyosis. Fig.  1 illustrates the distribution of these indications across both surgical groups, highlighting that fibroid uterus remained the predominant reason for undergoing hysterectomy in this cohort. Fig. 1 Distribution of indications for surgery among patients undergoing Total Abdominal Hysterectomy (TAH) and Total Laparoscopic Hysterectomy (TLH) Distribution of indications for surgery among patients undergoing Total Abdominal Hysterectomy (TAH) and Total Laparoscopic Hysterectomy (TLH) FSH levels were checked pre-operatively and 6 months after the surgery. FSH values showed increasing trends in the post-operative period indicating reduction in ovarian function. The mean pre-operative FSH level was 6.20 mIU/mL (SD 3.27) increasing to 7.31 mIU/mL (SD 3.04) post-operatively. Comparison between pre-operative and post-operative mean FSH levels are in Table  2 . Table 2 Mean FSH levels among two surgical groups before and after surgery N Pre-op FSH Mean ± SD mIU/mL Post-op FSH Mean ± SD mIU/mL TAH 37 6.57 ± 3.33 7.73 ± 3.20 TLH 44 5.89 ± 3.22 6.96 ± 2.88 Mean FSH levels among two surgical groups before and after surgery Mann-Whitney U test was used to compare whether two surgeries differ in FSH levels (TAH vs. TLH) since serum FSH levels show non-normal distribution (Shapiro-wilk, all p  < 0.05). However, p values showed no significant difference in pre ( p  = 0.341) or post-operative ( p  = 0.348) FSH levels in both groups. Wilcoxon Signed-Rank Test was used to check whether FSH levels significantly change after surgery (pre vs. post-op in the same patient). This demonstrated a significant increase in FSH levels after both surgeries. In TAH group, 32 patients showed increased FSH while 5 showed decreased levels; Z = − 4.428; p  < 0.001; effect size = 0.728. Meanwhile in TLH group 39 patients showed increased FSH while 4 showed decreased levels and 1 remained unchanged; Z = − 4.806; p  < 0.001; effect size = 0.724. Both the TLH and TAH groups demonstrated an increase in FSH levels at six months postoperatively, indicating a reduction in ovarian function; however, comparison between the two groups revealed no significant difference in the degree of increase, suggesting that the decline in ovarian function was similar in both techniques. Serum oestrogen levels was also checked pre-operatively and 6 months after the surgery. Unlike FSH, the raw oestrogen values demonstrated marked variability among patients, likely due to differences in the timing of the ovulatory cycle at which samples were collected; therefore, median values with interquartile ranges (IQR) were analysed to ensure accurate comparison. The median pre-operative Estradiol level was 171.5 pmol/L (IQR 196.45), which decreased to 125.0 pmol/L (IQR 139.25) post-operatively. Table  3 summarizes the pre and post-operative median values of serum E2 levels. Table 3 Median (IQR) E2 levels among two surgical groups before and after surgery N Pre-op E2 Median (IQR) pmol/L Post-op E2 Median (IQR) pmol/L TAH 37 184.05 (298.08) 157.20 (205.36) TLH 44 163.60 (155.83) 122.17 (117.99) Median (IQR) E2 levels among two surgical groups before and after surgery Wilcoxon Signed-Rank Test was used to compare E2 levels within each group. In both groups E2 levels have dropped down significantly after the surgery. (TAH: Z = -2.527, p  = 0.012 and effect size = 0.415 and TLH: Z = -4.353, p  < 0.001 and effect size = 0.656). However, the baseline comparison between two groups with Mann-Whitney U test showed no significant differences in pre ( p  = 0.244) or post-operative ( p  = 0.057) E2 levels. The reduction in oestrogen levels further reflects a decline in ovarian function, which was consistently observed in both the TLH and TAH groups. Similar to the FSH findings, the intergroup comparison of oestrogen demonstrated no statistically significant difference, indicating that both surgical techniques are associated with a comparable reduction in ovarian function. Sexual function was assessed using the FSFI score before and 6 months after the surgery. The mean pre-operative FSFI score was 24.19 ± 6.86 declined to 22.66 ± 6.76 post-operatively. Table  4 summarises the mean pre and post-operative FSFI values, as well the change (ΔFSFI = post-op FSFI - pre-op FSFI) for each surgery type. Table 4 Summary of FSFI scores for each surgery type Surgery type ΔFSFI Mean ± SD Pre-op FSFI Mean ± SD Post-op FSFI* Mean ± SD TAH -1.30 ± 2.00 25.77 ± 7.25 24.46 ± 6.87 TLH -1.72 ± 2.46 22.87 ± 6.30 21.14 ± 6.35 * unadjusted raw post-op FSFI Summary of FSFI scores for each surgery type * unadjusted raw post-op FSFI Baseline comparison through Mann-Whitney U test gave a significantly higher pre-operative FSFI scores in TAH group ( p  = 0.030), indicating baseline imbalance. While raw postoperative FSFI scores differed between groups ( p  = 0.005), this does not account for baseline FSFI and other covariates. ANCOVA adjusting for pre-operative FSFI, parity, marital status and level of education level showed that surgery type does not independently affect postoperative sexual function (F = 0.606, partial eta squared = 0.011, p  = 0.440). Estimated marginal means were similar between groups (TAH: 22.831, 95% CI = 21.78–23.88; TLH: 22.327, 95% CI = 21.60-23.04). The magnitude of change in sexual function (ΔFSFI) did not significantly differ between groups ( p  = 0.507). ΔFSFI is derived from raw pre- and post-operative scores: recalculating using adjusted postoperative values would result in double adjustment and is therefore not performed. Within-group analysis using Wilcoxon- Signed-Rank Test confirmed a decline in FSFI post operatively in both surgical groups (TAH: Z= -3.237, p  = 0.001, effect size = 0.532 TLH: Z= -4.161, p  < 0.001, effect size = 0.627), indicating a moderate to large reduction in sexual function after hysterectomy regardless of surgical technique. Spearman’s correlation analysis revealed no significant correlation between changes in FSH and change in sexual function ( p  = 0.410) or between changes in E2 and sexual function ( p  = 0.946). Even changes in FSH and E2 were largely independent from each other ( p  = 0.426). These results imply that the decline in sexual function following a hysterectomy cannot be directly explained by changes in ovarian markers. Hormonal changes might not be the only factor influencing it; other surgical psychological or relational factors might also play a role.

Hysterectomy is one of the most common major gynaecological surgeries performed in women worldwide [ 1 ]. It is indicated in a wide range of gynaecological symptoms and diseases, such as abnormal uterine bleeding, pelvic pain, myomatous uterus and uterine prolapse [ 1 ]. Hysterectomies can be performed using various techniques, including total abdominal hysterectomy (TAH), total laparoscopic hysterectomy (TLH), and vaginal hysterectomy (VH) [ 1 , 2 ]. TLH procedures are known to have a shorter hospital stay and better wound healing but increased hospital costs, and duration of surgery [ 3 ]. There are studies which have shown, less post-operative pain, better recovery profile and higher quality of life in patients undergoing TLH, while other studies report no differences in the major complications, quality of life and sexual function among different techniques of hysterectomy [ 3 – 7 ]. The ovarian function can be monitored using clinical symptoms of menopause and biochemical investigations. It has been shown that anti-müllerian hormone (AMH), follicle-stimulating hormone (FSH), and estradiol (E2) are good markers of ovarian function, with AMH recognized as one of the most favourable predictors of ovarian reserve and timing of menopause [ 8 ]. Furthermore, the antral follicle count (AFC) is considered a dependable approach for evaluating the ovarian response to ovarian stimulation [ 9 ]. It is less expensive as it utilizes routine ultrasound rather than specialized laboratory assays. Moreover, research shows that there is a negative correlation between AFC and chronologic age [ 9 ]. Maintaining ovarian health plays an important role in the health of women. Therefore, one should use a technique which has the least effect on ovarian function during hysterectomy particularly in younger women. The evidence has shown a reduction in ovarian function secondary to hysterectomies and furthermore, some studies have shown that menopause can occur quite earlier than we anticipate in women who have undergone hysterectomies [ 10 ]. Studies have shown that both TAH and TLH are associated with a reduction in ovarian function, but studies comparing the effect of 2 techniques are scarce [ 1 , 3 ]. The ovarian function may be affected by the cauterization of the mesosalpinx during salpingectomy impeding the blood flow to the ovary. This can happen during electrocauterization as well as suture ligation during open surgery. However, which technique damages the blood flow to the ovary is unknown. Modern laparoscopic techniques often rely on energy devices (e.g., bipolar electrocautery) for tissue and vessel sealing, whereas traditional abdominal hysterectomy commonly employs sutures [ 3 , 5 , 11 , 12 ]. It is recommended to preserve ovaries if it is not indicated during hysterectomy irrespective of the type of surgery. Recent guidelines, such as the American College of Obstetricians and Gynaecologists, suggest retaining ovaries in premenopausal women with a negative genetic risk of ovarian cancer and oophorectomy for women who are already menopaused [ 13 ]. However, to come to an actual conclusion, the available evidences are inadequate. Available evidence supports removing both fallopian tubes as it reduces the risk of developing ovarian cancers when ovaries are reserved during the surgery. In conventional open surgery, the traditional suture material is used to secure vascular pedicles so there is minimal thermal damage to surrounding tissues. In contrast, laparoscopic procedures use electrocautery extensively to clamp the vascular pedicle. Furthermore, the removal of the fallopian tube during laparoscopic surgery too may be contributing to the thermal spread to nearby tissues [ 9 , 12 ]. Oestrogen is an essential hormone for a female in reproductive age as well as in the peri and post-menopausal stages. It is a well-known fact that women who get their uterus removed reach menopause a few years earlier than women with the uterus [ 14 , 15 ]. The Female Sexual Function Index (FSFI) is a widely used, standardized, self-report questionnaire designed to evaluate key domains of female sexual function, including desire, arousal, lubrication, orgasm, satisfaction, and pain [ 16 , 17 ]. It has been rigorously validated in multiple languages and cultural settings, making it a reliable tool for assessing sexual health across diverse populations. However, to date, a Sinhala version is not available. Having such an instrument in one’s own language is crucial, as it allows women to express their experiences, perceptions, and concerns more accurately and comfortably, thereby improving the quality of data obtained in both clinical practice and research. The FSFI has been applied in various contexts, including studies on the impact of medical and surgical interventions on female sexual well-being. The uterus, beyond its reproductive role, is closely linked to body image and plays a significant part in sexual function, influencing lubrication, sensation, and overall sexual satisfaction. Many women express concern about the potential impact of hysterectomy, as the procedure may be associated with changes or loss in sexual function. Thus, adapting and validating the FSFI in Sinhala is essential to better understand and address these issues within the local population. Thus, this study seeks to address this important knowledge gap by evaluating both hormonal changes and sexual function outcomes following two commonly performed hysterectomy techniques. By developing and validating a Sinhala version of the FSFI and applying it to this population, we aim to generate culturally relevant evidence that can guide clinical decision-making and improve patient-cantered care. Ultimately, the findings will provide valuable insights into the quality of life and sexual well-being of women undergoing hysterectomy.

This study investigated the comparative effects of TAH and TLH on ovarian reserve and sexual function. The findings demonstrated that both surgical groups experienced an increase in serum FSH levels accompanied by a reduction in serum E2 concentrations, indicating a postoperative decline in ovarian reserve. In parallel, a significant reduction in FSFI scores was observed within each surgical group, however, after adjusting for covariates, the type of surgery was not independently associated with postoperative sexual function. The magnitude of change in FSFI (ΔFSFI) also did not differ significantly between the two surgical approaches, suggesting that the extent of postoperative decline was comparable. Moreover, those postoperative changes in FSH and E2 were not significantly associated with changes in sexual function as measured by FSFI. Various biochemical markers have been employed to assess ovarian function, including AMH, FSH, luteinizing hormone (LH), and E2. Among these, AMH has received particular attention as it directly correlates with the remaining follicular pool and remains relatively stable throughout the ovulatory cycle, making it a more reliable indicator of ovarian reserve [ 8 , 11 ]. In contrast, other hormones, particularly FSH, tend to fluctuate during the menstrual cycle and even more prominently during the perimenopausal period [ 15 ]. In our cohort, FSH values did not demonstrate marked fluctuations; however, E2 levels showed considerable variability between patients, largely influenced by the timing of sample collection within the ovulatory cycle. As it is challenging to determine the exact phase of the cycle in the absence of regular menstruation, interpreting E2 values becomes difficult and potentially misleading [ 15 ]. To minimise the impact of this variation, FSH-which is less cycle dependent- was prioritised for interpretation, and E2 values were summarised using medians to reflect distributional skew. Based on our experience and the variability observed in this study, we suggest that E2 is less reliable under current sampling conditions for assessing ovarian function. AFC is another reliable method of measuring ovarian reserve [ 18 ]. However, this was not performed in this cohort as it was time consuming and not practical in the follow up setting. A recent systematic review and meta-analysis on the effect of hysterectomy on ovarian function, involving 1457 premenopausal women, has reported elevation in serum FSH levels postoperatively which aligns with our findings [ 10 ]. The same study demonstrated a decreasing trend of serum E2 level, which echoes our findings, although the change was not statistically significant [ 10 ]. This may suggest a potential trend towards diminished E2 function even when the ovaries are preserved. Possible mechanisms for these results could be disruption of ovarian blood supply, surgical trauma and inflammatory changes, altered ovarian-pituitary feedback, and potential effects of opportunistic salphingectomy [ 10 ]. Sexual function of this cohort was assessed using the FSFI score. While within-group declines in FSFI were significant for both groups, adjusted analyses controlling for baseline FSFI, parity, marital status, education level revealed that the type of surgery was not independently associated with postoperative sexual function, and magnitude in decline of scores was similar across two groups. A large, 5 year follow up study revealed mixed outcomes. According to them women who were not sexually active prior to surgery experienced improvement in their sexual function whereas, those who were sexually active pre-operatively had a decline [ 19 ]. Another systematic review and meta-analysis done in 2023 also found no significant overall change in sexual function irrespective of the surgical route. However, many women continue to report sexual dysfunction after the surgery [ 20 ], suggesting that individual factors such as hormonal changes, spousal dynamics and body image rather than surgical route per se determine outcomes. With respect to between-group findings, both surgeries had similar endocrine outcomes. Although baseline FSFI scores differed, covariate adjusted postoperative FSFI revealed no significant difference between TAH and TLH. In addition, alterations in sexual function as assessed by the FSFI were not significantly correlated with postoperative changes in FSH and E2 in this prospective cohort. The above findings imply that sexual outcomes following a hysterectomy could be more affected by other non-hormonal factors, such as pelvic floor integrity, relationship dynamics, psychological adjustment, and surgical morbidity. This interpretation is in line with Till et al. (2022). According to them sexual function following a hysterectomy varies considerably more by surgical indication than by hormonal status [ 21 ]. The same results were made by Beyan et al. (2020), who observed that both TLH and TAH affect sexual function and quality of life, with variations more related to surgical technique and recuperation than to endocrine changes [ 22 ]. Yet, meta-analytic evidence shows that ovarian reserve may be influenced by hysterectomy, leading to gradual hormonal changes [ 10 ]. However, our research suggests that these changes might not, immediately result in FSFI changes. The absence of correlation also supports Cochrane findings that postmenopausal women’s sexual function is not fully restored by hormonal therapy alone [ 14 ]. This indicates that the type of surgery may not be the main driver of sexual function changes; rather, baseline characteristics, pre-existing comorbidities and patient expectations could be more important. Possible explanations for the findings of our study could be cut down of ovarian blood supply [ 3 , 23 ], extensive tissue manipulation during procedures [ 10 , 24 ], surgical technique in vaginal cuff closure [ 5 , 12 ], suture vs. barbed closure [ 12 ], and psychosocial aspects like perception of “major” surgery, recovery process, stigma, and marital support [ 4 , 20 ]. The clinical implications of this study include the necessity of pre-operative counselling on menopausal symptoms and importance of follow up, as both types of hysterectomy may reduce the ovarian reserve. Counselling sessions should also address the potential impact on sexual function and discuss possible interventions. Emerging evidence shows that advanced imaging tools, including MR defecography, can improve postoperative assessment, of pelvic floor dysfunction [ 25 ]. Surgical innovations such as robotic and mini-laparoscopic colposacropexy are useful in managing pelvic organ prolapse [ 26 ]. Sentinel lymph node mapping and predictive nomograms can lower the surgical morbidity, thereby improving patient outcomes in endometrial pathology [ 27 , 28 ]. In young women, fertility-sparing options, including hormonal therapy and oocyte vitrification are increasingly recommended to preserve reproductive potential in early endometrial disease [ 29 ]. Research on circulating microRNA and chromatin-level epigenetic changes is also reshaping early endometrial cancer diagnosis and fertility-sparing strategies [ 30 , 31 ]. Collectively, these developments reinforce the value of personalized surgery, and comprehensive counselling, as neither hysterectomy approach in our study displays a superiority in long term ovarian reserve preservation or quality of life. The prospective nature and inclusion of both biochemical (FSH, E2) and functional (FSFI) outcomes strengthens the validity of the outcomes. However, there are few limitations. The relatively small, single centre sample limits the generalizability. As well, even though all procedures were performed by a single experienced surgeon using standardized techniques and energy settings to reduce inter-surgeon variability and strengthen internal validity, it may limit generalizability of our findings to settings with different levels of surgical expertise or technique. The follows up period was short, which could miss the delayed endocrine changes. Our analysis adjusted postoperative FSFI for baseline FSFI, parity, marital status and educational level; however, other unmeasured confounders may still influence sexual function outcomes. The major limitation is the absence of AMH-the most stable marker of ovarian reserve- which was not included due to cost and feasibility constrains in our setting. Because FSH and E2 fluctuate with cycle dynamics and external factors, relying solely on these markers reduce the precision with which ovarian reserve changes can be interpreted. Consequently, while our findings suggest a decline in ovarian reserve after hysterectomy, the magnitude of this change should be interpreted cautiously. Therefore, future studies should need to conduct on a larger scale involving multiple centres with a long-term follow-up, incorporating additional ovarian reserve markers like AMH or AFC to provide a more definitive assessment.

The objectives of this study are threefold. Firstly, to develop a Sinhala version of the FSFI and validate it among the general population, thereby providing a culturally and linguistically appropriate tool for assessing female sexual function. Secondly, to evaluate ovarian function following open hysterectomy and total laparoscopic hysterectomy using biochemical markers, and to compare the differences between these two commonly practiced surgical techniques. Finally, to assess postoperative sexual function in women undergoing hysterectomy and to evaluate whether the type of surgery independently influences sexual function after adjusting for baseline sexual function and relevant covariates.

In conclusion, this study demonstrated that both TAH and TLH are associated with a postoperative reduction in ovarian reserve and sexual function, with no significant difference in the degree of decline between the two surgical techniques. E2 proved to be a less reliable marker for assessing ovarian reserve due to its marked variability and cycle-dependent fluctuations. These findings highlight the need for careful preoperative counselling, close postoperative follow-up, and individualized decision-making to ensure that patients are well-informed about potential outcomes when selecting the surgical approach.