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Archives of Sexual Behavior, Vol. 33, No. 1, February 2004, pp. 31–42 ( C° 2004)
The Effects of Hysterectomy on Sexual Arousal in Women
With a History of Benign Uterine Fibroids
Cindy M. Meston, Ph.D.1
Received January 3, 2003; revision received June 26, 2003; accepted August 14, 2003
Research indicates hysterectomy surgery may adversely affect the pelvic autonomic nerves and au-
tonomic mechanisms are integral to the sexual arousal response in women. This study explored the
possibility that women who undergo hysterectomy may experience an impaired vasocongestive re-
sponse to erotic stimulation. Thirty-two women with a history of benign uterine fibroids who had
(nD 15) or had not (nD 17) undergone hysterectomy participated in two experimental sessions in
which self-report and physiological (vaginal pulse amplitude; VPA) sexual responses were recorded
during an erotic film presentation. In one of the sessions, the women exercised on a treadmill for
20 min prior to viewing the erotic films as a means inducing autonomic arousal. Exercise signifi-
cantly increased VPA but not subjective sexual responses in both groups of women. VPA responses
were marginally higher among the fibroid than hysterectomy group in the no-exercise condition. The
hypothesis that physiological sexual arousal may be impaired with hysterectomy surgery was only
partially supported.
KEY WORDS: hysterectomy; uterine fibroids; sexual arousal; exercise; vaginal photoplethysmography.
INTRODUCTION
Hysterectomy is the most common nonpregnancy-
related surgery performed among American women.
About 600,000 women undergo this procedure each year
in the United States, and by the age of 60 nearly one
out of every three American women will have undergone
hysterectomy (Easterday & Grimes, 1983; Lepine et al.,
1997; Wilcox et al., 1994). Approximately 90% of hys-
terectomies are conducted for benign conditions such as
leiomyomas (fibroids), dysfunctional uterine bleeding, en-
dometriosis, chronic pelvic pain, and prolapse (Pokras &
Hufnagel, 1987). Reports of positive outcomes posthys-
terectomy include the cessation of abnormal uterine bleed-
ing, relief from menstrual symptoms and pelvic pain, and
decreases in depression and anxiety (for review, see
Farquhar et al., 2002). A high proportion of women, how-
ever, develop new symptoms posthysterectomy which
include depression, fatigue, urinary incontinence, con-
stipation, early ovarian failure, and sexual dysfunction
1Department of Psychology, University of Texas at Austin, 108 E. Dean
Keeton, Austin, Texas 78712; e-mail: meston@psy.utexas.edu.
(e.g., Carlson, Miller, & Fowler, 1994; Thakar, Manyonda,
Stanton, Clarkson, & Robinson, 1997). In one retrospec-
tive study of women at a minimum of 2 years posthysterec-
tomy, at least half reported symptoms caused or worsened
by hysterectomy (Bachmann, 1990). Thus, it is not surpris-
ing that concern has been raised regarding the appropri-
ateness of this surgery for the treatment of nonmalignant
conditions. Nerve-sparing surgical techniques and pro-
cedures, such as endometrial ablation and supracervical
hysterectomy, are offered as alternatives to total hysterec-
tomy for the treatment of benign conditions but, as of yet,
they have not substantially impacted hysterectomy rates
(Farquhar & Steiner, 2002).
The extent to which hysterectomy impacts sexual
function is of debate in the literature. Studies have es-
timated anywhere from 4% (Schofield, Bennett, Redman,
Walters, & Sanson-Fisher, 1991) to 40% (Carranza-Lira,
Murillo-Uribe, Trejo, & Santos-Gonzalez, 1997) of
women report decreases in sexual desire, and between 8%
(Eicher, 1994) and 25% (Dennerstein, Wood, &
Burrows, 1977) of women report decreased orgasmic abil-
ity posthysterectomy. Other studies have concluded that
hysterectomy has a largely positive impact on the sex
31
0004-0002/04/0200-0031/0 C° 2004 Plenum Publishing Corporation
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32 Meston
lives of women (e.g., Rhodes, Kjerulff, Langenberg, &
Guzinski, 1999; Schofield et al., 1991), and that sexual
desire and orgasm are most likely either unchanged or en-
hanced following surgery (e.g., Coppen, Bishop, Barnard,
& Collins, 1981; Ewert, Slangen, & Van Herendael, 1995).
To date, information on the relation between hys-
terectomy and sexual function is based almost exclusively
on self-report measures. Retrospective questionnaire stud-
ies are prone to recall biases and cannot account for the ef-
fects of preoperative sexual functioning on postoperative
assessment. Prospective studies that assess sexual func-
tioning pre- and posthysterectomy are complicated by the
fact that baseline sexuality data are generally collected just
prior to surgery when the woman is likely to be experi-
encing decreased sexual interest due to anxieties about the
upcoming surgery (e.g., Carlson et al., 1994; Rhodes et al.,
1999). For women who undergo hysterectomy to treat be-
nign uterine fibroids, presurgery sexual function may also
be influenced by excessive menstrual bleeding and con-
sequent anemia, pain with sexual activity, and treatment
with gonadotrophin releasing hormone (GnRH) agonists
which have been reported to cause side effects such as
vaginal dryness and decreased libido (Auber et al., 1990;
Brogden, Buckley, & Ward, 1990; Chrisp & Goa, 1990).
Moreover, many studies assess sexual functioning as early
as 6 months posthysterectomy while evidence suggests
that the effect of surgery on sexuality, whether positive or
negative, evolves gradually, and that the follow-up should
occur at least 12 months after surgery (for review, see
Farrell & Kieser, 2000). Differences in factors such as age,
relationship with partner, hormonal effects (i.e., hormone
replacement therapy, oophorectomy), psychological well-
being (i.e., anxiety, depression), indication for surgery (fi-
broids, menstrual disorders, cancer), and type of surgery
could also help explain the discrepancy between findings
from self-report studies.
Also, limiting to the understanding of how hysterec-
tomy impacts sexuality is the fact that most studies have
failed to use validated measures of sexual functioning and
do not provide justification for how or what they are assess-
ing. For example, the Maryland Women’s Health Study
(Rhodes et al., 1999), a prospective survey of over 1,200
women, concluded that sexual functioning improved over-
all after hysterectomy. Rhodes et al. based these conclu-
sions, in part, on the finding that frequency of “sexual
relations” increased posthysterectomy and stated that
Increased sexual activity after hysterectomy may be the
strongest evidence of a positive effect of hysterectomy
on sexual functioning. This is because improved sexual
functioning and increased sexual enjoyment are the most
obvious explanations for increased sexual relations after
hysterectomy. (pp. 1938–1939)
This conclusion seems overstated in light of a number of
factors. First, Rhodes et al. did not define whether “sexual
relations” referred specifically to intercourse or whether it
also included behaviors such as masturbation, kissing, and
petting. For some women, frequency of intercourse may be
a better indicator of partner availability and drive than their
own sexual enjoyment or desire. Second, Rhodes et al. did
not assess sexual enjoyment either prior to or following
hysterectomy and provided no evidence to suggest a link
between increased “sexual relations” and sexual pleasure.
Third, a significant proportion of women in the study re-
ported decreases in sexual pain following hysterectomy. If
sex was no longer painful, the women may have been more
willing to engage in sexual activity and this could account
for the increases in sexual activity also noted posthysterec-
tomy. Of course willingness to engage in sexual activity
and sexual pleasure are not necessarily linked.
Another limitation to the understanding of how hys-
terectomy impacts sexual function is that studies have fo-
cused almost exclusively on measures of sexual desire and
orgasm and, to a lesser extent, sexual satisfaction. With
one exception, sexual arousal has been discussed only
in studies that have examined women who have under-
gone oophorectomy (e.g., Dennerstein et al., 1977; Weber,
Walters, Schover, Church, & Piedmonte, 1999). This is
surprising given that sexual arousal, as defined in the DSM-
IV-TR (American Psychiatric Association, 2000), pertains
specifically to a genital response and hysterectomy is an
operation that focuses primarily on the genitalia.
In the one previous study that examined physiologi-
cal sexual arousal in women who had undergone hysterec-
tomy (Bellerose & Binik, 1993), comparisons of vagi-
nal pulse amplitude (VPA) responses to erotic stimuli
were made between five groups of women: those who
had undergone hysterectomy but maintained at least one
ovary (nD 15), three groups of women who had under-
gone hysterectomy plus bilateral salpingo-oophorectomy
(those on estrogen replacement therapy (nD 15), those on
androgen–estrogen therapy (nD 8), and those not on hor-
mone replacement therapy (nD 5)), and a group of non-
surgical control women (nD 15). The women participated
in two sessions: an interview/questionnaire session and a
session that measured subjective and VPA responses to
erotic films. No significant group differences were found
on physiological measures of sexual arousal. Although
these findings provide important information on the sex-
ual responses of hysterectomized women, they are lim-
ited in that the single VPA assessment session allowed for
only between-group comparisons. It has been argued that,
given the inability to calibrate VPA and the wide vari-
ability in VPA responses between women, it is question-
able whether VPA data should be used in between-group
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Hysterectomy and Sexual Arousal 33
comparisons, particularly in studies with small sample
sizes (e.g., Janssen, 2002).
This study examined subjective and physiological
sexual arousal processes in women with a history of be-
nign uterine fibroids who had or had not undergone hys-
terectomy. The women participated in two experimental
sessions in which self-report and physiological (VPA) sex-
ual responses were recorded during an erotic film presen-
tation. In one of the sessions, the women exercised on
a treadmill for 20 min at 70% of their maximum heart
rate (HRmax)2 prior to viewing the erotic films. In a se-
ries of studies conducted in nonhysterectomized, sexually
functional women, Meston and Gorzalka (1995, 1996a,
1996b) found that exercise at the duration and intensity
employed here significantly enhanced VPA responses to
erotic films. It could not be determined from these
studies whether the increases in VPA postexercise were
attributable to increased sympathetic nervous system ac-
tivity, parasympathetic nervous system activity, or an in-
teraction between the two. Regardless, the findings are
congruent with a body of literature indicating an important
role of autonomic arousal in the female sexual physiolog-
ical arousal response (for review, see Giuliano, Rampin,
& Allard, 2002).
The autonomic nerves of the female internal gen-
ital organs are thought to be supplied via the superior
hypogastric plexus, which divides and eventually forms
the inferior hypogastric plexuses. The inferior hypogas-
tric plexus extends into the left and right cardinal and
uterosacral ligaments. Hysterectomy may affect the pelvic
autonomic nerves through excision of the cervix and sep-
aration of the uterus from the cardinal and uterosacral
ligaments (Thakar et al., 1997). If sexual arousal processes
are negatively impacted by hysterectomy surgery, and this
is associated with impaired autonomic innervation, dif-
ferences between women who have and have not under-
gone hysterectomy would be expected to emerge under
conditions of heightened autonomic arousal. This study
extends previous research on hysterectomy and sexual
function by: (1) examining sexual arousal processes under
2Participants were asked to run at a constant target heart rate (70%
HRmax, determined using Karvonen’s formula (American College of
Sports Medicine, 1995). HRmax is an indirect assessment of the maxi-
mal volume of oxygen one can consume during exhausting work, and is
closely linked to aerobic fitness levels (e.g., Sutton, 1992). HRmax was
used as a criterion for exercise intensity, rather than an absolute crite-
rion (e.g., a specific length of running time) to ensure that participants
of potentially different fitness levels exercised at comparable levels of
exertion. Fitness levels were not assessed because Meston and Gorzalka
(1995) reported no correlation between fitness levels and physiological
measures of sexual arousal when participants exercised at equivalent
levels of their HRmax.
conditions of heightened autonomic arousal, (2) making
within-subject comparisons of physiological and subjec-
tive sexual arousal, (3) examining self-report measures of
sexual function using an inventory that has been validated
on sexually dysfunctional women, and (4) using a control
group that matches the hysterectomy group on history of
benign uterine fibroids—the most common indication for
hysterectomy.
METHOD
Participants
Participants were obtained through referrals from the
Renaissance Women’s Medical Clinic, via advertisements
in the local and University of Texas newspapers, and via
posters placed in women’s restrooms across the University
of Texas campus. The advertisements called for women
to participate in a study directed toward understanding
the effects of hysterectomy and uterine fibroids on sexual
function.
The final total sample size was 32: 15 women who
had and 17 women who had not received hysterectomy
surgery. Inclusion criteria for all participants were: over
age 20, premenopausal (as determined by assays assessing
FSH and estradiol), heterosexual, absence of vaginal dis-
ease, and currently involved in a sexually active relation-
ship. Participants who met the initial criteria were given a
clinical interview via telephone and were excluded from
participation if they met criteria for a DSM-IV Axis I dis-
order, including organic mental syndromes and disorders,
schizophrenia, delusional disorder or psychotic disorders
not classified elsewhere, or if they were at risk for suicide
(nD 0). Patients who were currently receiving any medi-
cations known to affect vascular or sexual functioning (in-
cluding antidepressants, antihypertensives) were excluded
from participation (nD 2). Individuals previously on med-
ications known to affect vascular or sexual functioning
were required to have a 3-week wash-out period prior to
participation.
Further inclusion criteria for women who had un-
dergone hysterectomy (experimental group) were: having
undergone hysterectomy for the primary purpose of treat-
ing benign uterine fibroids no less than 1 year and no
more than 10 years prior, and at least one intact ovary.
This latter criterion was used because bilateral oophorec-
tomy and the consequent decrease in ovarian hormones
may adversely impact sexual function by, for example,
decreasing vaginal lubrication (e.g., Dennerstein et al.,
1977) or compromising a woman’s sexual attractiveness
via destruction of axillary pheromonal secretions (Cutler,
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34 Meston
1996). One woman was excluded from participation be-
cause she had had both ovaries removed. Further inclu-
sion criteria for women who had not undergone hysterec-
tomy (fibroid group) were: diagnosis of benign uterine
fibroids as per ultrasonography screening, and not sched-
uled or planning for hysterectomy surgery. This latter cri-
terion was used because it may be expected that upcom-
ing gynecological surgery would create a certain degree
of anxiety, fear, and concern for the woman involved,
and subsequently might adversely impact sexual function.
Women who were currently receiving treatment for uter-
ine fibroids with GnRH agonists (e.g., Goserelin acetate,
Nafarelin, Buserelin) were excluded from participation
(nD 0). Thirty-four premenopausal women with a history
of benign uterine fibroids met initial inclusion criteria and
were scheduled for their medical screening visit at the Re-
naissance Women’s Medical Clinic. Seventeen of these
women had undergone hysterectomy for the treatment of
benign uterine fibroids; 17 had not undergone hysterec-
tomy.
There were no significant differences between the
hysterectomy and fibroid groups on age, weight, race, ed-
ucation, marital status, length of relationship, marital sat-
isfaction, body satisfaction, or depression (see Table I). All
women were premenopausal; none of the women were on
hormone replacement therapy.
For women in the fibroid group, the average length of
time that they had been diagnosed with benign uterine fi-
broids was 4 years (range, 2 months–11 years). The mean
number of fibroids detected upon ultrasound screening
was 3 (range, 1–7) and the mean size of the largest fibroid
was 48 mm. None of the women in this group reported hav-
ing undergone any procedure for fibroid removal. Among
the women in the hysterectomy group, the average length
of time since hysterectomy surgery was 3 years, 8 months
(range, 13 months–10 years). All but two of the women
had both ovaries intact; two women had received unilateral
oophorectomies. Seven women had received an abdominal
hysterectomy and seven women received a vaginal hys-
terectomy. Of these women, nine had undergone subto-
tal hysterectomy and five had undergone total hysterec-
tomy. Data on these two variables were missing for one
woman.
Procedure
Session 1 (Medical Screening)
During this session, the participants signed the in-
formed consent document and were given a chance to ask
any questions. A registered nurse then conducted a brief
Table I. Participant Characteristics
Hysterectomy Fibroid
(N D 15) (N D 17)
Age
Mean (SEM) 41.4 (0.86) 40.0 (0.99)
Range 36–46 35–49
Weight (pounds)
Mean (SEM) 149 (17.6) 169 (14.98)
Race (%)
Caucasian 11 (73) 12 (71)
Other 4 (27) 5 (29)
Education (%)
High school graduate or less 1 (7) 1 (6)
Some college–2 year degree 9 (60) 7 (41)
4 year degree 4 (27) 1 (6)
Advanced degree 1 (7) 8 (47)
Marital status (%)
Single 1 (7) 4 (24)
Married 10 (67) 8 (47)
Divorced 4 (27) 5 (29)
Length of relationship (%)
0–6 months 0 (0) 1 (6)
6 months–10 years 7 (47) 12 (71)
>10 years 8 (53) 4 (24)
Locke–Wallace Marital Adjustment Test
Mean (SEM) 105 (1.00) 95 (7.67)
Body Satisfaction Scale
Mean (SEM) 19.8 (1.24) 22.0 (2.15)
Beck Depression Inventory
Mean (SEM) 8.0 (2.7) 7.1 (1.51)
Range 0–32 1–23
Female Sexual Function Index
Desire Mean (SEM) 6.5 (0.56) 6.2 (0.52)
Arousal Mean (SEM) 14.7 (1.51) 14.5 (1.67)
Lubrication Mean (SEM) 15.2 (1.63) 16.2 (1.33)
Orgasm Mean (SEM) 12.0 (1.12) 11.6 (1.06)
Satisfaction Mean (SEM) 10.4 (1.01) 10.5 (0.91)
Pain Mean (SEM) 12.9 (1.14) 10.6 (1.40)
Index of Sexual Satisfaction Mean (SEM) 131 (4.0) 129 (3.21)
cardiovascular exam to ensure the women would not be
at risk when exercising. None of the women were consid-
ered at risk. Blood samples were drawn so that analyses
of FSH and estradiol could be made. Because menopause
is likely to affect sexuality, information on these hormone
levels allowed for the identification of women who were
within this transitional period. Participants were then ad-
ministered a demographics questionnaire, a medical his-
tory questionnaire, the Beck Depression Inventory (BDI;
Beck & Beamesderfer, 1974), the Index of Sexual Satis-
faction (Hudson, Harrison, & Crosscup,
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