Hysterectomy and Postoperative Problems

Sexual feeling and desire after hysterectomy

I am scheduled for a hysterectomy in about a month. I have uterine prolapse. I have put off surgery for about 2 yrs. I am 34 yrs old. I would like some input from others about this type of surgery. I was told that an abdominal incision was necessary due to needed repair work to vaginal wall prolapsing too. Will I lose all feeling during sexual relations?

No. Changes in sexual response after hysterectomy is a very uncertain area. It's almost impossible to study scientifically because many hysterectomies are performed for some sort of pain or bleeding. The pain may be chronic and/or associated with sexual relations. If that pain is relieved, there can be an improvement because pain is known to decrease sexual response and orgasm. Pain also decreases sexual desire (libido) so that may improve. So a first question is -- Are you currently having pain with sexual relations due to the prolapse? How bad is it and does it currently decrease desire for sex?

Certain physiology changes with removal of the uterus (I assume at your age the ovaries will not be removed). The body of the uterus (fundus) often has small, rapid contractions at the time of orgasm. If you have these, they almost always disappear after hysterectomy. Those contractions don't seem to stay in most women if the cervix is left in although some women feel they still experience them even with a subtotal (cervix left in) hysterectomy. Vaginal contractions during orgasm should still be the same. The cervix contributes mucous to vaginal secretions, but during sex, almost all fluid/lubrication comes from vaginal walls so most women don't report any change in lubrication after hysterectomy.

Most orgasm response comes from blood congestion in the pelvis and then release after orgasm just like an erection in a male with subsequent detumescence (going limp). All of the blood supply to the sidewalls (adnexa) of the pelvis remains after a hysterectomy so most women report no change in that part of the sexual response. In some women, much of the vascularity is in the uterus so in them, the response may be different. That same vascularity can cause pain (from chronic congestion) or pleasure during the sexual response so you can see why women report so many different responses to hysterectomy.

Another difference in your case (prolapse) is that probably you notice the uterus/cervix moving during sexual relations. Depending upon the degree of prolapse, this sensation may be painful or pleasurable or even both. With removal of the cervix and fundus and then suspending the end of the vagina to ligaments in the pelvis so the vagina won't fall down (prolapse) in later years, this movement sensation with intercourse will change.

Will I lose all desire for sex?

Hysterectomy should not affect desire. The most common causes of decreased sexual desire are stress causing fatigue, anger at one's partner (conscious or unconscious), and fear of pain with relations. All of these components can change with hysterectomy and the time of recovery. (see the February 1, 1998, Woman's Diagnostic Cyber News -- Decreased Sexual Desire - Its Many Causes

Ovary removal with hysterectomy at age 28

I am 28 years old with two children (vaginal deliveries). I have been informed by my trusted gynecologist that I need a hysterectomy and bladder suspension. I am concerned about leaving in my ovaries (he said I should leave them in). I would love someone else's input on this situation.

Age 28 is usually felt to be too young to remove ovaries if there is no disease (there shouldn't be with just prolapse). If a woman didn't take estrogen replacement therapy after a hysterectomy at age 28, she would have an "extra" 23 years of menopausal change with premature aging, earlier heart disease and earlier bone thinning. Lack of estrogen replacement after the menopause at average age 51 reduces a woman's life span by about three years, it is estimated. If you started at age 28, I would suspect life span would be reduced by even more. The answer would seem to be to take estrogen replacement starting immediately after hysterectomy and ovary removal. The problem is that across the board, only about one third of women who intend to take estrogen replacement actually do. Some stop just because it is a pain in the neck to take a daily medicine while others stop because they may have side effects to the estrogen such as headaches, irritability, breast soreness etc. The net result is that there are many women who develop "aging" problems earlier than they need to.

On the other hand, there are sometimes strong family histories of ovarian cancer, breast and colon cancer that might indicate an increased risk to leaving the ovaries in, which would outweigh the risks of earlier heart disease. Thus, sometimes the decision needs to take into account your family history of medical problems.

Ovary removal with hysterectomy at age 42 with PCOD

I am 42 yrs old & my doctor is recommending a hysterectomy. I have fibroid tumors (my uterus is the size of a 3 month pregnancy) with chronic uterine pain, very heavy bleeding and cramps. We have been watching and waiting for 1 yr. I had a D&C done last year to do a biopsy on uterine polyps which were benign. I urinate frequently. I had an abnormal pap 25 yrs ago and had cryosurgery. I have polycystic ovarian disease. I also have HPV. My question is whether or not at age 42, I should also have my ovaries removed when we do the hysterectomy. My doctor recommends having them removed but says that decision is up to me. I have nothing to base my decision.

At age 45 it is usually recommended to remove the ovaries. Under age 40, leave the ovaries in. Women who have a family history of cancer, endometriosis or a history of ovarian problems would be exceptions to these guidelines. In your case you have an additional problem of the polycystic ovarian disease. The ovaries don't have to be removed because of it but sometimes doctors feel that polycystic ovaries can lead to recurrent cysts and pain that may result in further surgery (on the ovaries) between now and the time of natural menopause. If you have had any ovarian pain problems or frequent cyst formation, you might want to have the ovaries removed at the time of hysterectomy.

Also, is the cervix removed during a hysterectomy?

Usually the cervix is removed during a hysterectomy in order to reduce the future incidence of cervical cancer or abnormal PAP smears (It doesn't decrease the incidence to zero however so you still need periodic PAP smears). There has been a recent trend to leave the cervix in place as more support for the vaginal vault and for improved, post hysterectomy sexual response. Some women note that orgasm, while it still takes place after hysterectomy, is slightly altered in its nature. Leaving the cervix is thought by some to preserve the original nature of the orgasmic response. This really hasn't been determined in well-controlled scientific studies yet. In your case, the HPV history might increase the risk for cervical dysplasia/abnormal PAPs etc.

Ovary removal with hysterectomy at age 43 with family history of colon cancer

Today I saw my new OB-GYN, I really liked him. He said I have a few choices because of large fibroids. The main two we talked about were D&C plus tubal ligation. Or a hysterectomy. I am so tired of the bleeding and cramps with backache I am leaning toward the latter. He also said I need to decide at age 43 if I want to keep the ovaries. He asked if there is cancer in my family. I explained my younger sister had cervical cancer when she was 18 and now at age 39 has terminal colo-rectal cancer metastatic to the liver. She is on chemotherapy and not doing well. Would you suggest keeping the ovaries? He also said because I have been on BCP for so many years my risk of ovarian cancer is less. After watching my sister waste away I am scared to death of cancer.

Age 43 is an in between time (40-45) for whether or not to remove the ovaries at the time of hysterectomy. In your case the family history of the colon cancer could slightly increase your lifetime risk of ovarian cancer from 1.5% to 2-3%. In view of your experience with your sister and fear of cancer, a decision to remove the ovaries at age 43 at the time of hysterectomy would seem to be quite reasonable.

You are at a decreased risk of ovarian cancer because of birth control pill use. In fact if you used pills for 6 years or more, your risk of ovarian cancer is about 40% of what it would be if you hadn't used pills. You really could go either way on this. Most women under those circumstances would probably choose to have them removed, but I would go with your gut feeling on this.

Also if I lose the ovaries I need to go on estrogen. What is involved and what are the dangers of that?

After hysterectomy, hormone replacement therapy would consist of estrogen alone (no need for progestins), usually given daily by pill or sometimes weekly or biweekly skin patch.

Generally estrogen therapy is felt to be safe after hysterectomy with moderate cardiovascular benefits. Long term use may be associated with a small increase in breast cancer (still slightly controversial) but decreased heart attacks and hip fractures due to osteoporosis are well established. Overall average years of life gained with estrogen replacement is about three years. Your individual family history should be taken into account however. See our Test your Knowledge about Menopause

Ovarian removal with hysterectomy for fibroids at age 48

I am 48 years old and have large fibroid tumors (8, 7,and 6 cm). I have experienced much discomfort in the last few months and want to have a hysterectomy but am confused. My doctor is encouraging removal of the ovaries so that I won't have to worry about ovarian cancer but I feel that I would benefit from hormones that the ovaries would give me. I have had night sweats and am beginning to have irregular periods but I don't know how close to menopause I may be. Should I insist that he leave my ovaries?

Most of the doctors use a cutoff of age 45 at which time to do an oophorectomy at the time of hysterectomy. The intent is to prevent ovarian cancer in later life. If it were a perfect world in which all women could take hormone replacement therapy (HRT) with no side effects then there would not be a downside to taking the ovaries before menopause. Unfortunately compliance and side effects reduce the number of women who take HRT and thus ovary removal before menopause can hasten heart disease by several years in those women who cannot take HRT. See the article below by Speroff who addresses that. On the other hand, some women do get ovarian cancer in later life and if they had had their ovaries removed at the time of a hysterectomy, some of those cancers would be prevented. See the second article below that I gleaned from Medline. With current symptoms of hot flashes, your doctor could order an FSH (follicle stimulating hormone) blood test to see if the ovaries have already stopped functioning (elevated level usually over 30 in most labs). If they have stopped functioning, there would not be any reason not to remove them at the time of hysterectomy unless the surgical time were substantially increased due to adhesions, anatomy etc. Average age of menopause is 51 y.o. but obviously it could be next month, next year or in 7 years in any individual at 48 y.o. Other factors to consider -- positive family history of ovarian, breast or colon cancer might sway one to oophorectomy because of the small incidence, but real, of genetic predisposition to those cancers. A family history of heart attacks, strokes or atherosclerotic heart disease at younger ages (eg. less than 50] would sway one toward leaving in the ovaries until natural menopause.

All things being equal, I would probably recommend removing the ovaries in the situation you describe because too many times menopause has started right after the surgery (perhaps the stress/trauma) and then you feel really bad they are still there to possibly develop ovarian cancer and yet give no hormonal benefit. Alas! If the question was easy to answer, it wouldn't be of such high concern, but many women have the same question you have.

Am J Obstet Gynecol 1991 Jan;164(1 Pt 1):165-174

A risk-benefit analysis of elective bilateral oophorectomy: effect of changes in compliance with estrogen therapy on outcome.

Speroff T, Dawson NV, Speroff L, Haber RJ

Department of Epistemology and Biostatistics, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio.

A bilateral oophorectomy at the time of elective hysterectomy is often performed to prevent ovarian cancer. The assumption that endogenous estrogen can be easily replaced with supplemental medication fosters the decision for routine oophorectomy. Published reports on the use of postmenopausal estrogen indicate that compliance is less than perfect. This fact could affect the overall outcome. Decision analysis techniques with Markov cohort modeling were used to evaluate the policy of elective bilateral oophorectomy. Results from studies judged methodologically sound were combined to determine values representing the influence of estrogen on coronary heart disease, breast cancer, and osteoporosis fracture. The decision tree also explicitly incorporated patient compliance. When compliance with estrogen therapy is assumed to be perfect, oophorectomy yields longer life expectancy than retaining the ovaries. When actual drug-taking behavior is considered, retaining the ovaries results in longer survival. This analysis highlights the importance of including the effects of patient compliance with treatment recommendations when the impact of a health policy decision such as prophylactic surgery is assessed.

Am J Surg 1997 Jun;173(6):495-498

Is incidental prophylactic oophorectomy an acceptable means to reduce the incidence of ovarian cancer?

Rozario D, Brown I, Fung MF, Temple L

Department of Surgery, Ottawa General Hospital, University of Ottawa, Ontario, Canada.

BACKGROUND: According to previous reports, the lifetime risk of developing ovarian carcinoma is 1.4%. This figure varies with age from 6.6 per 100,000 among women aged 35 to 39 years up to 55.1 per 100,000 among women aged 75 to 79 years. Prophylactic oophorectomy remains a modality to decrease the incidence of ovarian cancer. What proportion of women diagnosed with an ovarian malignancy had a preceding laparotomy at which time a prophylactic oophorectomy could have been performed?

METHODS: We reviewed the new ovarian cancer diagnoses seen in patients between August 1988 and August 1993 at the Ottawa Regional Cancer Foundation. Four hundred and four patients were identified. These patients were analyzed for preceding abdominal surgery, age, time to disease progression, time to death, time to death from other causes, and average follow-up. The previous abdominal surgeries were divided into: (1) major gynecological surgery; and (2) general surgery procedures, which were further divided into laparotomy and pelvic surgery (group A surgeries) and general surgery that included other abdominal surgeries (ie, appendectomy, cholecystectomy) where access to the pelvis could be more difficult (group B surgeries).

RESULTS: A total of 270 abdominal surgeries was performed, prior to the diagnosis of ovarian cancer. The group was stratified according to the timing of the surgery ( greater or =40 years, 41 to 45 years, 46 to 50 years, >50 years). Based on these data, and on the grouping of general gynecologic surgeries plus the general surgical procedures of group A, 10.9% of ovarian cancers would have been prevented if prophylactic oophorectomy had been performed in patients who had surgery over 40 years of age; over 45 years this was 6.7%, over 50 years it was 4%. If one adds all major surgeries, including general surgery groups A and B, the results were 26.9% over 40 years of age, 20% over 45, and 16.6% over 50.

CONCLUSION: We found that, depending on the age of the patient, prophylactic oophorectomy results in a 4% to 10.9% reduction in the incidence of ovarian carcinoma. This increases to 16.6% to 26.9% if one considers general surgery procedures in which access could be more difficult. Although we are not advocating the frequent use of this procedure, we recommend that surgeons routinely discuss this option before surgery with their postmenopausal female patients over 49 years of age. Given that the decision for prophylactic oophorectomy is multifaceted, we feel that a risk scoring for ovarian cancer and a discussion of the risk and benefit ratio should be undertaken. The ultimate goal is to heighten patient awareness of the risk factors to ensure that an informed decision is made concerning this consistently lethal disease.

Ovarian and cervix removal with hysterectomy at age 50

Is it possible to keep your ovary and cervix, following a diagnosis of adenomyosis, I don't mind the uterus being removed, but I am concerned about the other organs, if they're healthy.

I am 50 yrs. of age still have regular monthly periods, 2 days heavy. I only have one ovary, the other was removed in my 20's for a large cyst. I have an enlarged uterus, 4 to 5 month pregnancy size with fibroids. There is no pain involved, just frequent discharge.

It IS possible to have just the fibroids in the body of the uterus removed and not remove the ovary or cervix. This would be a subtotal hysterectomy. You might want to talk to your doctor about it. Your menstrual periods would stop and the pelvic pressure from the fibroids should be cured.

You need to carefully examine your reasons for wanting to keep the remaining ovary and the cervix. Both of them can develop cancerous lesions in the future and if you have them removed, almost all (about 98%) of those cancers could be prevented. At age 50 the chance of a future cancer of the ovary or cervix is about 1-2%.

If you keep the cervix, you will need more frequent Pap smears and occasionally you may have some bleeding from the cervix if you take estrogen replacement. Ovaries can sometimes form cysts after menopause and Pap smears can become abnormal also. While these are not cancerous changes, the worry and concern that you would undergo at the time as well as the extra studies and medical visits can be more than worth having them removed at the time of the hysterectomy. I would guess that the future ovarian or cervical problem that you might have that needs medical attention is in the range of 5% or 1 out of 20 chance.

I do not know of negatives from removing the ovary at age 50 except that you may need to start estrogen replacement right away rather than in a few more months or years with natural menopause. Ovaries due secrete small amounts of testosterone for a short while after menopause but this too can be replaced if needed.

The main negative from removing the cervix is that orgasm with intercourse can change. It is not noted as less pleasurable but the fine uterine contractions that are sometimes present with orgasm either change or go away. A recent patient of mine was concerned about this and asked for just a subtotal hysterectomy. Unfortunately postoperatively she actually complained of a new pain with intercourse after her subtotal hysterectomy. I do not know the cause of the pain but it is reproducible by moving the cervix on pelvic exam. It may be because of adenomyosis of the cervix or perhaps the stitches that are suspending the cervix to keep it from prolapsing may be putting a stretch on the ligaments that the woman is not used to. I only relate this to you as an example that we still do not have all the answers about how surgery affects each individual person and there can be other disadvantages to leaving the cervix in. Truthfully, no one yet knows whether the chance of painful intercourse is higher after removal of the cervix with hysterectomy or higher after a subtotal hysterectomy.

Most gynecologic surgeons who are old enough to have performed moderate numbers of both total and subtotal hysterectomies will tell you that more women in the years post follow-up regret not having the ovary or ovaries removed (over age 45) and not having the cervix removed, than regret having them removed. I do not think these doctors are perceiving these complaints erroneously. I just would not want you to be someone who later regrets a decision about surgery because of not investigating the alternatives.

I'm glad you are evaluating the alternatives and asked!

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