J0C;M P R I N C I P L E S Pr P R A C T I C E
M A R V E L L. W I L L I A M S O N , R N , P H D
Adjustment After Hysterectomy Se&
H
ysterectomy is the most common major surgical procedure in the United States. Approximately 665,000 hysterectomies are performed each year, half of which are performed on women who are still in their reproductive years. The average age of women undergoing hysterectomy is 42.7 years (well below the average age of 50 years for natural menopause) (“Hysterectomy Patterns Changing,” 1987). In Canada, more than 62,000 hysterectomies are performed annually, 77% of which are on women younger than 55 years of age (Health Division of Statistics Canada, 1987, 1988). Although most gynecologic surgery nurses have developed excellent plans for the immediate physical care of their patients, the educational and counseling needs are too often neglected. Although concerned about the surgical procedure and how soon they can return to work routines, according to research, women are most concerned about sexual functioning after their hysterectomy (Lalinec-Michaud & Engelsmann, 1984). To neglect their need for information about this important aspect is to neglect an important part of their recovery.
The Impact of Hysterectomy on Sexual Identity and Relationships
The impact of hysterectomy or oophorectomy is not limited to problems of altered body image and depression. Uterus removal, compounded by the possible loss of estrogen and androgens, alters sensations and reactions that had been part of a woman’s sexual response. Sexual and marital adjustment after hysterectomy depends on anticQatory guidance regarding decreased libido, physical changes, loss and grief reactions, and the possible complications of cancer therapy. Nurses can afect outcomes through straightforward counseling and education.
The removal of the uterus carries the same implications for an altered body image and postoperative physical recovery as other major surgeries carry, but hysterectomy can also alter a woman’s perspective on how she functions sexually and how she perceives herself as a female. The uterus is a symbol of reproduction. If the woman’s lifework and sense of identity come from her childbearing role, hysterectomy can invoke a symbolic loss of purpose, even if it is performed after menopause. For many women, the uterus is proof that they are female. Without it, they feel neither male nor female, but a sort of neutral being. Gender identity based on any physical attribute is jeopardized when that physical characteristic is altered or removed. Thus, if a woman’s gender identity is based on her uterus and it is removed, her femininity must be redefined in new terms of unalterable factors: personality, self-worth, accomplishments, genetic code, and other lasting elements.
Accepted: September 1991
Misconceptions Some women may not realize that they will no longer menstruate. Some erroneously believe that the vagina will be removed or sewn shut, making intercourse impossible. Others may think that a uterus is necessary for orgasm. Women with cancer may worry that sexual
42 J O C N N
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Sexual Adjustment After Hysterectomy
Sexual functioning after hysterectomy beads the list of concerns of patients.
contact can transmit cancer to their partners; their partners may also be fearful. For others, the uterus represents strength. They believe its removal renders them incapable of performing the same amount of work. The woman who worries aloud that she will not be able to keep up with the housework may be referring not only to the recovery period; she may also fear permanent alterations in how she cares for her family’s needs. Oophorectomy can complicate the misconception that intact organs are a symbol of youth. A woman may worry that without estrogen, her skin will wrinkle prematurely and lose its elasticity. She may develop extreme anxiety about physical attractiveness. Some women even believe that they will die at an earlier age without their ovaries. In addition, some women have the misconception that the uterus is necessary as an organ of excretion to rid the body of wastes during menstruation. In spite of the complaints that women have about menstrual periods, many still feel that menstruation is important to good health. Women may also grieve over the loss of menstrual rhythmicity and reproductive ability, even when they have suffered through difficulties directly related to menstruation. Depression and grief Most women can expect to feel sadness, regardless of how much they welcomed the hysterectomy as a relief for their symptoms. While anxiety and grief are common, depression requiring professional intervention does not occur in a majority (Lalinec-Michaud & Engelsmann, 1984). The severity of depression that develops after a hysterectomy is related to the loss of sexual identity, altered body image, cultural background, and family roles. A woman’s preoperative outlook is a good indicator of whether she will suffer depression and a resultant loss of sexual desire. Women who claim that a hysterectomy will not affect them are most likely to demonstrate postoperative psychopathology (Newman & Newman, 1985). Denying that the hysterectomy may have an impact on her feelings prevents the patient from realistically confronting her fears and planning coping strategies. Although this optimism may appear to be a sign of strength in the preoperative patient (showing that she has accepted the need for surgery), it most likely shows that she has not thought through and considered the meaning of having her
Januuy/Februuly, 1992
uterus removed and the possibility that her ovaries will also be removed. Some women deny the potential impact of hysterectomy because health professionals minimize the implications. Whether they wish to encourage the patient toward a positive outlook or because the hysterectomy seems routine to them, nurses and physicians may not encourage the patient to analyze the possible effects, Husbands and significant others also minimize their emotions, thinking that the surgery is so common it entails no risk. Or they may deny the potential adjustments in the face of fear for their loved ones’ welfare. Alterations in sexual feelings and sensations may compound a patient’s feelings of loss of feminine identity and can lead to embarrassment, despair, and sexual dysfunction.
How the patient describes her surgery is another indicator of the degree of depression, because it may reflect her body image or self-concept disturbance. If she tells a caller that “they took everything out,” she may feel an emotional as well as a physical emptiness; or she may say of her operation, “They cleaned me out,” by which she implies that her uterus or ovaries were dirty (Williamson, 1991). Nurses must avoid similar expressions with negative connotations. Marital dysfunction If marital problems existed before the hysterectomy, they are often exacerbated afterward. Whether the woman’s altered perception of her body image or a change in how her partner views her affects their relationship after the surgery, this is one crisis that does not usually strengthen a dysfunctional relationship. Partners are not always supportive and are vulnerable to misconceptions as well. In Newman and Newman’s (1985) study, 2 of 1 2 husbands no longer viewed their wives to be as sexually desirable after hysterectomy as they had before. If other stressors are also present, the woman will probably become depressed.
The Sexual Impact of Hysterectomy on Physiology and Anatomy Hormonal efects A necessary precursor for sexual arousal is the desire
for sex. The libido, or sex drive, in the human is inspired both psychologically through such means as visual stimuli or fantasies and physically through
J O G N N 43
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touch, smell, and the effect of circulating androgens. Higher than normal levels of testosterone produce no aphrodisiac effect, but testosterone stimulates the libido. In men with testosterone deficiency, the sex drive is diminished but can be revitalized through testosterone therapy. Androgens are important stimulants of the sex drive in women also (Persky et al., 1982). Testosterone is the main androgen that increases proceptivity (sexual desire) and receptivity (response to sexual stimuli) in women (Wallen, 1990). A major source of androgens is the ovaries. Even after natural menopause, the ovaries continue to produce androgens that help maintain the desire for sexual fulfillment. Oophorectomy in animals reduces female sexual-initiating behaviors, indicating decreased sexual desire (Wallen, 1990). Ovary removal occurs with 20% to 30% of all hysterectomies (Garcia & Cutler, 1984), affecting more than 50,000 premenopausal women each year, 15%of all hysterectomies for that group (Speroff, Dawson, Speroff, & Haber, 1991). Therefore, the impact of the reduction of androgens, as well as the loss of estrogen, must be considered.
Ovarian testosterone and estrogen increase sexual desire, responsiveness to sexual stimuli, and the reactivity of genital tissues.
as significant as risks of osteoporosis and decreased quality of life produced by estrogen and androgen deficiencies (Owens et al., 1989).
Structural changes In addition to the hormonal effects of hysterectomy, anatomic changes can cause alterations in sexuality. The best way to understand the role of the uterus during sexual arousal and orgasm is to use the human sexual response stages classically described by Masters and Johnson (1966). Normally, during the excitement and plateau stages, the uterus enlarges slightly and elevates within the pelvis. This produces the tenting effect, a phenomenon characterized by a ballooning open of the innermost two-thirds of the vagina. The tenting effect is manifested in many women as a feeling of needing to be filled up or vaginal achiness, an intense desire for intercourse and for internal pressure. With hysterectomy, this phenomenon disappears. While not necessary for sexual fulfillment, the physical urge for penetration is noticeably missed by some women (Williamson, 1991). Kegel exercises during intercourse may help to enhance sexual enjoyment by increasing intravaginal pressure.
In addition to the hormonal eflects of hysterectomy, anatomic changes resulting from surgery or other therapies can also alter sexuality.
The adrenals continue to produce some androgen after oophorectomy, but no entirely satisfactory way of replacing ovarian androgen is available that does not also produce some masculinizing side effects. Furthermore, some supplements must be given parenterally because of the breakdown of testosterone when taken orally. Women who receive the injections every 4 to 8 weeks after oophorectomy have reported more desire, arousal, and sexual thoughts than have those who receive estrogen alone (Gelfand & Sherwin, 1988). The onset of menopause due to oophorectomy is accompanied by a sense of aging, even if the woman is in her 20s. This is not entirely psychologic. If estrogen therapy is neglected, the changes that occur in vaginal lubricating ability, tissue atrophy, and other hormonally dependent functions exaggerate feelings of lost femininity and sexual attractiveness. In correct doses, estrogen replacement therapy after oophorectomycan be highly valuable in promoting good mental and physical health. There is a trend to remove the ovaries only when absolutely necessary. The risk of ovarian cancer is not
Sexual dysfunction Without intervention, the fear of pain during intercourse can produce vaginismus, the spastic tightening of the pubococcygeal muscles around the vaginal introitus. Intercourse becomes difficult, and atrophy of the vaginal wall can ensue if abstinence is prolonged. Many couples suffer in silence because they are too
44 J O G N N
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I
Another characteristic of the excitement and plateau phases that makes intercourse more enjoyable is natural vaginal lubrication, which results from the increased circulation around the vaginal walls during arousal. Whether a result of loss of estrogen from oophorectomy, decreased sexual desire, or normal postoperative discomfort, the ability to lubricate can be diminished. Intercourse can become painful, if not impossible. Dyspareunia then produces fear of pain and fear of intercourse. These are common circumstances surrounding the development of a sexual dysfunction.
embarrassed to seek help and unaware that treatment is possible. Artificial, water-soluble lubricants or estrogen therapy can relieve vaginal dryness, as can prolonged foreplay or clitorally stimulated orgasm before attempting intercourse. If vaginismus persists despite these interventions, the nurse should refer the couple to a specialist in the treatment of sexual dysfunction. Fear of intercourse is common also because some women believe the body cannot tolerate sexual activity after hysterectomy. Like the fear that develops from dyspareunia, this fear can' also produce vaginismus. The woman may experience normal abdominal tenderness for several weeks, especially after hysterectomy requiring an abdominal incision. Or she may be unsure about how intercourse will feel, doubting the durability of the vaginal tissues and scarred areas. Whatever the reason, she is afraid of how intercourse will be when she resumes it. Her partner may have similar fears and anxieties about hurting her. If anticipatory guidance is neglected and these feelings go unexpressed, her partner may develop sexual dysfunction as well. Physical sexual response A woman should be instructed to wait at least 6 weeks
after surgery before attempting intercourse. Tissue strength is adequate by this time, and the risk of infection is virtually nonexistent in the presence of complete healing. Even before the 6 weeks, however, the nurse should give the couple permission to explore other forms of sexual expression. Two weeks or so after surgery, clitoral stimulation to orgasm without intercourse can be resumed, as can various methods for satisfying the partner, short of intercourse. Many women find that experiencing orgasm for the first time after surgery is best if done alone through selfstimulation (Barbach, 1975;Williamson, 1991), which allows them to take their time, tune in to any new sensations, and experience an orgasm without the pressure of their partner. Self-stimulation can be a very reassuring strategy that could be recommended to women who do not object to masturbation, because it allows them to affirm their retained orgasmic potential (Barbach, 1975). Although under normal conditions tenderness may persist as long as 12 weeks postoperatively, the couple needs to resume their sexual relationship in some form as soon as possible. They should be instructed on positions for intercourse to avoid abdominal or vaginal discomfort. Some women report decreased sexual response after hysterectomy, which may be because the scar tissue at the surgical site within the vagina is not as tactile
January/Februury 1992
and will not engorge and stretch as well as other genital tissue during the excitement and plateau phases. While the inner vagina does not contain many tactile nerve endings, it has pressure-sensitive nerves that can promote sexual enjoyment. Preoperatively, deep penile thrusting may have been very enjoyable because of the pressure it placed on the inner vagina and cervix. Penile thrusting can also produce pleasurable feelings through movement of internal abdominal organs caused by the motion of the cervix and uterus during intercourse. Postoperatively, this sensation of movement is absent (Williamson, 1991). If this had been a noticeable part of the woman's routine and preferred arousal pattern, she will have to learn to focus on other sensations that will assist in building her sexual response. In contrast, women undergoing hysterectomy for fibroids and endometriosis often find postsurgical intercourse less painful than before, because of the lack of internal movement of affected organs, particularly when inflamed tissues are removed (Williamson, 1991). The character of orgasm is another change in physical sexual response. Preoperatively, the uterus contracts rhythmically during orgasm (Masters & Johnson, 1966). These contractions also occur throughout the pelvis and are part of the pleasurable feelings of release (Williamson, 1991). The absence of uterine sensations, however, is not a common cause of orgasmic dissatisfaction. Tissue damage Hysterectomy sometimes involves the radical removal of more than the uterus and ovaries. The excision of ligaments, lymph nodes, and other structures can destroy blood vessels that contribute to engorgement during sexual arousal. Nerves may also be damaged by extensive surgery. All women must be prepared for the possibility of some temporary numbness of the pelvis and genitals postoperatively; however, the significance of any vessel or nerve damage cannot be ascertained for several weeks. Because of the trauma and resultant edema around the surgical site, nerve response can be inhibited until healing is complete. Even with vulvectomy or other forms of surgery that may affect the clitoris, orgasmic ability can be retained through a relearning of the techniques and foci of arousal (Cavanaugh et al., 1990; Schultz, vandeweil, Bouma, Janssen, & Littlewood, 1990). Hysterectomy usually includes removal of the cervix, which can decrease the length of the vagina, but not to the extent of preventing intercourse. Some experimentation on a comfortable depth for penile penetration can alleviate concerns about the integrity of the vaginal vault.
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Radiotherapy When radiation therapy is necessary, fragile tissues in the genital area become more fibrotic and lose their elasticity. Loss of pubic hair and cessation of ovarian function are common. Although the hair will probably grow again, the fibrosis will not disappear. Furthermore, any fibrosis or scar tissue at the surgical site within the vagina will not engorge and stretch as well as other genital tissue. Vaginal fibrosis can also cause vaginal shortening and narrowing (Jenkins, 1988). Vaginal dilators, lubricants, and new intercourse positions may relieve dyspareunia and preserve vaginal function. Sexual activity should be maintained during this time. Intercourse should be temporarily avoided only if radiation implants are placed. Resuming intercourse before the full effects of radiation develop is best. This helps the couple maintain a sense of sexual normalcy and also preserves the patency of the vagina threatened by adhesions (Smith, 1989). Intercourse should occur at least once a week. Fear of pain from friction, fibrosis, or even the burning sensation that semen can cause are not adequate reasons for abstaining. These difficulties can be ameliorated by using lubricants, vaginal dilators, and condoms. Even women who have no sexual partners can take steps to maintain vaginal function through masturbation, which increases circulation to the pelvis and vagina, or through the use of a dildo or vaginal dilator. Without these precautions, corrective surgery may become necessary because adhesions, fibrosis, or loss of elasticity may result. All of these effects must be discussed frankly without implying that these changes signal the end of the woman’s sexual potential.
I asked questions about sexual functioning after hysterectomy before my surgery and did not get adequate information from my doctor or nurse. They were surprised by my questions. I received guidance from nurses about the effects of the complications, but nothing about sexual adjustment. I also felt a definite need for husband education. My doctor . . . seemed to feel my questions about sexuality were inappropriate (Williamson, 1991).
Only 15%of the women interviewed by Webb and Wilson-Barnett (1983) reported receiving information from nurses in preparation for discharge after hysterectomy. Another woman facing hysterectomy after 20 years of marriage was told by a physician when she asked about resuming intercourse, “After 20 years, why should you care?” (Williamson, 1991). Such responses are damaging. Patients who receive such treatment are unlikely to bring up the subject again and will face their concerns alone. Patients may interpret the nurse’s silence on the subject of sex to mean that the topic should not be of concern to the patient or that discussion is not warranted because sexuality i s now a thing of the past.
Despite the potential for a change in sexual response after hysterectomy, most women agree that their sex lives do not lose quality. In a study by Webb and Wilson-Barnett (1983), approximately 83% of respondents felt their sexual enjoyment after several weeks of recovery was as good or better than before their surgery. These reassuring statistics can be helpful as part of a teaching program for patients before or after hysterectomy. No studies describe the postoperative adjustment of lesbians, but the same principles for resuming sexual activity apply. Nurses’ counseling of patients undergoing hysterectomy makes a difference in the chances for sexual adjustment (Krueger et al., 1979). Nurses, however, may be unprepared or too uncomfortable with sexuality to counsel hysterectomy patients (Wilson & Williams, 1988). A 33-year-old woman recalled:
Patients do not usually initiate the discussion of sex. They may think the staff is too busy or that it seems ludicrous to wonder about sex when surgery as serious as hysterectomy is being contemplated. Also, the patient may interpret the nurse’s silence on the subject of sex as an indication that the patient’s sex life is over after hysterectomy-that nothing is left to discuss (Smith, 1989). Nurses can improve their care of women undergoing hysterectomy by first assessing any misconceptions their patients might have. The potential for misconceptions is endless, but nurses are in an ideal position to gently alleviate anxieties resulting from the misconception or situation. Every teaching plan should include, at the minimum, a list of what will and will not be removed by the surgery, a discussion of the physical and emotional feelings that may change, and an exploration of tangible ways to adjust sexually. Hospitalization decreases the likelihood of touching and intimacy between partners. Nurses should encourage partners to stay physically close. Patients and their partners should be given privacy, and the nurse should bring up the subject of physical aloofness for
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Nursing Implications
Sexual Adjustment AJer Hysterectomy
discussion. At follow-up visits, nurses should ask questions under the assumption that the couple has resumed their sexual relationship. To imply that they should merely be glad to be alive and that sex is not a priority is damaging. Whether a woman describes a loss of sexual desire because of psychologic or hormonal depression, altered body image, or low androgen is of minor consequence considering the excellent potential for a positive prognosis if treatment is sought. Intervention in each case should center on counseling and instructing the patient in other ways that she can stimulate her libido through the senses and mental imagery. Furthermore, each patient and her partner need to be encouraged to grieve their loss. The grief response indicates a healthy reaction and must not be mislabeled as depression or low self-esteem. The resolution process will also be more satisfactory if the support of the partner can be incorporated into the resumption of undemanding sensual pleasure and sexual activity (Webb & Wilson-Barnett, 1983). With nursing guidance, the prognosis is excellent for an enjoyable sexual relationship and a healthy selfimage.
Summary A significant number of women undergo hysterec-
tomy each year. The physical effects of uterus removal include paresthesia and altered genital and pelvic sensations. Ovary removal can cause the level of testosterone to drop (resulting in decreased sexual desire and responsiveness) and a decrease in the level of estrogen (changing the condition of genital and other tissues). Other treatments for pelvic pathologies involving hysterectomy or oophorectomy or both require special adjustment. Each alteration in sexuality can be prevented, counteracted, or adjusted to by education, counseling, and hormone replacement therapy for the patient. Alleviating a woman’s misconceptions about hysterectomy and teaching her how to cope with the therapy can keep manageable inconveniences from becoming major sexual dysfunctions.
References Barbach, L. G. (1975). Foryourseg ThefulJillment offemale sexuality. New York: Signet/Doubleday. Cavanaugh, D., Fiorica, J., Hoffman, M., Roberts, W., Brysen, S., La Polla, J., & Barton, D. (1990). Invasive carcinoma of the vulva. American Journal of Obstetrics a n d Gynecology, 163, 1007-1015. Garcia, C., & Cutler, W. (1984). Preservation of the ovary: A reevaluation. Fertility a n d Sterility, 42, 510-515. Gelfand, M. L., & Sherwin, B. B. (1988). Debate over post-
Januury/February 1992
menopausal androgens continues. Medical World News, 29, 27. Health Division of Statistics Canada. (1987, 1988). Data. Ottawa: Author. Hysterectomy patterns changing. (1987). Medical World News, 28, 20. Jenkins, B. (1988). Patients’ reports of sexual changes after treatment for gynecological cancer. Oncology Nursing Forum, 15, 349-354. Krueger, J. C., Hassell, J., Goggins, D. B., Ishimatsu, T., Pablico, M., & Tuttle, E. (1979). Relationship between nurse counseling and sexual adjustment after hysterectomy. Nursing Research, 28, 145-150. Lalinec-Michaud, M., & Engelsmann, F. (1984). Depression and hysterectomy: A prospective study. Psychosomatics, 25, 550-558. Masters, W. H., &Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown. Newman, G., & Newman, L. E. (1985). Coping with the stress of hysterectomy. Journal of Sex Education and Therapy, 1 I, 65-68. Owens, S., Roberts, W., Fiorica, J., Hoffman, M., La Polla, J., & Littlewood, J. (1989). Ovarian management at the time of radical hysterectomy for cancer of the cervix. Gynecologic Oncology, 35,349-35 1. Persky, H., Dreisbach, L., Miller, W., O’Brien, C., Khan, M., Lief, H., Charney, N., & Strauss, D. (1982). Relation of plasma androgen levels to sexual behavior and attitudes of women. Psychosomatic Medicine, 44, 305. Schultz, W., vandeweil, H., Bouma, J., Janssen, J., & Littlewood, J. (1990). Psychosexual functioning after the treatment of cancer of the vulva. Cancer, 66 402-407. Smith, D. B. (1989). Sexual rehabilitation of the cancer patient. Cancer Nursing, 12, 10-15. Speroff, T., Dawson, N., Speroff, L., & Haber, R. (1991). A risk-benefit analysis of elective bilateral oophorectomy. American Journal of Obstetrics a n d Gynecology, 164, 165-174. Wallen, K. (1990). Desire and ability: Hormones and the regulation of female sexual behavior. Neuroscience and Behavioral Reviews, 14, 233-241. Webb, C., & Wilson-Barnett, J. (1983). Hysterectomy: A study in coping with recovery. Journal of Advanced Nursing, 8, 311-319. Williamson, M. L. (1991). [Interviews of women who have had hysterectomies, Kansas City, Missouri]. Unpublished raw data. Wilson, M. E., & Williams, H. A. (1988). Oncology nurses’ attitudes and behaviors related to sexuality of patients with cancer. Oncology Nursing Forum, 15, 49-53. Address for correspondence: Marvel L. Williamson, RN, PhD, Park College, 8700 River Park Drive, Parkville, MO 64152. Marvel L. Williamson is a professor and the director of the Department of Nursing, Park College in Parkville, Rolla, and Sikeston, Missouri.
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M A R V E L L. W I L L I A M S O N , R N , P H D
Adjustment After Hysterectomy Se&
H
ysterectomy is the most common major surgical procedure in the United States. Approximately 665,000 hysterectomies are performed each year, half of which are performed on women who are still in their reproductive years. The average age of women undergoing hysterectomy is 42.7 years (well below the average age of 50 years for natural menopause) (“Hysterectomy Patterns Changing,” 1987). In Canada, more than 62,000 hysterectomies are performed annually, 77% of which are on women younger than 55 years of age (Health Division of Statistics Canada, 1987, 1988). Although most gynecologic surgery nurses have developed excellent plans for the immediate physical care of their patients, the educational and counseling needs are too often neglected. Although concerned about the surgical procedure and how soon they can return to work routines, according to research, women are most concerned about sexual functioning after their hysterectomy (Lalinec-Michaud & Engelsmann, 1984). To neglect their need for information about this important aspect is to neglect an important part of their recovery.
The Impact of Hysterectomy on Sexual Identity and Relationships
The impact of hysterectomy or oophorectomy is not limited to problems of altered body image and depression. Uterus removal, compounded by the possible loss of estrogen and androgens, alters sensations and reactions that had been part of a woman’s sexual response. Sexual and marital adjustment after hysterectomy depends on anticQatory guidance regarding decreased libido, physical changes, loss and grief reactions, and the possible complications of cancer therapy. Nurses can afect outcomes through straightforward counseling and education.
The removal of the uterus carries the same implications for an altered body image and postoperative physical recovery as other major surgeries carry, but hysterectomy can also alter a woman’s perspective on how she functions sexually and how she perceives herself as a female. The uterus is a symbol of reproduction. If the woman’s lifework and sense of identity come from her childbearing role, hysterectomy can invoke a symbolic loss of purpose, even if it is performed after menopause. For many women, the uterus is proof that they are female. Without it, they feel neither male nor female, but a sort of neutral being. Gender identity based on any physical attribute is jeopardized when that physical characteristic is altered or removed. Thus, if a woman’s gender identity is based on her uterus and it is removed, her femininity must be redefined in new terms of unalterable factors: personality, self-worth, accomplishments, genetic code, and other lasting elements.
Accepted: September 1991
Misconceptions Some women may not realize that they will no longer menstruate. Some erroneously believe that the vagina will be removed or sewn shut, making intercourse impossible. Others may think that a uterus is necessary for orgasm. Women with cancer may worry that sexual
42 J O C N N
Volume 21 Number 1
Sexual Adjustment After Hysterectomy
Sexual functioning after hysterectomy beads the list of concerns of patients.
contact can transmit cancer to their partners; their partners may also be fearful. For others, the uterus represents strength. They believe its removal renders them incapable of performing the same amount of work. The woman who worries aloud that she will not be able to keep up with the housework may be referring not only to the recovery period; she may also fear permanent alterations in how she cares for her family’s needs. Oophorectomy can complicate the misconception that intact organs are a symbol of youth. A woman may worry that without estrogen, her skin will wrinkle prematurely and lose its elasticity. She may develop extreme anxiety about physical attractiveness. Some women even believe that they will die at an earlier age without their ovaries. In addition, some women have the misconception that the uterus is necessary as an organ of excretion to rid the body of wastes during menstruation. In spite of the complaints that women have about menstrual periods, many still feel that menstruation is important to good health. Women may also grieve over the loss of menstrual rhythmicity and reproductive ability, even when they have suffered through difficulties directly related to menstruation. Depression and grief Most women can expect to feel sadness, regardless of how much they welcomed the hysterectomy as a relief for their symptoms. While anxiety and grief are common, depression requiring professional intervention does not occur in a majority (Lalinec-Michaud & Engelsmann, 1984). The severity of depression that develops after a hysterectomy is related to the loss of sexual identity, altered body image, cultural background, and family roles. A woman’s preoperative outlook is a good indicator of whether she will suffer depression and a resultant loss of sexual desire. Women who claim that a hysterectomy will not affect them are most likely to demonstrate postoperative psychopathology (Newman & Newman, 1985). Denying that the hysterectomy may have an impact on her feelings prevents the patient from realistically confronting her fears and planning coping strategies. Although this optimism may appear to be a sign of strength in the preoperative patient (showing that she has accepted the need for surgery), it most likely shows that she has not thought through and considered the meaning of having her
Januuy/Februuly, 1992
uterus removed and the possibility that her ovaries will also be removed. Some women deny the potential impact of hysterectomy because health professionals minimize the implications. Whether they wish to encourage the patient toward a positive outlook or because the hysterectomy seems routine to them, nurses and physicians may not encourage the patient to analyze the possible effects, Husbands and significant others also minimize their emotions, thinking that the surgery is so common it entails no risk. Or they may deny the potential adjustments in the face of fear for their loved ones’ welfare. Alterations in sexual feelings and sensations may compound a patient’s feelings of loss of feminine identity and can lead to embarrassment, despair, and sexual dysfunction.
How the patient describes her surgery is another indicator of the degree of depression, because it may reflect her body image or self-concept disturbance. If she tells a caller that “they took everything out,” she may feel an emotional as well as a physical emptiness; or she may say of her operation, “They cleaned me out,” by which she implies that her uterus or ovaries were dirty (Williamson, 1991). Nurses must avoid similar expressions with negative connotations. Marital dysfunction If marital problems existed before the hysterectomy, they are often exacerbated afterward. Whether the woman’s altered perception of her body image or a change in how her partner views her affects their relationship after the surgery, this is one crisis that does not usually strengthen a dysfunctional relationship. Partners are not always supportive and are vulnerable to misconceptions as well. In Newman and Newman’s (1985) study, 2 of 1 2 husbands no longer viewed their wives to be as sexually desirable after hysterectomy as they had before. If other stressors are also present, the woman will probably become depressed.
The Sexual Impact of Hysterectomy on Physiology and Anatomy Hormonal efects A necessary precursor for sexual arousal is the desire
for sex. The libido, or sex drive, in the human is inspired both psychologically through such means as visual stimuli or fantasies and physically through
J O G N N 43
P R I N C I P L E S
A N D
P R A C T I C E
touch, smell, and the effect of circulating androgens. Higher than normal levels of testosterone produce no aphrodisiac effect, but testosterone stimulates the libido. In men with testosterone deficiency, the sex drive is diminished but can be revitalized through testosterone therapy. Androgens are important stimulants of the sex drive in women also (Persky et al., 1982). Testosterone is the main androgen that increases proceptivity (sexual desire) and receptivity (response to sexual stimuli) in women (Wallen, 1990). A major source of androgens is the ovaries. Even after natural menopause, the ovaries continue to produce androgens that help maintain the desire for sexual fulfillment. Oophorectomy in animals reduces female sexual-initiating behaviors, indicating decreased sexual desire (Wallen, 1990). Ovary removal occurs with 20% to 30% of all hysterectomies (Garcia & Cutler, 1984), affecting more than 50,000 premenopausal women each year, 15%of all hysterectomies for that group (Speroff, Dawson, Speroff, & Haber, 1991). Therefore, the impact of the reduction of androgens, as well as the loss of estrogen, must be considered.
Ovarian testosterone and estrogen increase sexual desire, responsiveness to sexual stimuli, and the reactivity of genital tissues.
as significant as risks of osteoporosis and decreased quality of life produced by estrogen and androgen deficiencies (Owens et al., 1989).
Structural changes In addition to the hormonal effects of hysterectomy, anatomic changes can cause alterations in sexuality. The best way to understand the role of the uterus during sexual arousal and orgasm is to use the human sexual response stages classically described by Masters and Johnson (1966). Normally, during the excitement and plateau stages, the uterus enlarges slightly and elevates within the pelvis. This produces the tenting effect, a phenomenon characterized by a ballooning open of the innermost two-thirds of the vagina. The tenting effect is manifested in many women as a feeling of needing to be filled up or vaginal achiness, an intense desire for intercourse and for internal pressure. With hysterectomy, this phenomenon disappears. While not necessary for sexual fulfillment, the physical urge for penetration is noticeably missed by some women (Williamson, 1991). Kegel exercises during intercourse may help to enhance sexual enjoyment by increasing intravaginal pressure.
In addition to the hormonal eflects of hysterectomy, anatomic changes resulting from surgery or other therapies can also alter sexuality.
The adrenals continue to produce some androgen after oophorectomy, but no entirely satisfactory way of replacing ovarian androgen is available that does not also produce some masculinizing side effects. Furthermore, some supplements must be given parenterally because of the breakdown of testosterone when taken orally. Women who receive the injections every 4 to 8 weeks after oophorectomy have reported more desire, arousal, and sexual thoughts than have those who receive estrogen alone (Gelfand & Sherwin, 1988). The onset of menopause due to oophorectomy is accompanied by a sense of aging, even if the woman is in her 20s. This is not entirely psychologic. If estrogen therapy is neglected, the changes that occur in vaginal lubricating ability, tissue atrophy, and other hormonally dependent functions exaggerate feelings of lost femininity and sexual attractiveness. In correct doses, estrogen replacement therapy after oophorectomycan be highly valuable in promoting good mental and physical health. There is a trend to remove the ovaries only when absolutely necessary. The risk of ovarian cancer is not
Sexual dysfunction Without intervention, the fear of pain during intercourse can produce vaginismus, the spastic tightening of the pubococcygeal muscles around the vaginal introitus. Intercourse becomes difficult, and atrophy of the vaginal wall can ensue if abstinence is prolonged. Many couples suffer in silence because they are too
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Another characteristic of the excitement and plateau phases that makes intercourse more enjoyable is natural vaginal lubrication, which results from the increased circulation around the vaginal walls during arousal. Whether a result of loss of estrogen from oophorectomy, decreased sexual desire, or normal postoperative discomfort, the ability to lubricate can be diminished. Intercourse can become painful, if not impossible. Dyspareunia then produces fear of pain and fear of intercourse. These are common circumstances surrounding the development of a sexual dysfunction.
embarrassed to seek help and unaware that treatment is possible. Artificial, water-soluble lubricants or estrogen therapy can relieve vaginal dryness, as can prolonged foreplay or clitorally stimulated orgasm before attempting intercourse. If vaginismus persists despite these interventions, the nurse should refer the couple to a specialist in the treatment of sexual dysfunction. Fear of intercourse is common also because some women believe the body cannot tolerate sexual activity after hysterectomy. Like the fear that develops from dyspareunia, this fear can' also produce vaginismus. The woman may experience normal abdominal tenderness for several weeks, especially after hysterectomy requiring an abdominal incision. Or she may be unsure about how intercourse will feel, doubting the durability of the vaginal tissues and scarred areas. Whatever the reason, she is afraid of how intercourse will be when she resumes it. Her partner may have similar fears and anxieties about hurting her. If anticipatory guidance is neglected and these feelings go unexpressed, her partner may develop sexual dysfunction as well. Physical sexual response A woman should be instructed to wait at least 6 weeks
after surgery before attempting intercourse. Tissue strength is adequate by this time, and the risk of infection is virtually nonexistent in the presence of complete healing. Even before the 6 weeks, however, the nurse should give the couple permission to explore other forms of sexual expression. Two weeks or so after surgery, clitoral stimulation to orgasm without intercourse can be resumed, as can various methods for satisfying the partner, short of intercourse. Many women find that experiencing orgasm for the first time after surgery is best if done alone through selfstimulation (Barbach, 1975;Williamson, 1991), which allows them to take their time, tune in to any new sensations, and experience an orgasm without the pressure of their partner. Self-stimulation can be a very reassuring strategy that could be recommended to women who do not object to masturbation, because it allows them to affirm their retained orgasmic potential (Barbach, 1975). Although under normal conditions tenderness may persist as long as 12 weeks postoperatively, the couple needs to resume their sexual relationship in some form as soon as possible. They should be instructed on positions for intercourse to avoid abdominal or vaginal discomfort. Some women report decreased sexual response after hysterectomy, which may be because the scar tissue at the surgical site within the vagina is not as tactile
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and will not engorge and stretch as well as other genital tissue during the excitement and plateau phases. While the inner vagina does not contain many tactile nerve endings, it has pressure-sensitive nerves that can promote sexual enjoyment. Preoperatively, deep penile thrusting may have been very enjoyable because of the pressure it placed on the inner vagina and cervix. Penile thrusting can also produce pleasurable feelings through movement of internal abdominal organs caused by the motion of the cervix and uterus during intercourse. Postoperatively, this sensation of movement is absent (Williamson, 1991). If this had been a noticeable part of the woman's routine and preferred arousal pattern, she will have to learn to focus on other sensations that will assist in building her sexual response. In contrast, women undergoing hysterectomy for fibroids and endometriosis often find postsurgical intercourse less painful than before, because of the lack of internal movement of affected organs, particularly when inflamed tissues are removed (Williamson, 1991). The character of orgasm is another change in physical sexual response. Preoperatively, the uterus contracts rhythmically during orgasm (Masters & Johnson, 1966). These contractions also occur throughout the pelvis and are part of the pleasurable feelings of release (Williamson, 1991). The absence of uterine sensations, however, is not a common cause of orgasmic dissatisfaction. Tissue damage Hysterectomy sometimes involves the radical removal of more than the uterus and ovaries. The excision of ligaments, lymph nodes, and other structures can destroy blood vessels that contribute to engorgement during sexual arousal. Nerves may also be damaged by extensive surgery. All women must be prepared for the possibility of some temporary numbness of the pelvis and genitals postoperatively; however, the significance of any vessel or nerve damage cannot be ascertained for several weeks. Because of the trauma and resultant edema around the surgical site, nerve response can be inhibited until healing is complete. Even with vulvectomy or other forms of surgery that may affect the clitoris, orgasmic ability can be retained through a relearning of the techniques and foci of arousal (Cavanaugh et al., 1990; Schultz, vandeweil, Bouma, Janssen, & Littlewood, 1990). Hysterectomy usually includes removal of the cervix, which can decrease the length of the vagina, but not to the extent of preventing intercourse. Some experimentation on a comfortable depth for penile penetration can alleviate concerns about the integrity of the vaginal vault.
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P R I N C I P L E S
A N D
P R A C T I C E
Radiotherapy When radiation therapy is necessary, fragile tissues in the genital area become more fibrotic and lose their elasticity. Loss of pubic hair and cessation of ovarian function are common. Although the hair will probably grow again, the fibrosis will not disappear. Furthermore, any fibrosis or scar tissue at the surgical site within the vagina will not engorge and stretch as well as other genital tissue. Vaginal fibrosis can also cause vaginal shortening and narrowing (Jenkins, 1988). Vaginal dilators, lubricants, and new intercourse positions may relieve dyspareunia and preserve vaginal function. Sexual activity should be maintained during this time. Intercourse should be temporarily avoided only if radiation implants are placed. Resuming intercourse before the full effects of radiation develop is best. This helps the couple maintain a sense of sexual normalcy and also preserves the patency of the vagina threatened by adhesions (Smith, 1989). Intercourse should occur at least once a week. Fear of pain from friction, fibrosis, or even the burning sensation that semen can cause are not adequate reasons for abstaining. These difficulties can be ameliorated by using lubricants, vaginal dilators, and condoms. Even women who have no sexual partners can take steps to maintain vaginal function through masturbation, which increases circulation to the pelvis and vagina, or through the use of a dildo or vaginal dilator. Without these precautions, corrective surgery may become necessary because adhesions, fibrosis, or loss of elasticity may result. All of these effects must be discussed frankly without implying that these changes signal the end of the woman’s sexual potential.
I asked questions about sexual functioning after hysterectomy before my surgery and did not get adequate information from my doctor or nurse. They were surprised by my questions. I received guidance from nurses about the effects of the complications, but nothing about sexual adjustment. I also felt a definite need for husband education. My doctor . . . seemed to feel my questions about sexuality were inappropriate (Williamson, 1991).
Only 15%of the women interviewed by Webb and Wilson-Barnett (1983) reported receiving information from nurses in preparation for discharge after hysterectomy. Another woman facing hysterectomy after 20 years of marriage was told by a physician when she asked about resuming intercourse, “After 20 years, why should you care?” (Williamson, 1991). Such responses are damaging. Patients who receive such treatment are unlikely to bring up the subject again and will face their concerns alone. Patients may interpret the nurse’s silence on the subject of sex to mean that the topic should not be of concern to the patient or that discussion is not warranted because sexuality i s now a thing of the past.
Despite the potential for a change in sexual response after hysterectomy, most women agree that their sex lives do not lose quality. In a study by Webb and Wilson-Barnett (1983), approximately 83% of respondents felt their sexual enjoyment after several weeks of recovery was as good or better than before their surgery. These reassuring statistics can be helpful as part of a teaching program for patients before or after hysterectomy. No studies describe the postoperative adjustment of lesbians, but the same principles for resuming sexual activity apply. Nurses’ counseling of patients undergoing hysterectomy makes a difference in the chances for sexual adjustment (Krueger et al., 1979). Nurses, however, may be unprepared or too uncomfortable with sexuality to counsel hysterectomy patients (Wilson & Williams, 1988). A 33-year-old woman recalled:
Patients do not usually initiate the discussion of sex. They may think the staff is too busy or that it seems ludicrous to wonder about sex when surgery as serious as hysterectomy is being contemplated. Also, the patient may interpret the nurse’s silence on the subject of sex as an indication that the patient’s sex life is over after hysterectomy-that nothing is left to discuss (Smith, 1989). Nurses can improve their care of women undergoing hysterectomy by first assessing any misconceptions their patients might have. The potential for misconceptions is endless, but nurses are in an ideal position to gently alleviate anxieties resulting from the misconception or situation. Every teaching plan should include, at the minimum, a list of what will and will not be removed by the surgery, a discussion of the physical and emotional feelings that may change, and an exploration of tangible ways to adjust sexually. Hospitalization decreases the likelihood of touching and intimacy between partners. Nurses should encourage partners to stay physically close. Patients and their partners should be given privacy, and the nurse should bring up the subject of physical aloofness for
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Sexual Adjustment AJer Hysterectomy
discussion. At follow-up visits, nurses should ask questions under the assumption that the couple has resumed their sexual relationship. To imply that they should merely be glad to be alive and that sex is not a priority is damaging. Whether a woman describes a loss of sexual desire because of psychologic or hormonal depression, altered body image, or low androgen is of minor consequence considering the excellent potential for a positive prognosis if treatment is sought. Intervention in each case should center on counseling and instructing the patient in other ways that she can stimulate her libido through the senses and mental imagery. Furthermore, each patient and her partner need to be encouraged to grieve their loss. The grief response indicates a healthy reaction and must not be mislabeled as depression or low self-esteem. The resolution process will also be more satisfactory if the support of the partner can be incorporated into the resumption of undemanding sensual pleasure and sexual activity (Webb & Wilson-Barnett, 1983). With nursing guidance, the prognosis is excellent for an enjoyable sexual relationship and a healthy selfimage.
Summary A significant number of women undergo hysterec-
tomy each year. The physical effects of uterus removal include paresthesia and altered genital and pelvic sensations. Ovary removal can cause the level of testosterone to drop (resulting in decreased sexual desire and responsiveness) and a decrease in the level of estrogen (changing the condition of genital and other tissues). Other treatments for pelvic pathologies involving hysterectomy or oophorectomy or both require special adjustment. Each alteration in sexuality can be prevented, counteracted, or adjusted to by education, counseling, and hormone replacement therapy for the patient. Alleviating a woman’s misconceptions about hysterectomy and teaching her how to cope with the therapy can keep manageable inconveniences from becoming major sexual dysfunctions.
References Barbach, L. G. (1975). Foryourseg ThefulJillment offemale sexuality. New York: Signet/Doubleday. Cavanaugh, D., Fiorica, J., Hoffman, M., Roberts, W., Brysen, S., La Polla, J., & Barton, D. (1990). Invasive carcinoma of the vulva. American Journal of Obstetrics a n d Gynecology, 163, 1007-1015. Garcia, C., & Cutler, W. (1984). Preservation of the ovary: A reevaluation. Fertility a n d Sterility, 42, 510-515. Gelfand, M. L., & Sherwin, B. B. (1988). Debate over post-
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menopausal androgens continues. Medical World News, 29, 27. Health Division of Statistics Canada. (1987, 1988). Data. Ottawa: Author. Hysterectomy patterns changing. (1987). Medical World News, 28, 20. Jenkins, B. (1988). Patients’ reports of sexual changes after treatment for gynecological cancer. Oncology Nursing Forum, 15, 349-354. Krueger, J. C., Hassell, J., Goggins, D. B., Ishimatsu, T., Pablico, M., & Tuttle, E. (1979). Relationship between nurse counseling and sexual adjustment after hysterectomy. Nursing Research, 28, 145-150. Lalinec-Michaud, M., & Engelsmann, F. (1984). Depression and hysterectomy: A prospective study. Psychosomatics, 25, 550-558. Masters, W. H., &Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown. Newman, G., & Newman, L. E. (1985). Coping with the stress of hysterectomy. Journal of Sex Education and Therapy, 1 I, 65-68. Owens, S., Roberts, W., Fiorica, J., Hoffman, M., La Polla, J., & Littlewood, J. (1989). Ovarian management at the time of radical hysterectomy for cancer of the cervix. Gynecologic Oncology, 35,349-35 1. Persky, H., Dreisbach, L., Miller, W., O’Brien, C., Khan, M., Lief, H., Charney, N., & Strauss, D. (1982). Relation of plasma androgen levels to sexual behavior and attitudes of women. Psychosomatic Medicine, 44, 305. Schultz, W., vandeweil, H., Bouma, J., Janssen, J., & Littlewood, J. (1990). Psychosexual functioning after the treatment of cancer of the vulva. Cancer, 66 402-407. Smith, D. B. (1989). Sexual rehabilitation of the cancer patient. Cancer Nursing, 12, 10-15. Speroff, T., Dawson, N., Speroff, L., & Haber, R. (1991). A risk-benefit analysis of elective bilateral oophorectomy. American Journal of Obstetrics a n d Gynecology, 164, 165-174. Wallen, K. (1990). Desire and ability: Hormones and the regulation of female sexual behavior. Neuroscience and Behavioral Reviews, 14, 233-241. Webb, C., & Wilson-Barnett, J. (1983). Hysterectomy: A study in coping with recovery. Journal of Advanced Nursing, 8, 311-319. Williamson, M. L. (1991). [Interviews of women who have had hysterectomies, Kansas City, Missouri]. Unpublished raw data. Wilson, M. E., & Williams, H. A. (1988). Oncology nurses’ attitudes and behaviors related to sexuality of patients with cancer. Oncology Nursing Forum, 15, 49-53. Address for correspondence: Marvel L. Williamson, RN, PhD, Park College, 8700 River Park Drive, Parkville, MO 64152. Marvel L. Williamson is a professor and the director of the Department of Nursing, Park College in Parkville, Rolla, and Sikeston, Missouri.
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