Authors: Barry R. Komisaruk, Eleni Frangos, Beverly Whipple

Study from: University of Medicine and Dentistry of New Jersey

Problem: The prevailing view in the medical literature is that hysterectomy improves the quality of life. This is based on claims that hysterectomy relieves painful intercourse and abnormal bleeding and improves sexual response. Because hysterectomy requires cutting the sensory nerves that supply the cervix and uterus, it is surprising that the reports of negative effects on sexual response are so limited. However, almost all articles report that some women find that hysterectomy is detrimental to their sexual response. It is likely that the degree to which a woman’s sexual response and pleasure are affected by hysterectomy depends not only on which nerves were severed by the surgery, but also the genital regions whose stimulation the woman enjoys for eliciting sexual response.

Study: A review of the medical literature regarding female sexual response and the effects of hysterectomy on sexual response.

Results:

1. While most women report improvement of sexual functioning after hysterectomy, this may be the result of relief of symptoms after removal of a diseased uterus, such as vaginal bleeding and pain with intercourse.
2. Hysterectomy may eliminate anxiety about cancer risk (uterine, cervix, ovarian) and unwanted pregnancy.
3. Multiple factors may be related to the negative effects of hysterectomy on sexual response including:
   1. For some women, uterine contractions are an important aspect of orgasm and hysterectomy eliminates this sexual response.
   2. Scar tissue at the top of the vagina (when the cervix is removed) may make intercourse difficult because the top of the vagina is less elastic.
   3. Internal scarring or nerve damage may cause pain or may interfere with feeling sexual pleasure.
   4. Surgical removal of some of the vaginal wall may result in decreased vaginal blood flow, which may decrease sexual arousal and the possibility of multiple orgasms.
4. The vagina and cervix have a plentiful nerve supply. The hypogastric nerves come from the uterus and cervix, the pelvic nerves come from the vagina and the pudendal nerves come from the clitoris, labia majora, and labia minora. The ilioinguinal and genitofemoral nerves come from the mons pubis, labia, and vulvar skin.

When a woman is lying on her back, the region of the vagina near 12-o’clock (the “G spot”) is often the most sensitive area to physical stimulation and more likely to produce orgasm than stimulation of other regions of the vagina.

One study reported that 35% of 128 healthy women said they experience orgasm from penile stimulation of the cervix during sexual intercourse, 63% reported that they experience orgasm from vaginal stimulation, and 94% reported that they experience orgasm from clitoral stimulation.

Authors’ Conclusions: Based on the nerve supply of the clitoris, vagina, and cervix, it would not be surprising if responses to genital stimulation are decreased by hysterectomy. There is a glaring omission in the literature on the effects of hysterectomy on sexual response; women’s reports of their preferred source of genital stimulation have not been included in any studies and their sexual response may depend on whether a woman’s preferred genital site of stimulation is desensitized by hysterectomy.

Further research that considers these factors may help to reconcile the reported variability of the effects of hysterectomy on sexual response.

Dr. Parker’s Comments: For women who are considering a hysterectomy for severe adenomyosis or failure of less invasive treatment options, the issue of sexual response is important to think about. Unfortunately, there are no studies about sexual response following myomectomy or UAE.

Although some women report improvement of sexual response after a hysterectomy, this is usually related to the relief of symptoms, such as vaginal bleeding and pain with intercourse. However, some women note a change in sexual response for the worse. This article beautifully outlines the issues and describes why the medical literature about sexuality and hysterectomy has been so unhelpful for women. Not one study has asked women what they find pleasurable before surgery, or whether there is any difference in what they find pleasurable after surgery.

I have been discussing this issue with women for years and the conversation is interesting and sometimes humorous. I review the differences in pleasurable sexual response among women (stimulation of clitoris, vagina, cervix, and uterine contractions) and some women know exactly what gives them pleasure. And, some women say, “what the heck are you talking about?” The next step is a homework assignment – see what works for you before you decide on surgery.

Since fibroids or adenomyosis almost never involve the cervix and since removing the cervix does cut nerves and support ligaments to the pelvis, many women who chose to have a hysterectomy wish to leave the cervix. My feeling is, if the cervix isn’t broken, don’t fix it. Other issues regarding hysterectomy are discussed here: http://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Although not explored here, if your ovaries are removed major hormonal changes are likely to occur, which can lead to vaginal dryness and loss of vaginal elasticity. Decreased sleep quality and resultant fatigue can also influence sexuality. For women who are not an increased risk of ovarian cancer due to family history, keeping your ovaries decreases the risk of heart disease, stroke, lung cancer and osteoporosis. More about the benefits of keeping your ovaries can be found at the bottom of this page: http://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Until the proper studies are done, we will not be able to make any general conclusions about sexual response following surgery (or UAE, HIFU). However, because sexual response can be so different for different women, no matter what future studies show the questions about sexual response will always need to be considered by each woman for herself.

Journal: American Journal of Obstetrics and Gynecology (in press, available now on-line for subscribers)

Authors: William Parker

From: UCLA School of Medicine, Los Angeles, CA.

Problem: Fibroids can usually be diagnosed by pelvic examination and ultrasound, but neither gives us exact information about the sizes, number, and positions of all fibroids present. Excellent studies show that MRI is the most accurate way to get all this information, but most gynecologists do not order MRIs or know how to interpret them.

Clinical Opinion: This article describes how MRI works, illustrates normal pelvic anatomy and the appearance of fibroids (and adenomyosis) on MRI and discusses the ways to limit the number of images and, therefore, the cost of an MRI. Three actual cases from my practice are presented to show how MRI can change the treatment options available to women with fibroids.

Authors’ (Dr. Parker’s) Conclusions: If your gynecologist is able to perform only a hysterectomy, then precise imaging of fibroids is not necessary since they will all be removed with the uterus. However, with many other treatment options now available, magnetic resonance imaging (MRI) can help tell us which options may be best. If your gynecologist does not offer the available, often less invasive, treatment options, accurate information allows you to find a gynecologist who has the skills to take care of you.

Journal: Journal of Clinical Endocrinology and Metabolism. 2011;96:412-21.

Authors: Sinclair DC, Mastroyannis A, Taylor HS.

Study from: Yale University School of Medicine

Problem: Women with submucous fibroids have decreased fertility, increased miscarriage rates, and heavy menstrual bleeding. Why this happens has not been well understood. The authors tested to see if proteins that interfere with fertility and/or cause heavy bleeding were produced by fibroids.

Study: Sophisticated laboratory tests were performed on fibroids and normal uterine muscle to see if the cells made proteins that could cause infertility or heavy bleeding.

Results: Fibroids make different amounts of proteins than normal uterine muscle and these proteins make it more difficult for a fertilized egg to stick to the uterine lining. Fibroids also make other proteins that interfere with the blood clotting in the uterine lining which causes heavy bleeding.

Dr. Parker’s Comments: This is cutting edge science from the fertility group at Yale. Using techniques from molecular biology, the authors showed that fibroids make proteins that both decrease fertility and increase menstrual bleeding. We knew these effects existed, but now we have a better idea as to why.

Journal: Procedings of the National Acadamy of Science U S A. 2008 Dec 16;105(50):19887-92.

Authors: Peddada SD, Laughlin SK, Miner K, Guyon JP, Haneke K, Vahdat HL, Semelka RC, Kowalik A, Armao D, Davis B, Baird DD.

Study from: National Institute of Environmental Health Sciences, NC

Problem: Fibroids are the leading cause of hysterectomy in the United States. Black women have a greater fibroid burden than whites, yet no study has systematically evaluated the growth of fibroids in blacks and whites.

Study: The authors tracked growth of 262 fibroids (size range: 1-13 cm in diameter) from 72 premenopausal participants (38 black and 34 white women). Fibroid volume was measured by computerized analysis of up to four MRI scans over 12 months.

Results: The average growth rate over 12 months was 9%, but the difference among women was very large: from -89% to +138%.  Seven percent of fibroids got smaller (>20% shrinkage). Fibroids from the same woman grew at different rates.

Black and white women younger than 35 had similar fibroid growth rates. However, growth rates declined with age for white, but not for black women.  Growth rates were not dependant on initial fibroid size, location in the uterus, women’s weight, or number of children.

Most fibroids did not grow (0% change), but other fibroids either grew or got smaller.

Authors’ Conclusions: 1) fibroids can get smaller; 2) fibroids from the same woman grow at different rates, despite exposure to the same hormones in the blood; 3) initial fibroid size does not predict its growth rate; 4) as black women age, they do not experience slower fibroid growth which may explain why black women have more fibroid-related symptoms.

Dr. Parker’s Comments: This is the first study to accurately track fibroid growth, both in different women and different fibroids in the same woman. I (and other gynecologists) have been telling women for 30 years that fibroids do not get smaller until after menopause – this study proves that idea wrong.  I have also been telling women that fibroid growth is unpredictable, some fibroids grow slowly, others fast and others go through growth spurts and then slow down (see next study below).  This idea turns out to be correct.  We do not understand what makes fibroids grow (or shrink), but it is clearly NOT estrogen excess.  If this were the case, as specifically addressed in this article, all fibroids in the same women, and thus exposed to the same hormone levels, would either grow or not grow.  And, that clearly does not happen.  Unfortunately, we still have a lot to learn about fibroid growth.

Short-term change in growth of uterine leiomyoma: tumor growth spurts.

Journal: Fertility & Sterility. 2011 Jan;95(1):242-6.

Authors: Baird DD, Garrett TA, Laughlin SK, Davis B, Semelka RC, Peddada SD.

Study from: National Institute of Environmental Health Sciences, North Carolina

Problem: No one has ever followed fibroid growth closely enough to see what happens over 3 month periods.

Study: 18 black and 18 white premenopausal women had 101 fibroids measured with MRI at the study beginning and again at 3, 6, and 12 months. Growth spurts were defined by growth rates greater than 30% in 3 months.

Results: Growth spurts were seen in 37 of the 101 fibroids. Fibroids from the same woman did not have similar growth, nor were age, race/ethnicity, number of children or a woman’s weight related to growth spurts.  However,fibroids smaller than 5 cm went through growth spurts more often than larger fibroids.

Authors’ Conclusions: Short spurts of growth are common for fibroids.

Dr. Parker’s Comments: As noted above, we do not understand what causes fibroids to grow, but these two studies show that fibroid growth is unpredictable and that small fibroids are likely to grow more quickly than larger (>5 cm) fibroids.

Journal: British Journal of Obstetrics and Gynecology  2011;118:936–944.

Study From: North Glasgow University Hospitals, Glasgow, UK

Problem: Women with uterine fibroids now have a number of treatment options available. Very few studies have compared the results of treatment with different options.

Study: This study was designed to compare the results for women who had uterine artery embolization with women who had surgery (myomectomy or hysterectomy) five years after treatment.  Women filled out quality-of-life questionnaires and the authors recorded any complications from treatment or the need for women to have additional treatment for fibroids during the 5 years of follow-up.

Results: 106 women were randomized to UAE and 51 to surgery (42 had abdominal hysterectomy and 9 had abdominal myomectomy).  Symptom reduction and patient satisfaction with both treatments were very high and there were no significant differences between the UAE and surgery groups.

Rates of adverse events were similar in both groups.  In the surgery groups there were 5 wound problems (either infections or blood collections), 2 surgeries with excessive blood loss, and 2 anesthetic complications.  In the UAE group there were 2 women with pain and infection needing readmission to the hospital, 4 with fibroid expulsion, 1 pelvic abscess requiring hysterectomy, 2 with persistent pain requiring hysterectomy and 1 woman with heavy bleeding that required blood transfusion.

The need for further treatment during the 5 years was 32% for UAE and 4% for surgery.  In the UAE group, 4 women had repeat UAE and 13 women had hysterectomies.  In the surgery group, 1 woman had a hysterectomy due to technical difficulties (I imagine due to surgeon inexperience?) during her myomectomy.

Authors’ Conclusions: UAE is a satisfactory alternative to surgery for fibroids. The less invasive nature of UAE needs to be balanced against the need for further treatment in almost a third of patients. The choice should lie with the informed patient.

Dr. Parker’s Comments: This study shows that most women will do well with either UAE or surgery as treatment for fibroids.  Although not discussed in this paper, the recovery from UAE is usually much easier than from abdominal surgery and a bit easier than from laparoscopic or robotic surgery.  On the other hand, this study found that more women required additional procedures after UAE than after surgery.

The author’s last sentence is a guiding principle: “the choice of treatment should lie with the informed patient”.  For any patient, each of these treatment options is going to have pros and cons.  I see my job as a physician as one figuring out what the pelvic examination plus imagining studies (MRI or ultrasound) reveals about the sizes and positions of the fibroids.  Then my role is helping each woman understand which symptoms are caused (or not caused) by her fibroids.  I then describe the different treatment options and how they might help her situation.  Then, the decision of which option to choose, including watchful waiting, is up to the patient.

Journal: Human Reproduction. 2011;26:834-9.

Authors: Somigliana E, De Benedictis S, Vercellini P, Nicolosi AE, Benaglia L, Scarduelli C, Ragni G, Fedele L.

Study from: Department of Obset/Gynecol-Fondazione Cà Granda, Milano, Italy.

Problem: Other studies show that fibroids that bulge into the uterine cavity (submucous) decrease fertility and removal of these fibroids increases fertility.  Fibroids outside the uterine wall do not influence fertility.  Although some studies show a small decrease in fertility for fibroids within the uterine wall (intramural) other studies show no change in fertility.  This study compared the rate of success of in vitro fertilization (IVF) in women with and without intramural fibroids smaller than 5 cm diameter (2”).

Study: Women with intramural fibroids with a diameter below 5 cm who needed  IVF were compared to similar women without fibroids also having IVF

Results: There was no difference in the number of pregnancies and healthy deliveries between the 80 women with intramural fibroids less than 5 cm and the 119 women without fibroids.

Authors’ Conclusions: In patients selected for IVF, small fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure.

Dr. Parker’s Comments: This study adds to other studies that show no decreased fertility in women with medium size fibroids within the wall, but not bulging into the cavity, of the uterus.  The benefit of studies using IVF is that all the other factors that might influence fertility are minimize during IVF.  Each of the fertility studies to date, including this one, have included only a small number of women.  But, when added all together, the studies demonstrate that neither  surgery, UAE nor focused ultrasound treatment is needed for these women before they try to conceive.

Journal: Journal of Obstetrics and Gynaecology Research 2010; 36:364–369.

Study From: Mersin University School of Medicine, Turkey

Problem: There are very few studies that report on the improvement in quality-of-life following fibroid treatments, and virtually none following myomectomy.

Study: A standardized health-related quality-of-life questionnaire was filled out before, and 6 months after, myomectomy in 72 women with fibroids. These results were compared with the questionnaires from 75 women without fibroids.

Results: At the beginning of the study, women with larger fibroids had worse quality-of-life than women with small fibroids or women with no fibroids. Following myomectomy, significant improvement in physical role (physical interference with work and daily activities), bodily pain, general health, vitality (energy), social function (interference with social activities) and emotional role (emotional interference with work and daily activities) were noted. Physical functioning (dressing, bathing) and mental health (depression) were similar before and after surgery.

Author’s Conclusions: The findings from this study suggest that myomectomy improves health related quality-of-life.

Dr. Parker’s Comments: Despite 50 years of myomectomy surgery, this is the first study to carefully evaluate whether women actually feel better as a result of having a myomectomy. So, now we have studies of women following treatment with UAE, myomectomy and hysterectomy that show improvement in quality-of-life. As I said on an earlier post, this leaves the decision about which treatment to have up to each woman, since these three treatments all help. And, since I perform mostly myomectomy surgery, this study validates what my patients have been telling me for years – they feel great after myomectomy.

Journal: Obstetrics and Gynecology. 2010;116:685-93.

Authors: Barnett JC, Judd JP, Wu JM, Scales CD Jr, Myers ER, Havrilesky LJ.

Study from: Duke University, Durham, North Carolina

Problem: Robotic surgery has recently become popular, although the costs of robotic surgery are thought to be significantly higher than laparoscopic surgery. This study, compares the costs of laparoscopic, abdominal and robotic hysterectomy.

Study: The costs associated with robotic, laparoscopic, and abdominal hysterectomy were compared, including hospital and surgical costs, as well as lost income and caregiver costs (societal costs).

Results: The study calculations, which included hospital costs and societal costs, found that laparoscopic surgery was the least expensive approach. Abdominal surgery was the most expensive and robotic surgery was in between. Robotic surgery cost about $2,500 more per case due to the costs of the robot ($1.75 million), additional time needed for each surgery and the costs of disposable robotic equipment.

Authors’ Conclusions: Laparoscopy is the least expensive surgical approach for hysterectomy. Robotic is less costly than abdominal hysterectomy when the societal costs associated with recovery time are accounted for.

Dr. Parker’s Comments: Robotic surgery is being heavily promoted by the company that makes the robot and by surgeons who have been trained to do robotic surgery. However, it has been fairly clear that the robot is very expensive, the surgeries take longer and the disposable robotic instruments are also very expensive. Many of the gynecologists who have adopted robotic surgery were not accomplished laparoscopic surgeons, but are now able to perform minimally invasive surgery using the robot. While robotic surgery is more expensive than laparoscopic surgery, it is less expensive than abdominal surgery because it still provides a faster recovery and less time away from work and home.

(disclaimer – I have been doing laparoscopic surgery since 1987, and have been trained to do robotic surgery, but have only been performing this surgery for about two years with much fewer cases).

Journal: Obstetrics and Gynecology. 2010;116:865-75

Authors: Lukes AS, Moore KA, Muse KN, Gersten JK, Hecht BR, Edlund M, Richter HE, Eder SE, Attia GR, Patrick DL, Rubin A, Shangold GA

Study from: Carolina Women’s Research and Wellness Center, Durham, North Carolina

Problem: Heavy menstrual bleeding is a common problem for women and often leads to surgery or other treatments. Birth control pills help some women, but not all. Another oral medication option would be welcome.

Study: Adult women with heavy menstrual bleeding were randomized to receive either tranexamic acid (Lysteda) or a placebo for up to 5 days per menstrual cycle for six cycles. The amount of bleeding and health-related quality of life was measured using a questionnaire.

Results: Women who received tranexamic acid had a significant reduction in menstrual blood loss and this reduction was considered meaningful to women, in that they had improvements in limitations in social or leisure and physical activities and work inside and outside the home. Gastrointestinal side-effects were no more than with the placebo.

Authors’ Conclusions: Oral tranexamic acid treatment was well tolerated and significantly improved both menstrual blood loss and health-related quality of life in women with heavy menstrual bleeding.

Dr. Parker’s Comments: Tranexamic acid has been available in Europe for more than 15 years and has been found to be an effective treatment option for many women with heavy bleeding. Unfortunately, the drug had been around so long that it could not be patented in the US (the down side of the patent system). Recently, a slightly different compound was able to be patented and is now available here.

The medication works by allowing the blood to clot faster, so less is lost. There is some evidence that this medication also works for women with fibroids and may be worth trying, since there are minimal side-effects.

Authors: Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K.

Study from: Georgetown University Hospital Department of Radiology, Washington, DC

Problem: Despite the very common occurrence of fibroids, very few studies have evaluated the severity of symptoms caused by uterine fibroids, their effect on health-related quality-of-life, or the changes in symptoms after treatment compared with women who do not have fibroids.

Study: Groups of women with fibroids who were scheduled for hysterectomy, myomectomy, or uterine artery embolization, as well as women without fibroids were assessed using questionnaires designed to measure quality of life and symptoms, including physical functioning, pain, sexual function, vitality, energy/mood, social functioning and mental health. Questionnaires were completed before treatment and again at 6 and 12 months after treatment.

Results: A total of 375 women Participated in the study: 101 without fibroids, 107 who had embolization, 61 who had a myomectomy, and 106 who had a hysterectomy. Before treatment women with fibroids had more severe symptoms than women without fibroids. At both 6 and 12 months after treatment, women having treatment for their fibroids had as few symptoms as women who did not have fibroids. One year after treatment, the women who had a hysterectomy reported less symptoms and better health-related quality of life than women who had embolization or myomectomies. However, the majority of the benefit of hysterectomy was attributed to the absence of menstrual periods.

Authors’ Conclusions: At 12 months after treatment, all three leiomyoma therapies resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy due to the absence of menstrual periods.

Dr. Parker’s Comments: Since myomectomy, embolization and hysterectomy all reduce symptoms to the levels seen with women without fibroids, all three treatments should be very effective for women who have bothersome symptoms related to fibroids. Therefore, a woman’s choice for treatment should depend on other individual factors including the desire for fertility, the desire to preserve her uterus, willingness to undergo surgery and anesthesia, willingness to undergo embolization, etc. The other point here is that the women choosing to have treatment had significant symptoms; most women with minor symptoms will often choose watchful waiting and wait for menopause when fibroids shrink and bleeding stops.