Sexual function and pelvic floor function five years after hysterectomy.

Catharina Forsgren and Ulrika Johannesson: Study design, project development, data collection, data analysis, manuscript writing.

The study was approved by the regional ethics committee (Regionala Etikprovningsnamnden Stockholm, Sweden) on April 16, 2015 (reference number 2015/131–31). A supplement requesting a study period extension to 10 years' post‐hysterectomy was submitted and accepted on March 10, 2022 (nr 2021–06429‐02).

Catharina Forsgren and Ulrika Johannesson received a clinical research grant from Intuitive Surgical.

The original cohort consisted of 260 women. To optimize the analyses on pelvic floor and sexual function, the cohort was reduced to 242 patients, as presented in the published study of our one‐year results. 12 Women who underwent vaginal hysterectomy (VH) or laparoscopic‐assisted vaginal hysterectomy (LAVH) were excluded from the analysis due to the low number of cases during the study period. Additionally, women with previous pelvic organ prolapse surgery, previous incontinence surgery, or subtotal hysterectomy were excluded. Participants were followed with identical questionnaires at an average of 65.5 (SD 5.9) months after hysterectomy. The overall response rate after 65.5 months (5.4 years) was 145 out of 242 (60%). The response rate for each type of hysterectomy was 67.1% for RTLH (49/73), 49.3% for TLH (35/71) and 62.2% for TAH (61/98). Descriptive data and patient characteristics were presented in our published study of the one‐year results. 12 The main indications for hysterectomy included uterine fibroids (with or without menometrorrhagia) (58.0%), cervical dysplasia (14.6%), endometrial hyperplasia (9.6%) and menometrorrhagia (8.4%). Notably, pelvic organ prolapse was not an indication for surgery in any of the cases. Women in the TLH cohort were more frequently postmenopausal (27.8%). Women in the TAH cohort experienced a higher amount of blood loss during surgery (mean blood loss 492.9 mL) (SD 296.2) ( p  < 0.05) and their uterus weight was higher with a mean weight of 962.4 g (SD 596.2) ( p  < 0.05). Among the 200 premenopausal women, 20 (10%) underwent concomitant BSO at the time of hysterectomy. A comparison between sexually active ( n  = 162) and sexually inactive ( n  = 80) women at baseline revealed that sexually active women were significantly younger, with a mean age of 48.4 years (SD 7.6) ( p  < 0.05) compared to sexually inactive women with a mean age of 52.9 (SD 12.2). Sexually active women were more often premenopausal (87%) ( p  < 0.05). Among sexually active women, 15.4% underwent concomitant BSO compared to 26.2% of sexually inactive women ( p  = 0.065). No other significant differences in baseline preoperative characteristics were found. When comparing basic characteristics of responders and non‐responders, non‐responders had a higher mean BMI, 26.6 compared to 25.0 ( p  < 0.05) and were younger at the time of hysterectomy (46.6 years vs. 50.1 years) (p < 0.05). Women in the cohort described an overall reduction of more than 50% of pelvic floor, urinary, and bowel symptoms 5 years after hysterectomy, with the mean score of PFIQ‐7 significantly decreasing (Table  1 , Figure  1 ). There was also a significant decrease in bother and distress caused by pelvic floor symptoms, as indicated by a mean score for the PFDI‐20 (Table  1 , Figure  1 ). While women reported the same frequency of urge and stress incontinence as before surgery, they experienced fewer bladder symptoms, affecting household chores, physical activities, entertainment activities, ability to travel, and social activities (Table  1 , Figure  1 ). They described less impact on emotional health and feeling of frustration (mean score of UIQ‐7) (Table  1 , Figure  1 ). No significant differences were observed in urinary distress, frequent urination, small leakages, bladder emptying difficulties, or pain (mean score of UDI‐6) compared to before hysterectomy (Table  1 , Figure  1 ). Additionally, there was a reduction in symptoms related to pelvic organ prolapse and vaginal issues (mean score POPIQ‐7) (Table  1 , Figure  1 ). Women reported less distress from feelings of pressure in the lower abdomen, heaviness, bulging sensations, bladder emptying difficulties and manual defecation (mean score POPDI‐6) (Table  1 , Figure  1 ). At the five‐year follow‐up, women reported fewer bowel and rectum symptoms affecting their activities and relationships, as indicated by the mean score of CRAIQ‐7 (Table  1 , Figure  1 ). However, there were no significant changes in distress related to symptoms of constipation, straining, incomplete bowel emptying, anal incontinence, defecation pain, urgency, or anal prolapse, as measured by CRAD‐8 (Table  1 , Figure  1 ). Pelvic floor function at baseline and 5 years after hysterectomy in the hysterectomy cohort evaluated by mean score of Pelvic Floor Impact Questionnaire‐7 (PFIQ‐7), Urinary Impact Questionnaire (UIQ‐7), Colorectal‐Anal Impact Questionnaire (CRAIQ‐7), Pelvic Organ Prolapse Impact Questionnaire (POPIQ‐7), Pelvic Floor Distress Inventory (PFDI‐20), Pelvic Organ Prolapse Distress Inventory (POPDI‐6), Colorectal‐Anal Distress Inventory (CRAD‐8) and Urinary Distress Inventory (UDI‐6), Standard Deviation(SD). PFIQ‐7 Mean score (SD) 42.5 (51.7) 20.1 (40.6) <0.001 UIQ‐7 Mean score (SD) 16.0 (20.7) 10.2 (17.1) <0.001 CRAIQ‐7 Mean score (SD) 11.0 (18.9) 6.4 (16.5) <0.01 POPIQ‐7 Mean score (SD) 16.1 (24.0) 3.9 (12.5) <0.001 PFDI‐20 Mean score (SD) 69.6 (51.1) 58.0 (53.1) <0.01 POPDI‐6 Mean score (SD) 22.8 (18.6) 14.7 (17.0) <0.001 CRAD‐8 Mean score (SD) 18.5 (19.1) 18.5 (19.7) 0.30 UDI‐6 Mean score (SD) 28.2 (22.4) 24.8 (24.3) 0.05 Urge incontinence Mean score (SD) 0.3 Mean score of Pelvic Floor Impact Questionnaire‐7 (PFIQ‐7), Urinary Impact Questionnaire (UIQ‐7), Colorectal‐Anal Impact Questionnaire (CRAIQ‐7), Pelvic Organ Prolapse Impact Questionnaire (POPIQ‐7), Pelvic Floor Distress Inventory (PFDI‐20), Pelvic Organ Prolapse Distress Inventory (POPDI‐6), Colorectal‐Anal Distress Inventory (CRAD‐8) and Urinary Distress Inventory (UDI‐6) at baseline, 6 months,12 months, 36 months and 60 months follow‐up (mean score with 95% confidence interval). The route of hysterectomy (RTLH, TLH, AH), age at surgery or number of vaginal deliveries did not significantly impact the overall presence of urinary symptoms, pelvic floor symptoms, or bowel symptoms in women up to 5 years' post‐hysterectomy, as assessed by the PFIQ‐7 and PFDI‐20. However, undergoing hysterectomy at the age of 65 years or older was associated with lower scores of PFDI‐20 ( p  < 0.05), though there was no interaction between age and scores over time. There were no significant differences in PFIQ‐7 scores across follow‐up based on BMI at the time of surgery or BMI at 5 years. While there was no change in PFDI‐20 scores over time based on BMI at surgery, a correlation was observed at the five‐year follow‐up, indicating that a higher BMI was associated with a higher PFDI‐20 score (p < 0.05). At baseline, the mean score of FSFI was 17.9 (SD 11.7), with over half of the women (150 out of 242, 64.4%) reporting a score of less than 26, indicating sexual dysfunction. Five years' post‐hysterectomy, there was no significant change in the overall sexual function within the study population compared to baseline, with a mean FSFI score of 18.1 (SD 11.6) ( p  = 0.73) (Figure  2A ). No differences were observed across the FSFI domains of desire, arousal, lubrication, orgasm, satisfaction, and pain (Figure  2A ). Also, 66.7% of women reported a FSFI score below 26 at the five years' follow‐up. (A) Mean score of Female Sexual Function Index (FSFI) and domain scores over time from hysterectomy in the study population (mean score with 95% confidence interval). (B) Mean score of Female Sexual Function Index (FSFI) and domain scores over time from hysterectomy in women sexually active at the time of hysterectomy (mean score with 95% confidence interval). The route of surgery ( p  = 0.93), number of vaginal deliveries ( p  = 0.21), or concomitant BSO ( p  = 0.44) had no significant impact on overall sexual function, as measured by the FSFI score, at the five‐year follow‐up. Women who underwent BSO at the time of hysterectomy reported lower FSFI scores during the follow‐ups. However, when adjusting the results for advancing age, there were no significant differences in sexual function depending on BSO. Among sexually active women, who underwent concomitant BSO at hysterectomy, there was a borderline significance of lower sexual function over time ( p  = 0.07) (adjusted for age). Age at surgery, sexual activity prior to surgery, and follow‐up occasion affected overall sexual function, as presented in Figure  2 Women of age 65 or older reported lower sexual function at the time of hysterectomy ( p  = 65 years) reported lower scores of FSFI ( p  = <0.001). The effect of age was constant over follow‐up occasions. When focusing on the 162 (66.5%) participants who were sexually active at the time of hysterectomy a decline, or no change in sexual function, was observed in 58.6% after 5 years. The mean FSFI scores for this group were initially higher, although showing a significant decline in sexual function over time: the mean FSFI score decreased from 25.2 (SD 6.6) at baseline to 19.6 (SD 10.8) at the five‐year follow‐up ( p  < 0.001) (Figure  2b ). The decline in sexual function following hysterectomy was evident across all domains of female sexuality, including desire, arousal, lubrication, orgasm, and satisfaction. However, in the domain of pain, women reported experiencing less discomfort post‐surgery (Figure  2B ). The decline of sexual function in this group, was independent of surgical route, concomitant BSO, BMI, uterus weight, and number of vaginal deliveries. Interaction analyses identified a significant interaction between follow‐up occasion and baseline sexual activity ( p  < 0.001), with no evidence of interaction between follow‐up occasion and age at surgery ( p  = 0.97) (Figure  3 ). (A) Mean Female Sexual Function Index (FSFI) score over time by sexually activity status. Shown are predicted values with 95% confidence interval from a linear mixed model for women aged 50 to 64 years at time of hysterectomy. (B) Mean Female Sexual Function Index (FSFI) score over time by age at hysterectomy. Shown are predicted values with 95% confidence interval from a linear mixed model stratified by sexually activity status at baseline. Conversely, among the 80 non‐sexually active women at baseline, there was a predominant improvement in sexual function after 5 years, with 73.3% reporting higher FSFI scores than before hysterectomy. Nineteen (23.8%) of the women who were sexually inactive prior to surgery became sexually active by the five‐year follow‐up (Figure  3 ). There was an association between being non‐sexually active at the time of hysterectomy, and an improvement of sexual function on all the follow ups ( p  < 0.001) (Figure  3 ). A correlation analysis was conducted between PFIQ‐7 scores, PFDI‐20 scores and FSFI scores, to assess the impact of pelvic floor function, at the time of hysterectomy, on sexual function at baseline and 5 years post‐operatively. In the overall study population, and among sexually active, women who reported less bother and distress caused by pelvic floor symptoms (mean PFDI‐20 score) preoperatively described better sexual function (mean FSFI score) ( r  = −0.16, p  < 0.05) ( r  = −0.33 p  < 0.001). However, no significant correlation was found 5 years' post‐hysterectomy. Regarding pelvic floor function measured by PFIQ‐7 scores, no correlation with FSFI scores was observed before hysterectomy. In contrast, at the five‐year follow‐up, women reporting less pelvic floor, urinary, and bowel symptoms demonstrated better sexual function ( r  = −0.20, p  < 0.05). In women who were sexually active prior to surgery, lower levels of stress incontinence ( r  = −0.21, p  < 0.01), urge incontinence ( r  = −0.20, p  < 0.05), and pelvic floor symptoms (mean PFIQ‐7 score) ( r  = −0.27, p  < 0.001) were associated with improved sexual function (mean FSFI score).

Five years' post‐hysterectomy, women in our study reported improved pelvic floor function compared to preoperative levels, regardless of surgical route, age at surgery or number of vaginal deliveries. This finding contrasts with some literature indicating an increased risk for pelvic floor dysfunction in hysterectomized women, such as studies by Altman et al. and Vermeulen et al. 7 , 8 , 18 However, our results align with other studies, including a 10‐year follow‐up of 3582 women, where only 1.6% underwent pelvic organ prolapse surgery post‐hysterectomy. 19 Similarly, the LACE study, 20 a randomized trial comparing TAH and TLH in early endometrium cancer, reported no deterioration of pelvic floor function post‐hysterectomy, independent of surgical route. Laparoscopic surgery has gained popularity over time because of the advantages of favorable peri‐ and postoperative outcomes compared with abdominal surgery. Many studies emphasizing increased risk for pelvic floor disorders focus primarily on abdominal and VH, with some suggesting that vaginal approaches increase risks for pelvic floor disorders. 19 , 21 Studies focusing on laparoscopic hysterectomy, like the POP‐UP study by Vermeulen et al., 8 found no difference in the prevalence of POP between TLH and VH for non‐prolapse indications. The uterosacral ligaments are essential for level one pelvic organ support, 22 but it remains unclear how they are affected by laparoscopic hysterectomy. It can be hypothesized that the use of a uterine manipulator during laparoscopy may reduce damage to these ligaments. Furthermore, the careful exposure of the vaginal vault and ligaments, facilitated by the uterine manipulator, may improve the quality of surgical attachment. Whether this leads to a different prevalence of pelvic floor dysfunction later in life is yet unexplored. In our cohort, 60% of women underwent RTLH or TLH, which may be associated to the absence of observed deterioration in pelvic floor function. Additionally, increased awareness among gynecologists at our department about the risks of pelvic floor dysfunction post‐hysterectomy, has led to more careful laparoscopic techniques where surgeons use vaginal cuff sutures attaching the vaginal cuff to the uterosacral ligaments to create cuff suspension. Finally, prior pelvic floor and urinary incontinence surgeries, along with VH and LAVH, are acknowledged as potential risk factors for post‐hysterectomy pelvic floor disorders. 19 , 21 Excluding women with previous prolapse or incontinence surgery, as well as women who went through VH or LAVH, likely contributed to a lower frequency of pelvic floor disorders in our analysis. This approach may on the other hand, provide a clearer picture of the true impact of hysterectomy on pelvic floor function. Our findings at the five‐year follow‐up, indicating a correlation between higher BMI and elevated PFDI‐20 scores, align with existing literature that recognizes obesity as a risk factor for pelvic floor disorders. 22 The mean BMI in our study was 26.4 which is in the range of overweight, but in the context of the obesity pandemic, where approximately 70% of the United States population has a BMI of more than 25, 23 our study group must be considered a low‐risk cohort. We followed our cohort for 5 years, and it is important to acknowledge that some of the hysterectomy‐related pelvic floor problems may develop later. In a Danish national registry study, with a 20‐year follow‐up, it was observed that approximately two‐thirds of all pelvic organ prolapse surgeries were performed more than 5 years after hysterectomy. 7 We are planning a 10 year‐follow‐up of our study group. Regarding sexual function, the low mean FSFI score of 17.9 and the fact that over half of the women met the criteria of female sexual dysfunction at baseline, underscore the significant challenges faced by this population going through hysterectomy, aging as well as in many cases menopause. The indication for surgery, such as abnormal uterine bleeding, fibroids and lower abdominal pain, can themselves impair sexual function. Hysterectomy for benign indication was not associated with significant change in female sexual function 5 years postoperatively, and there was no difference in patient‐reported outcomes among the different modes of hysterectomy (RTLH, TLH or AH), similar to findings by Radosa et al. 24 Nevertheless, women who were sexually active prior to hysterectomy experienced a reduced sexual function. Women facing hysterectomy in our study were, on average 49.9 years old, suggesting that they were approaching menopause. Women older than 65 years experienced lower sexual function. Their age and changes of menopausal status may affect the results, as some studies suggest that sexual function changes with advancing menopause status. 25 In a cross‐sectional study including 4366 women, aged on average 51.7 years, seen in women's health clinics at a Mayo Clinic in the United States, 55.8% reported sexual dysfunction. 26 Several plausible mechanisms contribute to the worsening of sexual function with menopause and hysterectomy. Biological explanations, such as changes of vaginal anatomy and declining levels of sex steroids, play a major role. Levels of sex steroids post hysterectomy are influenced by concomitant BSO, and in our study, sexually active women who underwent concomitant bilateral BSO reported a non‐statistically but borderline significant lower sexual function. In contrast, some women who were not sexually active, at the time of hysterectomy became sexually active during the follow‐up period, and their sexual function improved at a group level. This may be associated with surgery‐related improvement and symptom relief from bleedings, fibroids, and endometriosis and may emphasize the role of hysterectomy in gynecological disease. Women in our study with pelvic floor dysfunction, generally reported worse sexual function, which is consistent with other studies, where severe stages of pelvic organ prolapse are associated with decreased orgasm. 27 However, the results were somewhat conflicting. Women in with a high prevalence of pelvic floor dysfunction symptoms, as assessed by the PFIQ‐7 score, reported low sexual function at 5 years, but there was no correlation when pelvic floor function was measured using the PFDI‐20 score. This discrepancy may reflect that, although the two scoring systems are similar, the PFDI‐20 primarily reveals symptoms and bother related to pelvic floor function, while PFIQ‐7 mainly measures health‐related quality of life related to pelvic floor symptoms. 28 Women's perception of health‐related quality of life may have a greater impact on sexual function. Furthermore, urinary incontinence negatively impacted sexual function in the sexually active group, a finding that has been previously described by several authors. 29 A strength of this study is that we included both sexually active and non‐sexually active participants. Many studies focus solely on sexually active women which can lead to bias toward better sexual function. In contrast, women who did not engage in sexual activity before hysterectomy but began doing so afterward, potentially benefiting from the procedure, are often excluded from studies. Additional strengths of this study, also include the long‐term follow‐up with self‐reported symptoms of pelvic floor and sexual function, combined with medical records detailing general health, obstetric history, and surgical parameters. The response rate was 60% after 5 years, which is adequate given the intimate nature of many questions and the likelihood that motivation to respond may diminish over time. We acknowledge that a simultaneous non‐hysterectomy cohort would have strengthened the study, however, this was partly compensated for, since participants served as their own controls. There was unpredictably low sexual activity in our study group, which made aspects of the study underpowered, and may have altered the interaction between pelvic floor function and sexual function. Another limitation was the lack of information on quality of life, and relative distress, related to low FSFI scores. Although the FSFI can indicate the presence of sexual dysfunction, it does not assess patient distress or determine whether women are bothered by their sexual problems, consequently highlighting the complexity of female sexuality.

Five years after hysterectomy, women reported a lower burden of pelvic floor symptoms compared to preoperatively. The entire study group indicated no change in overall sexual function over the five‐year period, while women who were not sexually active at the time of the hysterectomy reported improved sexual function. A decline in sexual function was observed among those who were sexually active before surgery, although the impact of aging and menopause, which were concurrently ongoing, made it difficult to isolate the surgical effects.

Hysterectomy, though performed less frequently during the last two decades, 1 , 2 remains a common gynecological procedure for benign conditions. 3 Hysterectomy is increasingly conducted using minimally invasive techniques, including vaginal, laparoscopic, and robotic approaches. 1 , 2 When considering hysterectomy for benign disorders such as fibroids, abnormal uterine bleeding, and endometriosis, long‐term postoperative well‐being is crucial. Both pelvic floor and sexual function significantly impact women's daily lives and are believed to be affected by hysterectomy. 4 Several studies suggest that hysterectomy may increase the risk of pelvic organ prolapse and urinary incontinence surgery. 5 , 6 The overall rate of prolapse surgery following hysterectomy for benign indications has been reported to between 12% and 13%. 7 , 8 Postoperative sexual function is of great concern to women; however, research on the changes in sexual function remains inconclusive. A 2023 review by Dedden et al., 9 and other authors, 4 found no significant changes in overall sexual function following hysterectomy, regardless of the surgical route or whether the cervix was removed. Additionally, there is a recognized association between pelvic floor dysfunction and sexual dysfunction, with urinary incontinence and pelvic floor prolapse potentially negatively affecting women's sexuality. 10 , 11 The aim of this prospective clinical cohort study, which followed women 5 years after hysterectomy, was to evaluate changes in sexual function and pelvic floor function and the interactions between the two. The study also sought to determine whether surgical technique, intra‐or perioperative factors and concomitant procedures affected long‐term postoperative outcomes.

Catharina Forsgren: No conflicts of interest. Ulrika Johannesson: Proctor for Intuitive Surgical.

Women scheduled for elective hysterectomy for benign indications at the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden, between January 2016 and September 2018 were asked to participate in the study. Out of 417 women who underwent hysterectomy, 260 met the inclusion criteria and agreed to participate. Exclusion criteria included inability to speak, understand or write Swedish, pelvic organ prolapse as indication for surgery, obstetric hysterectomy, and genital tract malignancy. The choice of surgical method was made collaboratively by the surgeon and the participant, with all participants providing both oral and written consent. Participants completed validated questionnaires the Pelvic Floor Impact Questionnaire (PFIQ‐7), Pelvic Floor Distress Inventory (PFDI‐20), and Female Sexual Function Index (FSFI) reoperatively, at 6 months, 1 year, 3 years and 5 years postoperatively. Results from the one‐year and three‐year follow‐ups have been previously published. 12 , 13 Participants were contacted by mail and received reminders on two occasions. The PFIQ‐7 and PFDI‐20 are short forms of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. Together, these instruments assess the extent to which symptoms related to the lower urinary tract, lower gastrointestinal tract, and pelvic organ prolapse, affect the quality of life of women with pelvic floor disorders. The PFIQ‐7 and PFDI‐20 are valid, reliable, and condition‐specific quality‐of‐life questionnaires commonly used to evaluate the impact of pelvic floor disorder on daily life. 14 The PFIQ‐7 consists of seven items each from the Urinary Impact Questionnaire (UIQ‐7), Pelvic Organ Prolapse Impact Questionnaire (POPIQ‐7), and Colorectal‐Anal Impact Questionnaire (CRAIQ‐7). To calculate a summary score for the PFIQ‐7, we used the following response scale: 0, (Not at all), 1, (Somewhat), 2, (Moderately), and 3, (Quite a bit). We obtained the mean value for all answered items within each scale (possible values range from 0 to 3), multiplied this by (100/3), and calculated a scale score (range 0–100). Missing items were addressed by using the mean from responded items only. The scores from the three scales were then summed to produce a summary score (range 0–300). The PFDI‐20 measures the degree of bother and distress caused by pelvic floor symptoms and serves as a symptom inventory. It includes questions from the Pelvic Organ Prolapse Distress Inventory (POPDI‐6), Colorectal‐Anal Distress Inventory (CRAD‐8) and Urinary Distress Inventory (UDI‐6). Each of the 20 questions starts with a “yes” or “no” response. If the participant answered “yes” on a question, they were asked to specify the extent to which bowel, bladder, or pelvic symptoms have bothered them in the past three month using a 4‐point scale ranging from “not at all” (0) to “quite a bit”. 3 Scale scores for PFDI‐20 were calculated by taking the mean value of their corresponding questions and then multiplying by 25, resulting in a range from 0 to 100. The scores from the three scales were summed to obtain the PFDI‐20 summary score, which ranges from 0 to 300. Both PFIQ‐7 and PFDI‐20 provide summery scores ranging from 0 to 300, with higher scores indicating a greater prevalence of symptoms. The FSFI is a validated, self‐report, multidimensional questionnaire that assesses sexual desire, arousal, lubrication, orgasm, satisfaction, and pain, consisting of 19 items. The summery score is calculated as the sum of the six domains, each multiplied by a predefined domain factor. Missing data values were replaced by the mean of the available responses within each domain. Question 18 was missing in the delivered data due to a typing error. A score of 26 or less is indicative of sexual dysfunction, while higher scores reflect better sexual function. 15 Being sexually active was defined as not reporting zero on any of the FSFI scores at baseline. All questionnaires demonstrated high validity, 14 , 15 and the Swedish short forms exhibited acceptable validity and reliability. 16 , 17 In a database, the following data were registered: surgical parameters, age, parity, vaginal deliveries, body mass index (BMI), family history of prolapse, smoking habits, menopausal status, the use of menopausal hormone therapy, previous prolapse or incontinence surgeries, and medical history. Baseline characteristics were termed as mean (standard deviation [SD] and median [range]) for continuous variables, with absolute and relative frequencies for categorical variables. Variation in baseline characteristics were assessed using the Kruskal‐Wallis's test for continuous variables and the Chi‐squared test for categorical variables. Ninety‐five percent confidence intervals (CI) for mean scores were derived using nonparametric ordinary resampling with 10 000 replicates. Initially, changes in questionnaire scores across follow‐up were assessed. To account for repetitive measurements, mixed effect models were fitted to examine changes in questionnaire scores over time. Each model included the occasion (baseline, 6 months, 12 months, 3 years, 5 years) as a fixed effect and a random intercept for participants. Next, we explored whether changes in questionnaire scores across follow‐up were dependent on factors such as age at surgery (<50, 50–64, 65+), number of vaginal deliveries (0, 1–2, 3+), type of surgery (robotic assisted total laparoscopic hysterectomy [RTLH], total laparoscopic hysterectomy [TLH] and abdominal hysterectomy [TAH]), sexually active at baseline (yes, no), and bilateral salpingo‐oophorectomy (BSO), (yes, no). For each factor showing evidence of association with questionnaires scores in the multivariate analysis test for an interaction effect between the factor and follow‐up occasion was performed. In all regression analyses, fixed effects were tested using a likelihood ratio test in nested models, using the Chi‐ square distribution. Finally, we calculated Pearson's correlation coefficients between the FSFI and PFIQ‐7 scores, and well as between the FSFI and PFDI‐20 scores, for both sexually active women and all participants. Cubic splines were fitted to graphically display correlation patterns. A p‐value <0.05 was considered statistically significant. All statistical analyses were performed using R version 3.6.2 ( https://www.R‐project.org/ ). A sample size calculation determined that a minimum of 60 participants would be sufficient to determine a 20% postoperative change in symptoms of pelvic floor function, with α  < 0.05 and β  = 0.80.