As a gynecologist who has performed hundreds of hysterectomies and now runs a sexual medicine clinic, I know firsthand how devastating it can be when this procedure solves a gynecologic problem, only to create a sexual one. And though that is not the case for most women, for others it is no coincidence that surgery coincides with the onset of painful intercourse or an inability to orgasm.
Since roughly one-third of women will lose their uterus by age 60, even a tiny percentage represents large numbers of women. At best, only half of gynecologists initiate a discussion of sex during pre- or post-op appointments, and few patients bring it up themselves. That means a lot of women who undergo a hysterectomy are blindsided when there is a change in sexual function.
Sometimes it is a sudden drop in hormones from ovary removal that leads to a decrease in libido, sensation and frequency of orgasm, but in other cases, the surgery itself is the culprit.
So, first the good news: Most women who undergo a hysterectomy do not report problems. Virtually every published study reports that sex is the same or better. Before you say, “No way!” keep in mind that most studies include only young women who had a hysterectomy because of pain or bleeding and who did not go into menopause as a result of surgery.
For those individuals, eliminating the cause of the pain allowed intercourse to become pleasurable again. Most women do not notice any difference in their ability to orgasm post-hysterectomy, because the clitoral nerves are not damaged during uterus removal. Nothing changes. But if you are in the minority for whom something very clearly changed, you are not imagining it.
What was removed matters
The term “hysterectomy” refers only to the removal of the uterus and has nothing to do with the fallopian tubes or the ovaries. If the ovaries are not removed, nothing changes hormonally.
When it comes to hysterectomy and a change in sexual function, there are two groups to consider.
Group 1: Those who enter menopause because of surgery
This group includes any woman who has her ovaries removed and was not already in menopause. In that case, sexual repercussions are almost always from the loss of estrogen. Women who become menopausal because of surgery experience all the same symptoms that a woman experiences when she enters natural menopause. Decreased libido, mood disturbance, vaginal dryness and insomnia from hot flashes are major contributors to sexual problems. Painful intercourse is hardly an aphrodisiac, and if your libido and/or orgasm are gone post-hysterectomy, nothing will get better until you eliminate pain. Local or systemic estrogen therapy or nonhormonal options to relieve vaginal dryness, hot flashes and insomnia will turn things around.
Group 2: Those who were already in menopause and those who are not in menopause but did not have their ovaries removed
This is a much smaller group, but it does exist. In this group, sexual repercussions are a consequence of surgery, not of a change in hormonal status. Here’s why.
Sexual impact of removing the uterus — in some women
During orgasm the uterus contracts. Some women are not aware that this occurs, and it is not part of the orgasm experience. But some women rely on this uterine sensation for sexual excitement and to achieve orgasm. If the uterus is removed, that aspect of orgasm is removed.
Sexual impact of removing the cervix — in some women
Most studies show that the fate of the cervix (the junction between the vagina and the uterus) does not alter the ability to orgasm. This is not surprising, as most orgasms arise from clitoral stimulation. But if you are in the small minority of women who experience vaginal orgasm from cervical stimulation, removal of the cervix means that that path to pleasure is interrupted. This explains the inconsistency in studies that look specifically at cervix removal. The only women who will have a negative impact will be those who had cervical orgasms pre-op.
“It just doesn’t feel the same”
What about the vagina? One small study (only 27 women) specifically looked at vaginal sensation following a hysterectomy. In 25 percent of the participants, there was a significant decrease in vaginal sensitivity to cold, warm and vibration post-hysterectomy. No one, however, experienced a change in clitoral sensation.
Psychological issues?
In 1890 an article in a medical journal identified hysterectomy as the surgery most likely to cause psychosis. The reality is just the opposite. Not only is it unusual to be depressed, but most women report a tremendous sense of relief that they no longer need to deal with pain, bleeding or fear of cancer. Having said that, for some women, hysterectomy symbolizes the end of fertility, femininity, sexuality and even their very identity. This belief can easily lead to a loss of self-confidence and sexual desire that has nothing to do with hormonal or surgical changes. In those cases, seeing a good sex therapist can be a godsend.
A woman’s sexual response after a hysterectomy depends on the kind of stimulation a woman enjoyed before this procedure. If you are in the group for whom things have changed, know that there are many pathways to pleasure and a hysterectomy does not mean that your sex life is over. If your gynecologist isn’t helpful, there are sexual-medicine experts who can facilitate a return to pain-free and pleasurable sexual activity.
Lan Truong
