Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain

Among a cohort of patients with pelvic pain, patients who were sexually active at 6-months following hysterectomy reported lower depression, higher resilience, better relationship satisfaction, and better emotional support and social participation at baseline compared to their peers who were not sexually active 6-months following hysterectomy. Only higher relationship satisfaction prior to surgery, preoperative sexual activity, and younger age were independently associated with higher likelihood of postoperative sexual activity. In patients who were sexually active prior to hysterectomy and at 6-months postoperatively, overall sexual function remained fairly stable despite shifts in individual sexual function domains, including improved dyspareunia. Baseline psychosocial characteristics such as depression, resilience, relationship satisfaction, emotional support, and social participation were not significantly associated with change in sexual function following hysterectomy. Notably, neither reported history of endometriosis nor pelvic pain severity prior to hysterectomy was associated with sexual activity or change in sexual function following hysterectomy. Female sexual function is driven by a complex interplay of emotional, cognitive, relationship, and physical factors. Existing research on sexual function following hysterectomy has primarily focused on surgical and clinical factors, and the impact of psychosocial factors has not been extensively explored. Impact of concurrent depression has been evaluated and results are mixed, with some studies demonstrating less robust improvement in sexual function and dyspareunia in patients with depression compared to their peers, 13 , 14 whereas other studies did not demonstrate this relationship. 7 , 38 We found that worse depression prior to hysterectomy correlated with lack of sexual activity at 6-months postoperatively, but this relationship was not significant once controlling for other factors such as relationship satisfaction. Prior studies evaluating impact of depression on sexual function have not assessed relationship satisfaction. Given extensive data demonstrating a strong bidirectional correlation between depression and relationship satisfaction, 39 , 40 it is possible that that purported impact of depression in prior studies may have been due to concurrent relationship dissatisfaction, given our finding that depression was not independently associated once accounting for relationship satisfaction. Depression prior to hysterectomy was not independently associated with magnitude or direction of change in sexual function in those who were sexually active at both time points. In other clinical settings or life transitions, including postpartum, 41 menopause, 42 , 43 risk-reducing bilateral salpingo-oopherectomy, 44 and vestibulodynia, 45 , 46 relationship satisfaction and partner support is associated with better sexual function. However, this has not been previously explored in a population undergoing hysterectomy. Relationship satisfaction prior to surgery was significantly associated with sexual activity at 6-months postoperatively but did not influence the magnitude or direction of change in sexual function in those who were sexually active at both time points. Similar to prior studies, prevalence of sexual dysfunction was high in this cohort of women with pelvic pain. Many patients report significant emotional and relationship distress related to sexual dysfunction and this is often a highly cited concern among those seeking care for pelvic pain conditions. Patients with pelvic pain and sexual dysfunction may be motivated to undergo hysterectomy with the hope that the procedure could result in improved sexual function, particularly related to dyspareunia. We did find significant improvement in the pain subscale of the FSFI in this population. Notably, the improvement in pain was not robust enough to result in improved overall sexual function or in the rate of sexual dysfunction in this cohort. Gynecologic surgeons should discuss sexual function during counseling for hysterectomy as this is an important consideration for many patients considering the procedure. While there is likely some variability regarding the impact of hysterectomy on sexual function, patients can be assured that sexual function appears to remain fairly stable following the procedure. Patients should be counseled that hysterectomy is unlikely to result in dramatic improvement in overall sexual function. Patients with pelvic pain are at higher risk for sexual dysfunction, which may have significant emotional and relationship consequences. Patients who report sexual dysfunction or dyspareunia should undergo a comprehensive evaluation for contributing conditions such as pelvic myofascial pain, vulvodynia, endometriosis, in addition to assessing psychosocial factors. Many patients may benefit from referral to a pelvic physical therapist or sexual health counselor, depending on the individual factors and contributing conditions. Patients in this cohort reported variable change on individual FSFI domains, with significant improvements in pain, desire, and arousal but significant decreases in orgasm and satisfaction. Exploring factors that influence individual FSFI domains, particularly in a larger sample that included other clinical and surgical factors, could be informative for both patients and surgeons. There is still very little understood about the clinical, surgical, and psychosocial factors that are associated with a clinically meaningful change in sexual function following hysterectomy, despite literature demonstrating that there are subsets of patients who experience significant improvement or decline in sexual function postoperatively. A robust phenotyping analysis in a large, heterogenous patient population with longitudinal postoperative follow up may help to address these knowledge gaps and improve perioperative counseling around hysterectomy. Female sexual dysfunction is still poorly understood, understudied, and undertreated, particularly compared to the advances made in research and treatment of male sexual function. More research is needed regarding impact of clinical and psychosocial factors associated with female sexual function and the ability or desire to be sexually active. Sexual activity and sexual function are overlapping but separate issues. A strength of this analysis is that we examined these issues individually, which may allow us to better differentiate the impact of specific factors that influence one but not the other. Additionally, this study utilized a validated and widely used questionnaire for sexual function that explores multiple functional domains, as well as validated questionnaires for psychosocial factors. Most cases were performed by a group of high-volume, specialty-trained surgeons with expertise in chronic pelvic pain who have training in multimodal treatment strategies for pelvic pain. Many patients with pelvic pain and dyspareunia are encouraged to consider pelvic physical therapy and management of other conditions that may contribute to pelvic pain prior to undergoing hysterectomy. The rate of sexual dysfunction is particularly notable given this clinical practice. The prospective nature of this study and 6-month follow up are also strengths. Limitations include that this study was conducted at a single, large academic medical center and this data may not be generalizable to other populations. We were unable to determine partner status for patients based on available data, which significantly impacts sexual activity and function. Additionally, we did not collect qualitative or quantitative data regarding reasons for sexual inactivity, which is certainly influenced by a wide range of factors apart from gynecologic conditions or procedures. Limited inference can be drawn regarding reason for sexual inactivity before or after hysterectomy given this limitation. It is notable that almost an equal number of patients reported no sexual activity at baseline and became sexual active postoperatively (n=17) as those who reported sexual activity at baseline but no sexual activity postoperatively (n=19). This analysis was limited to psychosocial factors, but these factors often overlap with endometriosis, nociplastic pain, and chronic overlapping pain conditions, which were not evaluated in this analysis but may impact sexual function. Lastly, this is a secondary analysis and therefore the study was not powered to assess this outcome. In this cohort of patients with pelvic pain, both sexual activity and sexual function remained fairly stable following hysterectomy. Higher relationship satisfaction, younger age, and sexual activity prior to hysterectomy were associated with greater probability of sexual activity at 6-months postoperatively. Psychosocial factors were not related to change in sexual function among patients who were sexually active both prior to hysterectomy and at 6-months following surgery. Patients with sexual dysfunction may benefit from evaluation for psychosocial factors as part of a comprehensive management strategy.

This prospective study enrolled 369 patients prior to scheduled hysterectomy. Baseline FSFI data was incomplete or missing in 47 (12.7%) patients. At 6-months, 86 (26.7%) patients were lost to follow-up. Of the 236 patients with 6-month follow up data, 43 (18.2%) were excluded because of missing data on FSFI or other measures of interest. Therefore, complete data was available for 193 patients for the analysis of six-month sexual activity. Of these, 25 (13.0%) reported no sexual activity within the prior month at both the baseline and 6-month time points, 19 (9.8%) reported sexual activity at baseline but not at 6-months, 17 (8.8%) reported no sexual activity baseline but were sexually active at 6-months, and 132 (68.4%) were sexually active at both baseline and 6-months, and these were included in the analysis of change in sexual function. ( Figure 1 ) Patients who reported sexual activity at 6-months (n=149) were younger (p=.001), reported lower depression scores at baseline (p<.001), better emotional support (p=.041) and social participation (p=.028) at baseline, better relationship satisfaction at baseline (p<.001), and higher resilience at baseline (p=.029) compared to those who were not sexually active at this time point. ( Table 1 ) In the binary logistic regression model examining sexual activity 6-months following hysterectomy, older age was associated with a lower likelihood of sexual activity at 6-months (OR=.91, 95% CI-= .85, .96, p = .002). Conversely, higher relationship satisfaction prior to surgery was associated with a greater likelihood of sexual activity at 6-months (OR=1.09, 95% CI-= 1.02, 1.16, p = .008). This finding suggests that each one-point increase on the 0-35 RAS is associated with a roughly 9% greater likelihood of being sexually active at 6-months post-surgery. As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (OR= 9.78, 95% CI=3.95, 24.19, p < .001). ( Table 2 ) Remaining analyses using FSFI scores were limited to patients who were sexually active at both time points (n=132). Total FSFI score did not change significantly from baseline to 6-months, but there were changes in several individual domains of sexual function. Patients reported significant improvement in desire (p=.012), arousal (p=.023), and pain (p<.001) domains. However, significant decreases were reported in orgasm (p<.001) and satisfaction (p<.001) domains. The proportion of patients who met criteria for sexual dysfunction was quite high at both time points, but there was not a statistically significant change in the proportion from baseline to 6-months. ( Table 3 ) In the multivariable linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity prior to surgery, or preoperative psychosocial measures. ( Table 4 )

This prospective observational cohort study enrolled women undergoing hysterectomy for benign, non-obstetric indications at the University of Michigan from December 2017 to July 2022. All patients scheduled for hysterectomy for benign indications during this period were contacted to assess eligibility. Baseline surveys were completed within 30 days of the scheduled surgery. Inclusion criteria included females between ages 21-69 scheduled to undergo hysterectomy for a benign, non-obstetric indication. Patients were excluded if they did not speak or read English, were unable to provide written consent, were pregnant or breastfeeding, were undergoing a concurrent major surgery that substantially impacts recovery (e.g. bowel resection), had a chronic medical condition that substantially altered daily physical function (e.g. currently undergoing treatment for any cancer), reported suicide attempt, illegal drug or substance misuse/abuse in the past two years, or were currently incarcerated. Once eligibility was confirmed, we classified patients into three groups: 1) chronic pelvic pain and endometriosis, 2) “in-between”, and 3) healthy controls. Chronic pelvic pain was defined as reporting average daily pelvic pain ≥4/10 for more than 5 days per month over the previous 6 months. For group classification purposes, endometriosis included surgical history of endometriosis or suspicion based on imaging or symptoms. The “in-between” group included dysmenorrhea, intermittent pelvic pain, and presence of pain outside of the pelvis. Dysmenorrhea was defined as average menstrual pelvic pain ≥4/10 for 5 or fewer days per month over the previous 6 months. The number of healthy, pain-free control participants was quite small and therefore were not included in this analysis as the small number limited inference for our outcomes of interest. The current manuscript is a secondary analysis from this cohort focusing on sexual function and psychosocial factors, whereas the primary focus of this ongoing study is to evaluate pre-surgical predictors of post-hysterectomy outcomes on pain and quality of life. Informed consent was obtained from all participants. This study was approved by the University of Michigan Institutional Review Board. Reporting of findings conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Patients completed a standardized questionnaire with 30 days prior to surgery, which included self-reported demographic information, past medical and surgical history including history of surgically-documented endometriosis, and a battery of validated self-report measures regarding pain and psychosocial factors. A similar standardized questionnaire was completed 6-months postoperatively. Sexual function was assessed using the Female Sexual Function Index (FSFI), which is a widely used, validated measure that assesses six domains of female sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. 31 , 32 The FSFI contains response options to indicate whether the participant is currently sexually active (yes/no), allowing for analysis of factors associated with the presence/absence of sexual activity. The FSFI total score should only be evaluated in participants who are sexually active, so this co-primary analysis was restricted to those who were sexually active at both timepoints. Higher scores correspond to better sexual function, with a total of 36 points possible. A score of <26.55 has typically been considered to be consistent with sexual dysfunction. Depression was evaluated using their respective Patient-Reported Outcomes Measurement Information System (PROMIS) measures, with higher scores indicating worse depression. 33 Resilience was measured using the Connor-Davidson Resilience Scale, with higher scores corresponding to higher resilience. 34 , 35 Relationship satisfaction was assessed using the Relationship Assessment Scale, with higher scores corresponding to better relationship satisfaction. 36 Emotional support and social participation were evaluated using their respective PROMIS measures, with higher scores corresponding to better emotional support and social participation. 37 Primary outcomes were sexual activity at 6-months following hysterectomy and change in sexual function from baseline to 6-months postoperatively, which was limited to patients who were sexually active at both time points. As this is a secondary analysis from an ongoing prospective cohort study, there was no a priori power calculation performed to determine necessary sample size to address this secondary outcome. We first compared baseline differences in psychosocial measures between participants who were/were not sexually active at post-operative month six using One-way analysis of variance. If homogeneity of variance assumptions were not met, we used the Brown-Forsythe test to determine statistical significance. Chi-square tests were used to compared presurgical categorical variables (sexual activity, history of endometriosis) between the groups. To compare the proportion of participants experiencing sexual dysfunction by the recommended cutoff, we used the McNemar test for paired samples. Significance was set at p< .05 for all analyses. To model factors associated with post-operative sexual activity at month six, binary logistic regression models were used with the psychosocial measures (depression, resilience, emotional support, social participation, and relationship assessment) as the primary predictors of interest. A priori covariates included patient age, average pelvic pain prior to surgery, a self-reported history of endometriosis and presurgical sexual activity (binary). To model factors associated with change in sexual function, the same predictors and covariates were used in a linear regression model but with presurgical FSFI score in place of the binary sexual activity variable.

Hysterectomy is the most common gynecologic procedure performed in the United States. 1 Potential impact on sexual function is an often cited concern for many patients considering hysterectomy. 2 – 4 Existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines postoperatively. 5 – 7 Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity postoperatively or magnitude and direction of change in sexual function. Impact on sexual function is an even more salient consideration in patients with pelvic pain as this population consistently demonstrates higher rates of dyspareunia and sexual dysfunction compared to their peers. 8 – 10 Additionally, pelvic pain is the primary indication for at least 15% of hysterectomies and 40% of patients undergoing hysterectomy report pelvic pain symptoms. 11 , 12 Patients with chronic pelvic pain appear to have less robust improvement in sexual function following hysterectomy compared to those without pain, but the duration of pain and contributing pelvic pain conditions likely moderate this relationship. 7 , 13 As expected, baseline levels of sexual function are associated with postoperative sexual function 13 , 14 , but there do not appear to be clear demographic or psychosocial predictors of postoperative sexual activity or function. A variety of surgical factors have been explored in the existing literature, but most of these demonstrate minimal impact on sexual function. Premature surgical menopause is fairly consistently associated with decline in sexual function, 15 – 19 although there are studies that have not demonstrated this effect. 20 , 21 A variety of surgical factors, including route of surgery, 22 , 23 removal versus preservation of cervix, 24 vaginal cuff closure technique, 25 , 26 and surgical indication, 7 appear to have little to no impact on degree or magnitude of change in sexual function. While surgical excision of deep infiltrating endometriosis without concurrent hysterectomy appears to result in improved dyspareunia in several studies, the impact on global sexual function appears neutral. 27 , 28 There is minimal data regarding the impact of concurrent surgical treatment of endometriosis at time of hysterectomy, but a recent prospective study did not find an independent association with change in sexual function. 7 While psychosocial factors are strongly associated with female sexual function 29 , 30 , there is minimal data exploring the potential impact of these factors on the change in sexual function following hysterectomy. A few studies have identified preoperative depression as a risk factor for lack of improvement in sexual function and dyspareunia, 13 , 14 but factors like social and emotional support, relationship quality, and resilience have not been explored. Understanding the potential impact of these factors can allow more informed counseling and setting accurate expectations and may also inform surgeons and patients as they consider therapeutic targets for sexual dysfunction. The objectives of this study were to evaluate the relationship between baseline psychosocial factors and sexual activity and sexual function at 6-months following hysterectomy.