Open Access

Original Article

The effect of total hysterectomy on

sexual function and depression
Sonay Baltaci Goktas1, Ismet Gun2, Tulin Yildiz3,
Mehmet Nafi Sakar4, Sabiha Caglayan5
ABSTRACT
Background & Objectives: To investigate whether the operations of Type 1 hysterectomy and bilateral
salpingo-oophorectomy performed for benign reasons have any effect on sexual life and levels of depression.
Method: This is a multi-center, comparative, prospective study. Healthy, sexual active patients aged
between 40 and 60 were included into the study. Data was collected with the technique of face-to-face
meeting held three months before and after the operation by using the demographic data form developed
by the researchers i.e.the Female Sexual Function Index (FSFI) and the Beck Depression Scale (BDS).
Results: In the post-operative third month, there was an improvement in dysuria in terms of symptomatology
(34% and 17%, P<0.001), while in FSFI (41.47±25.46 to 34.20±26.67, P<0.001) and BDS (12.87±11.19 to
14.27±10.95, P=0.015) there was a deterioration. For FSFI, 50-60 age range, extended family structure;
and for BDS, educational status, not working and extended family structure were statistically important
confounding factors for increased risk in the post-operative period.
Conclusion: While hysterectomy and bilateral salpingo-oophorectomy performed for benign reasons
brought about short-term improvement in urinary problems after the operation for sexually active and
healthy women, they resulted in sexual dysfunction and increase in depression. The age, educational
status, working condition and family structure is also important.
KEY WORDS: Depression, Female, Hysterectomy, Sexual dysfunction, Sexuality.
doi: http://dx.doi.org/10.12669/pjms.313.7368
How to cite this:
Goktas SB, Gun I, Yildiz T, Sakar MN, Caglayan S. The effect of total hysterectomy on sexual function and depression. Pak J Med Sci
2015;31(3):700-705. doi: http://dx.doi.org/10.12669/pjms.313.7368
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Sonay Baltaci Goktas, INTRODUCTION

Maltepe University, School of Nursing,
Surgical Nursing, Istanbul, Turkey;
2. Ismet Gun,
The majority of hysterectomies are performed on
Gulhane Military Medical Academy, benign reasons in order to increase quality of life;
Haydarpasa Training Hospital, Istanbul, Turkey. nevertheless, it can bring about some post-operative
3. Tulin Yildiz,
Namik Kemal University, School of Health, long-term problems such as sexual dysfunction,
Surgical Nursing, Tekirdag, Turkey. depression and especially, urinary incontinence.1,2
4. Mehmet Nafi Sakar,
Suleymaniye Training and Research Hospital, During the operation of hysterectomy, particularly
Istanbul, Turkey. in the course of the ablation of cervix, the bilateral
5. Sabiha Caglayan,
Medipol University Hospital, Istanbul, Turkey.
inferior hypogastric plexus, which enables the
sympathetic and parasympathetic innervations of
Correspondence:
the sub pelvic region, can sustain injury.3 In addition,
Dr. Sonay Baltaci Goktas, depending on the lack of uterus among women after
Maltepe University School of Nursing,
Istanbul, Turkey. hysterectomy and the termination of the capacity
E-mail: [email protected] of reproduction, the anxiety for no longer having
* Received for Publication: January 22, 2015 any sex increases the risk of depression, having an
* 1st Revision Received: January 26, 2015 impact on the thoughts, social life and partnering
* 2nd Revision Received: March 30, 2015 communication of women focusing too much on
* Final Revision Accepted: * April 8, 2015 reproduction.4 Male partners can also have sexual

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 Sexual function, depression and hysterectomy

anxieties after such an operation. In some studies had been using anti-depressant medications or had
it has been reported that alleviation of sexual sexual dysfunction, and those patients who had
problems and anxieties of partners undergoing developed complications during the operation or
hysterectomy has a positive effect quality of life of in the post-operative period, whose partner had a
the patients.5,6 In some studies, it has been pointed severe illness or had died in the meantime, did not
out that such operations do not have any effect on want to continue were excluded.
the sexual functions of women7, while some claim Demographic features of the women participating
positive effects8,9 and some others have reported in the research were determined through the
negative effects.10,11 As a consequence, the majority “Patient Diagnosis Form” prepared by the
of contemporary studies are retrospective and the researchers. Additionally, for the determination
short and long-term effects of hysterectomy on of the depression level of women, BDS and for
sexual function and depression are still not exactly the evaluation of their sexual functions, FSFI
known.12 scales were used through face-to-face meeting
The aim of this research was to determine, by held three months before and after the operation.
using the Female Sexual Function Index (FSFI) FSFI were grouped as the following: 0-15 (severe),
and the Beck Depression Scale (BDS), whether 16-25 (moderate), 26-35 (mild) and 36 and more
the operation of Total Abdominal Hysterectomy (normal); and the Beck Depression Scale was
and Bilateral Salpingo-oophorectomy (TAH+BSO) grouped as the following: 0-10 (non), 11-17 (mild),
performed on benign reasons among sexually 18-23 (moderate), 24 and more (severe). FSFI was
healthy and active women aged between 40-60 has also divided into sub-groups under the headings
any effect on sexual life and levels of depression in of satisfaction, lubrication, orgasm, arousal, sexual
the post-operative short period. desire and pain.
Statistical analysis: Data was evaluated by
METHODS using SPSS for Windows 15.0 software (Statistical
This study was planned as a prospective and Package for the Social Sciences - SPSS Inc., Chicago,
comparative, multi-center one. The patients Illinois, USA). Descriptive statistical mean values
included into the study were those sexually active were presented in terms of standard deviation,
and healthy patients, aged between 40-60, who frequency and percentage. For statistical analytical
underwent treatment between May 2013 and categorical changes, the chi-square test was used;
December 2013 in the Istanbul Gulhane Military for continuous data, the student-t test was used;
Medical Academy, Haydarpasa Training Hospital, and for the comparison of dependent qualitative
Obstetrics and Gynaecology Service, Suleymaniye date, the McNemar test was used. Multivariable
Training and Research Hospital and Namik Kemal logistic regression was performed to assess the
University Medical Faculty Hospital, These were independence of the associations by adjusting for
patients with no diagnosis of malignancy, planning potential confounding factors. For the purpose
to have an operation of Type 1 hysterectomy and of assessing the sexual function of women and
bilateral salpingo-oophorectomy and subsequently determining their level of depression, the categories
having this kind of operation. Our study was of age (40-45, 46-50 and 51-60), educational status
approved by the Ethics Committee of the Non- (primary school or its absence, middle school,
Invasive Clinical Trials of GATA Haydarpaşa high school, associate degree or undergraduate),
Training Hospital. All patients were informed employment status, family type (nuclear family and
about the research; discussions were held about the extended family) and smoking habits were all used
issues they worry about the operation and the post- as a potential confounding factor for multivariable
operative period. On benign reasons, all patients logistic regression models. For each potential
underwent the operation of Type 1 total abdominal confounder, we calculated adjusted odds ratios
hysterectomy and bilateral salpingo-oophorectomy. (ORs) and 95% CIs. Results were evaluated in a 95%
In the post-operative six. week, all patients were confidence interval, p<0.05 significance level and
routinely called in for control, given a briefing on p<0.01 P<0.001 advanced significance level. For all
sexual issues, and were encouraged. Either in the comparisons, nominal dual p value was accepted.
pre-operative or post-operative briefing period, the RESULTS
sexual partner was also informed and his anxieties
were thus dispelled. The  patients who had been One hundred fifty patients were included into the
under severe depression before the operation or study. 89 of these patients (59.4%) were in the pre-

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Sonay Baltaci Goktas et al.

Table-I: Demographic features of the patients. Table-II: Symptomatology and female sexual
Characters Frequency Percentage function index of the patients in the
(%) preoperative and postoperative periods.
Age 40-45age range 65 43.3 Characters Preoperative Postoperative P
46-50age range 58 38.7 Period Period
51-60age range 27 18.0 Symptoms, n(%)
Educational Literate 12 8.0 Hot flush and 75(50) 63(42) 0.203c
Status Primary school 44 29.3 perspiration
Middle school 28 18.7 Sleep problems 57(38) 57(38) 1.00c
High school 36 24.0 Urination problems 51(34) 25(17) <0,001c
Associate degree 10 6.7 Muscle and 54(36) 50(34) 0,716c
Undergraduate 20 13.3 joint disorders
Number of 0 8 5.3 FSFI, mean±SD 41.47±25.46 34.20±26.66 <0.001a
Children 1 23 15.3 Satisfaction 7.35±5.07 5.95±5.24 <0.001a
2 64 42.7 Lubrication 8.87±6.11 7.21±6.32 <0.001a
3 39 26.0 Orgasm 6.79±4.70 5.49±4.75 <0.001a
4 and more 16 10.7 Arousal 7.46±4.69 5.93±5.04 <0.001a
Family Nuclear family 107 71.3 Sexual desire 4.22±1.82 3.59±1.70 <0.001a
Type Extended family 43 28.7
Pain 6.77±5.22 6.03±5.49 0.017a
Employment Working 79 52.7
Premenopause 42.11±23.83 32.52±26.30
Status Not Working 71 47.3
FSFI, mean±SD
Personal Yes 129 86.0
Satisfaction 7.61±4.78 5.89±5.20 <0.001a
House
Lubrication 9.10±5.97 6.81±6.34 <0.001a
Ownership No 21 14.0
Cigarette Yes 61 40.7 Orgasm 7.04±4.44 5.18±4.58 <0.001a
smoking No 89 59.3 Arousal 7.45±4.46 5.57±5.14 <0.001a
Alcohol Use Yes 14 9.3 Sexual desire 4.17±1.74 3.57±1.75 <0.001a
No 136 90.7 Pain 6.74±5.01 5.49±5.15 <0.001a
Sports Yes 32 21.3 Menopause 40.52±27.85 36.66±27.23 0.19a
No 118 78.7 FSFI, mean±SD
Satisfaction 6.97±5.48 6.05±5.36 0.082a
Data are presented as frequency and percentage. Lubrication 8.54±6.34 7.80±6.30 0.258a
Orgasm 6.43±5.07 5.95±4.00 0.367a
menopausal period and 61 of them (40.6%) were in
Arousal 7.48±5.04 6.44±4.88 0.084a
the postmenopausal period. The average age of the
Sexual desire 4.30±1.95 3.61±1.64 0.002a
patients was 46.94±3.86 years; the average marriage Pain 6.82±5.55 6.80±5.92 0.976a
duration was 22.40±6.94 years; and average BMI FSFI, n(%)
was 26.87±4.14 kg/m2. Table-I shows the general Normal 100(66.7) 83(55.3) 0.001b
demographic features of the patients. Mild 10(6.7) 5(3.3)
In terms of the symptomatology in the pre- Moderate 2(1.3) 6 (4.0)
operative and post-operative periods, Table-II Severe 38(25.3) 56 (37.3)
shows that there is a statistically significant Premenopause FSFI, n(%) <0.001b
decrease in urinary problems in the post-operative Normal 62(69.7) 47(52.8)
period (34% and17%, p<0.001, respectively). As Mild 8(9.0) 3(3.4)
for a comparison in terms of FSFI, one can see that Moderate 1(1.1) 5(5.6)
Severe 18(20.2) 34(38.2)
there is a statistical difference between the total
Menopause FSFI, n(%) 0.564b
(41.47±25.46 to 34.20±26.67, p<0.001, respectively)
Normal 38(62.3) 36(59)
and pre-menopausal sub-groups (42.11±23.83 Mild 2(3.3) 2(3.3)
to 32.52±26.29, p<0.001, respectively) and this Moderate 1(1.6) 1(1.6)
difference also continues between sub-groups. And Severe 20(32.8) 22(36.1)
in the menopausal group, there was a difference FSFI abnormal, n(%) 50(33.3) 67(44.7) 0.058c
only in the sub-group of sexual desire (4.3±1.95 Premenopause 27(30.3) 42(47.2) 0.031c
to 3.61±1.64, p=0.002, respectively). However, FSFI abnormal, n(%)
when female sexual functions are grouped as Menopause 23(37.7) 25(41) 0.853c
normal and abnormal, there is a difference only FSFI abnormal, n(%)
in pre-menopausal patients (p=0.031). Table-II Data are presented as mean±SD and number (percent).
indicates that in terms of BDS there is a similar FSFI: Female Sexual Function Index;
statistical difference between the total (12.87±11.19 a
Student t test; bMcNemar test; cchi-square test.

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 Sexual function, depression and hysterectomy

Table-III: Depression among the patients in P=0.003] and extended family type [OR:2.57 (95%
the preoperative and postoperative periods. CI: 1.06-6.23), P=0.036]. Table-IV shows the adjusted
Characters Preoperative Postoperative P ORs for potential confounding factors that were
Period Period statistically significant for an increased risk of FSFI
BDS, mean±SD 12.87±11.19 14.27±10.95 0.015a and BDS.
BDS, n(%)
No Depression 77(51.3) 74(49.3) 0.016b DISCUSSION
Mild 19(12.7) 19(12.7) Hysterectomy is among the most frequently
Moderate 20(13.3) 20(13.3)
performed major gynaecological surgical
Severe 34(22.7) 37(24.7)
Premenopause BDS, n(%) interventions.1Whether with oophorectomy or not,
No Depression 40(44.9) 41(46.1) 0.028b anxieties concerning sexual function in the post-
Mild 14(15.7) 10(11.2) hysterectomy period are questionable and it is
Moderate 11(12.4) 10(11.2) emphasized that each partner’s life quality can be
Severe 24(27) 28(31.5) affected after such an operation. However, the exact
Menopause BDS, n(%) reason underlying the potential sexual dysfunction
No Depression 37(60.7) 33(54.1) 0.197b after hysterectomy could not be explained up until
Mild 5(8.2) 9(14.8)
now.13,14 It is thought that the neural support of the
Moderate 9(14.8) 10(16.4)
Severe 10(16.4) 9(14.8) upper vagina is related to orgasm and lubrication
Depression, n(%) 73(48.7) 76(50.7) 0.817c and that many nerves in the pelvic region perform
Premenopausal 49(55.1) 48(53.9) 0.880c their function through a structure known as
depression, n (%) uterovaginal plexus. However, literature search
Menopausal 24(39.3) 28(45.9) 0.583c for the last two decades shows that the ablation
depression, n(%) or non-ablation of cervix has no effect on sexual
Data are presented as mean ± SD and number (percent). BDS, Beck function15,16 and that there is no difference between
Depression Scale; aStudent t test; bMcNemar test; cchi-square test. the techniques of total abdominal hysterectomy,
subtotal hysterectomy and vaginal hysterectomy in
to 14.27±10.95, P=0.015, respectively) and pre-
terms of post-operative sexual activities and sexual
menopausal sub-group (P=0.028), but t there was
problems.17 There is also no evidence in relevant
no difference in the menopausal group.
literature that supports the possible relation
Comparing the existence or absence of depression
between vaginal length and sexual function.18
in the pre-operative and post-operative periods, no
While many researchers report that there is a
difference was observed in any category. Adjusted
measurable advance in the life style and sexual
ORs and 95% CIs of each potential confounder
function after simple hysterectomy,8,9,19,20 some
were calculated for the Female Sexual Function others point out to negative results.10,11 In the studies
Index (FSFI) and the Beck Depression Scale (BDS). pointing out to positive results, the main reason
When the adjusted odds ration (OR) of the potential has been shown as the decrease of dyspareunia21,
confounding factors affecting the existence of disappearance of pregnancy anxiety, absence of
female sexual dysfunction and depression, it was vaginal bleeding and thus the existence of more
educational status at the undergraduate level that time for relationship.7 And in a few studies, it has
was observed to have less frequent in the pre- been reported, that there is an improvement for the
operative period, [OR:7.32 (95% CI: 1.09-49.10), sexual functions of each partner after hysterectomy.22
p=0.040] and in the case of depression it was the 51- Some small-scale studies have indicated that the
60 age range that was observed to have less frequent. sexual well-being after hysterectomy depends upon
In the case of female sexual dysfunction in the post- the relationship between the partners before the
operative period, extended family type [OR:5.69 operation and physical well-being.15 And in a recent
(95% CI: 2.26-14.36), p<0.0001] and the 51-60 age review, it has been reported that if hysterectomy is
range [OR:3.24 (95% CI: 1.05-10.03), p=0.041] were performed under appropriate indications and with
observed more often; and in the case of depression, an appropriate technique, it would not have any
education status at the levels of primary school effect upon sexual functions and these claims do
[OR:11.40 (95% CI: 1.18-110.01), p=0.035], associate not have any scientific premise.7 Nonetheless, many
degree [OR:22.18 (95% CI: 1.28-383.52), P=0.033] of the long-term effects of hysterectomy on sexual
and undergraduate degree [OR:13.56 (95% CI: function are still unknown.
1.03-178.35), P=0.047] were observed less frequent; As for our study, it has been observe that female
and working women [OR:4.48 (95% CI: 1.67-12.05), sexual dysfunction increased after hysterectomy

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Sonay Baltaci Goktas et al.

Table-IV: Multivariable logistic regression analysis.

Potential confounding factors B p OR 95% C.I. for OR
Lower Upper
Postoperative FSFI Smoking 0,27 0,528 1,31 0,57 3,01
Literate 0,108
Primary school 0,64 0,409 1,90 0,41 8,77
Middle school 1,13 0,210 3,10 0,53 18,10
High school 1,56 0,084 4,75 0,81 27,73
Associate degree 1,09 0,307 2,97 0,37 23,88
Undergraduate -0,26 0,798 1,30 0,18 9,47
Working -0,91 0,066 2,49 0,94 6,60
Extended family 1,74 <0.001 5,69 2,26 14,36
40-45_age range 0,025
46-50 age range -0,38 0,373 0,69 0,30 1,58
51-60 age range 1,18 0,041 3,24 1,05 10,03
Constant -1,36 0,167 0,26
Postoperative BDS Smoking -0,02 0,954 1,02 0,44 2,37
Literate 0,111
Primary school -2,43 0,035 11,40 1,18 110,01
Middle school -1,49 0,225 4,42 0,40 48,64
High school -2,21 0,068 9,09 0,85 96,92
Associate degree -3,10 0,033 22,18 1,28 383,52
Undergraduate -2,61 0,047 13,56 1,03 178,35
Working 1,50 0,003 4,48 1,67 12,05
Extended family 0,95 0,036 2,57 1,06 6,23
40-45 age range 0,196
46-50 age range -0,10 0,809 1,11 0,48 2,55
51-60 age range -1,10 0,080 3,01 0,88 10,33
Constant 1,41 0,269 4,12
ORs, adjusted odds ratios; FSFI, Female Sexual Function Index; BDS, Beck Depression Scale.

(41.47±25.46 to 34.20±26.67, p<0.001) (Table-II) and operative period and the post-operative period was
that 50-60 age range [OR:3.24 (95% CI: 1.05-10.03), compared with respect to symptomatology, it was
P=0.041]and living within an extended family observed that there was a difference only in terms of
[OR:5.69 (95% CI: 2.26-14.36), p<0.0001] were the the urogenital system and unlike what the relevant
contributing factors (Table-IV). About 59.3% of literature states2, it was also observed that there
our patients were in the pre-menopausal group was a statistically significant decrease in urinary
and 40.7% of them were in the menopausal group. problems (34% and 17%, p<0.001, respectively)
In the pre-menopausal group, while there was an (Table-II). This can well be the consequence of the
increase in FSFI scores not only in the total group disappearance of the urogenital pressure problems
(42.11±23.83 to 32.52±26.29, p<0.001) but also in brought about by benign conditions and the
each and every sub-group, in the menopausal implementation of prophylactic antibiotic during
group there was a significant difference (in the form the operation.
of decrease) only in the sub-group of sexual desire For a woman, hysterectomy not only signals
(4.3±1.95 to 3.61±1.64, p=0.002) (Table-II). With a loss of the capacity of reproduction, but also of
regard to a comparison in terms of the existence or sexual function. This is because uterus makes its
absence of sexual dysfunction, there was not any contraction felt during orgasm.23 With the ablation
difference in the total group and the menopausal of ovaries, the sudden loss of sex hormones can
group in the post-operative period. However, further increase such anxieties and complaints
in the pre-menopausal sub-group, there was an of depression. The relevant literature points that
increase in the post-operative period in terms of situations like sexual dysfunctions and decrease
the existence of sexual dysfunction (30.3% to 47.2%, in sexual desire after hysterectomy usually leads
p=0.031) (Table-II). In fact, these results show not to a development of depression and that the most
only that sexual life in the early post-hysterectomy common psychiatric problem after hysterectomy
period is negatively influenced, but also that this is depression.24 In Manyonda’s study, related to
effect is less in menopausal patients. When the pre- the issue at hand, it is stated that hysterectomy

704 Pak J Med Sci 2015 Vol. 31 No. 3 www.pjms.com.pk

Sonay Baltaci Goktas et al.

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of the urinary bladder following major pelvic surgery. Br J Surg.
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Declaration of interest disclosure: Authors declare
no conflicts of interest. Authors’ Contribution:
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