Hysterectomy and sexual function: a systematic review and meta-analysis

Background Sexual function after hysterectomy can be a concern for patients, and research remains inconclusive about changes in sexual function associated with hysterectomy. Aim We meta-analyzed studies on change in sexual function from pre- to posthysterectomy and the role of total vs subtotal hysterectomy and concomitant bilateral salpingo-oophorectomy (BSO) in differences in such change. Methods We searched PubMed, Embase, and Cochrane databases from inception to January 2022. Two reviewers screened and included studies if they were published in a peer-reviewed journal and reported on sexual function pre- and posthysterectomy for benign nonprolapse indication. Methodological quality was assessed with the STROBE checklist. We used random effects multilevel models to meta-analyze standardized mean differences in pre- to postoperative sexual function and the posthysterectomy Female Sexual Function Index mean across study groups in R (RStudio). Outcomes Outcomes included overall sexual function, dyspareunia, desire, arousal, lubrication, and orgasm. Results Thirty-two articles were analyzed: 8 randomized controlled trials, 20 prospective studies, 2 retrospective studies, 1 cross-sectional study, and 1 secondary analysis, comprising a total of 4054 patients. Each study provided data for at least 1 outcome. Study quality was moderate, and effect sizes showed large between-study heterogeneity. Hysterectomy was not associated with significant change in overall sexual function irrespective of surgical route, with patients tending to report potentially remaining sexual dysfunction posthysterectomy. Cervix removal was not significantly associated with differences in magnitude of change. Hysterectomy without BSO was associated with significantly stronger improvement in lubrication and orgasm than hysterectomy with BSO, which was not the case for desire, arousal or overall sexual function. However, these significant differences were not replicated within studies that directly compared cases with and without BSO. Clinical Implications Clinicians should address remaining sexual dysfunction posthysterectomy, and BSO should not be considered if not medically required. Strengths and Limitations We analyzed a comprehensive number of trials and studied clinically relevant factors that might relate to differences in change in sexual function. Conclusions need to be interpreted with caution since many studies showed moderate methodological quality and large effect size heterogeneity. Conclusion Subtotal and total hysterectomy was not associated with significant change in overall sexual function irrespective of surgical route, with patients tending to report potentially remaining sexual dysfunction posthysterectomy. Hysterectomy without BSO was associated with significantly stronger improvement in lubrication and orgasm than hysterectomy with BSO. Future research on hysterectomy should analyze predictors of sexual function change trajectories, such as different indications.