子宫肌瘤患者子宫切除术后性唤起的影响

P1: GTQ Archives of Sexual Behavior pp1056-aseb-476971 November 27, 2003 16:11 Style file version July 26, 1999 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 P1: GTQ Archives of Sexual Behavior pp1056-aseb-476971 November 27, 2003 16:11 Style file version July 26, 1999 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 P1: GTQ Archives of Sexual Behavior pp1056-aseb-476971 November 27, 2003 16:11 Style file version July 26, 1999 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, P1: GTQ Archives of Sexual Behavior pp1056-aseb-476971 November 27, 2003 16:11 Style file version July 26, 1999 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,