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Effect of hysterectomy due to benign diseases on female sexual function: A systematic review and meta-analysis

  • Farideh Kazemi
    Correspondence
    Corresponding author's contact information: Farideh Kazemi, Hamadan University of Medical Sciences, Shaheed Fahmideh Ave. Hamadan, Islamic Republic of Iran, Fax number: +9881-38380447
    Affiliations
    Instructor, PhD in Reproductive Health, Mother and Child Care Research Center, Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
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  • Zainab Alimoradi
    Affiliations
    Assistant Professor, PhD in Reproductive Health, Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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  • Samira Tavakolian
    Affiliations
    MSC in Midwifery, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
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Published:October 31, 2021DOI:https://doi.org/10.1016/j.jmig.2021.10.012

      Abstract

      Objective

      Determination of the effect of hysterectomy due to benign diseases on female sexual function

      Data Sources

      A search was performed on Scopus, PubMed, Science Direct, ProQuest, ISI Web of Knowledge and Embase databases. The keywords included Hysterectomy (as exposure) and Female sexual function (as outcome). Original English observational studies, including cohort, case-control, and cross-sectional studies published as of February 2021, which reported an association between any type of hysterectomy due to benign female disease and sexual function as an outcome, were included in the study. Studies in participants who received HRT and had sex other than heterosexuals were not included. There was no limit to the initial search period, and articles published by February 2021 were searched.

      Methods of Study Selection

      The search process resulted in the retrieval of 5,587 potentially related articles. After removing duplicated studies, the title and abstract were reviewed and 77 articles remained with the removal of unrelated items. The full text of 14 articles was published in non-English languages, and 52 articles were removed because they did not meet the inclusion criteria, and finally 11 articles were included in the final analysis.

      Tabulation, Integration, and Results

      The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. The evidence was synthesized using meta-analysis via random effect model with the Der Simonian and Laird weighted method. Publication bias was assessed using the funnel plot and Begg's and Egger's tests. The pooled standardized mean difference for sexual function in hysterectomy versus non-hysterectomy group was .08 (CI95%: -.38 to .55; I2 = 96.8%; χ2 = 307.94, p-value <.001; τ2 = .59). Publication bias and small study effects were not detected. The results of the subgroup analysis showed that the possible sources of heterogeneity are the World Bank countries’ classification and type of hysterectomy (in some studies the type of hysterectomy was not specified separately for the study groups, because of this, comparisons were made between Total and supracervical/total). Pooled SMD was affected by type of sexual function scale, World Bank countries’ classification, type of hysterectomy, ovary status, and reproductive status. The results of meta-regression analysis also showed that for each month of distance from hysterectomy, women's sexual function score increases by .18.

      Conclusion

      The results of the present study showed that hysterectomy due to benign disease does not change the sexual function significantly.

      Registration of Systematic Reviews

      The study protocol was registered in PROSPERO system with the code CRD42021228314

      Keywords

      Introduction

      Hysterectomy is the most common gynecological surgery which 40% of women undergo this surgery before the age of 64 (1). Hysterectomy can be performed either through the vagina or abdomen or with less invasive procedures such as laparoscopy. Age, menopause, systemic diseases as well as gynecological surgeries can negatively affect sexual response of middle-aged women by altering their self-image, sexual pain and orgasm problems (2). Some studies have shown that sexual function is similar in different hysterectomy techniques, including abdominal, subtotal, and vaginal hysterectomy (3-5).
      It is thought that hysterectomy can lead to sexual dysfunction in a group of women who experience uterine orgasm. Thus, women may feel that their sex lives may be affected by a hysterectomy (2) because the belief that the uterus is important for sexual function can increase hysterectomy anxiety and worsen postoperative sexual function (1).
      The majority of women who undergo this surgery are concerned about its impact on their sex lives, and unfortunately there is still no consensus on the impact of this surgery on women's sexuality (1). In fact, damage to the uterine-vaginal neural network during a hysterectomy may interfere with vaginal neural support leading to orgasm and lubrication (6, 7).
      Wang concluded that total hysterectomy has a negative effect on women's sexual function by reducing the frequency of sexual activity, decreased libido, orgasmic dysfunction, and increased dyspareunia (8). In contrast, other reports suggest that hysterectomy can improve female sexual function because it reduces symptoms associated with benign conditions such as bleeding problems, dyspareunia, prolapse-related reluctance, fear of pregnancy. Regardless of the type of surgical procedure, hysterectomy can improve the quality of life and sexual function of women (1, 9-12). In this regard, the results of a narrative review showed that the majority of sexual disorders after hysterectomy due to benign diseases improved, and in most women, sexual function was similar to or better than the preoperative stage (13). In his review study, Yazbeck also concluded that hysterectomy did not have a negative effect on sexuality, but some points must be considered including poor design of included studies and importance of the impact of confounding factors such as type of operations(14). In Yazbeck's study, articles in English and French were included, and the outcome of the study was sexuality, while we studied sexual function in our study. In addition, no meta-analysis was performed and only conclusions were made based on a review of studies. Lethaby et al. also in his meta-analysis found no difference in sexual function (5) that of course, this study was done on trials. To the best of our knowledge, previous studies showed contradictory results about the effect of hysterectomy due to benign diseases on sexual function in women. Therefore, the present systematic review and meta-analytical study aimed to investigate the effect of hysterectomy because of benign diseases on female sexual function.

      Method

      The report of the present study was organized based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline (15). The study protocol was registered in PROSPERO system with the code CRD42021228314 (16).

       Search strategy

      A search was performed on Scopus, PubMed, Science Direct, ProQuest, ISI Web of Knowledge and Embase databases. Keywords in primary articles and published review articles, MeSH and EMTREE, were used to search. According to the PECO framework for research question (Patient-Problem (P), Exposure (E), Comparison (C) and Outcome (O) (17)), the keywords included Hysterectomy (E) and Female sexual function (O). There was no limit to the initial search period, and articles published by February 2021 were searched. In addition, the reference list of previous review articles and selected studies from the search in this study were also reviewed. The search was performed using Boolean method and AND / OR operators were used to compile search syntaxes, which were matched according to the advanced search features of each database. The search strategy is available in Appendix 1.

       Inclusion criteria

      Features of studies: Observational studies, including longitudinal cohort studies (pre/post), case-control, and cross-sectional studies published as of February 2021, which reported an association between any type of hysterectomy due to benign female disease and sexual function as an outcome, were included in the study. Original English research articles were included in the study, but systematic review articles, case reports, letters to the editor and abstracts of conference papers were not selected.
      Characteristics of the participants: Studies that evaluated women's sexual function in relation to hysterectomy and had a comparison group were selected. There was no restriction in terms of age, number of deliveries, BMI, time spent on hysterectomy, cause of hysterectomy, presence or absence of ovaries, etc. in selecting participants. Studies in participants who received HRT and had sex other than heterosexuals were not included.
      Type of exposure: Hysterectomy due to benign diseases of women was regarded as exposure. This condition should be diagnosed using a clinical interview.
      Objectives studied: The main objective of this study was to compare the mean score of sexual function among individuals who underwent hysterectomy compared to those who did not. The secondary objective was to determine the potential sources of heterogeneity (by performing subgroup analyzes on type of sexual function scale, World Bank countries classification, type of hysterectomy, ovary status, reproductive status and performing meta-regression on quality of studies, age, BMI, parity, evaluation time after surgery). The outcome of sexual function was acceptable when measured with a valid and reliable instrument. The instruments that evaluated sexual function in the articles used in our meta-analysis included the FSFI (Female Sexual Function Index), the PISQ-12 (Prolapse / Urinary Incontinence Sexual Function Questionnaire), and the ASEX (Arizona Sexual Experiences Scale).
      The FSFI Questionnaire (18) is a 19-item tool used to assess 6 different areas of sexual function (desire, lubrication, arousal, orgasm, satisfaction, and pain) over the past 4 weeks. The first two questions are scored with a Likert of 1 to 5, and the remaining questions with a Likert of 0 to 5. The scores obtained in each domain are multiplied by a specific coefficient of the same domain to homogenize the effects of different domains. The minimum and maximum scores of the questionnaire are 2 and 36, and a higher score indicates better sexual function (19). PISQ-12 is a 12-item form designed to assess sexual function in women with urinary incontinence or pelvic organ prolapse. The answers to the questions are given using Likert 0 to 5 "rarely = 0" to "always = 4" and the maximum score is 48, the higher the score, the better the sexual performance. This questionnaire can only be used for women who report sexual activity with a partner in the last three months (20). ASEX is a five-item scale with six different response levels that measures sexual function. Questions are about libido, arousal, lubrication, ability to reach orgasm, and satisfaction with orgasm (21). Each question is scored with 6 points Likert scale. The minimum and maximum scores are 5 and 30, with a higher score indicating better sexual function (22).

       Screening & Selection

      After searching and storing the retrieved information separately by databases, duplicate items were retrieved using EndNote software and were removed from the list of studies. Then, the titles and abstracts of the retrieved studies were reviewed in terms of relevance to the main purpose of the study and based on inclusion and exclusion criteria. Finally, the full text of the selected articles was reviewed for inclusion and exclusion criteria.

       Quality assessment

      In the present study, the NOS (Newcastle-Ottawa Scale) checklist was used to evaluate the methodological quality of the selected studies. This checklist is a valid tool used to assess the quality of observational studies (cohort, case-control, and cross-sectional). NOS examines three quality parameters: selection, comparability, and outcome. This checklist has 7 dedicated items each of which gets 1 point except the comparison item which can get a maximum of 2 points. Therefore, the maximum score for each study is 9, and if a study scores less than 5, it means that the risk of bias in that study is high (23). In the present study, based on quality score, no study was excluded, but the effect of quality scores on pooled effect size was evaluated using meta-regression.

       Data extraction and management

      After screening, selection and evaluation of the quality of selected studies, data were extracted and recorded. The following information was collected from each study: Name of the first author, year of publication, country of study and its World Bank classification for income, sample size of exposure and comparison group, age of women, BMI, distance from surgery to evaluation, study design, number of deliveries, type of hysterectomy performed, ovarian status, cervical status, reproductive status, data collection tools, quality of including studies and mean and standard deviation of total score of sexual function and its domains in the exposure and comparison group. It should be noted that the selection of studies, quality evaluation and data extraction were done independently by two project partners and, in case of disagreement, the problem was solved through discussion. The Cohen's Kappa coefficient was measured to determine the agreement between the two evaluators.

       Data synthesis

      The combination of the results of the selected studies was done quantitatively and based on the suggested items in the PRISMA using STATA-13 software. Due to the fact that the number of retrieved studies was sufficient for quantitative composition and there was no severe methodological heterogeneity between the retrieved studies, a meta-analysis was performed. Data related to the relationship between hysterectomy and women's sexual functions (as well as data related to different dimensions of sexual function as a secondary objective) were extracted between the hysterectomy group and the comparison group as mean and standard deviation. Therefore, SMD and 95% CI were calculated for analysis. Given that in most studies, the design was before-after, Hedges' g was used as the SMD. The interpretive areas of Hedges’ g were .20–.40 (considered small), .50–.70 (considered moderate), and .80≤ (considered large) (24).
      Because the studies were obtained from populations with different size effects, the random effect model was used using the Der Simonian and Laird weighted methods (25). Heterogeneity was statistically evaluated using the χ2 standard test; and due to the heterogeneity, a random-effect model was selected. Moreover, severe statistical heterogeneity was calculated using I2 index. If I2 <25% is mild heterogeneity, between 25 and 50% moderate heterogeneity, more than 70% is considered severe heterogeneity (26). Due to the severe heterogeneity in the total composition, subgroup analysis and meta-regression were used to identify a potential source of heterogeneity. In addition, meta-regression was used to evaluate the effect of the quality of the initial studies on the main outcome of the study. Publication bias was assessed using the funnel plot and the Begg's & Eggers test. Significance level was considered.05 in all analyses and.10 in meta-regression due to the small number of articles.

       Findings

      The search process resulted in the retrieval of 5,587 potentially related articles. After removing duplicated studies (n = 2296), the title and abstract were reviewed, and 77 articles remained with the removal of unrelated items. The full text of 14 articles was published in non-English languages which were excluded from the review process, and after studying the full text of the remaining articles, 52 articles were deleted due to lack of inclusion criteria, and finally 11 articles were included in the final analysis. The Cohen's Kappa coefficient between the two evaluators was calculated to be .80 (CI95%: .71 to .94) in the abstract review phase and .88 (CI95%: .76 to .97) in the full text review phase. Figure 1 shows the search process according to the PRISMA flowchart.
      Figure 1
      Figure 1PRISMA flowchart of selected studies

       Description of the studies

      Out of 11 studies, 10 studies were cohort with pre-post design (9 prospective cohort studies and 1 retrospective cohort study) and one study was cross-sectional. A total of 1,339 people participated in this study. With the exception of two studies, the rest were conducted in Turkey. The highest sample size was related to the study of Dedden et al. (27) with 260 samples, and the lowest sample size was related to the study of Sukgen et al. (28) (n = 28). In 9 studies, the FSFI tool was used to measure the main outcome of the study. The information is in Table 1.
      Table 1-Summarized characteristics of selected primary studies
      FirstAuthor (year)yearcountryStudy designSexual function scaleAge (mean ±SD or median)ovary status (% of BSO)NOSHysterectomy typeroute of hysterectomy
      Ercan (25)2016Turkeycross-sectionalPISQ-1254.43±6.1Not reported5total

      Abdominal/ vaginal/ laparoscopic
      Sukgen

      (24)
      2018Turkeyprospective cohortFSFI45.1±8.4Not reported6total

      laparoscopic
      Bayram (26)2008Turkeyprospective cohortFSFI45.4±5.6Not reported7totalAbdominal/ vaginal/
      Celik (27)2008Turkeyprospective cohortFSFI49.69± 4.2BSO*(100)6Not reportedAbdominal/ vaginal/
      Dedden (23)2020Netherlandsprospective cohortFSFI46.2±6.9Mixed(7.7)6Supracervial /totalNot reported
      Can (15)2020Turkeyprospective cohortFSFI49.32±9.0BSO(100)7totalAbdominal
      Doganay (1)2018TurkeyRetrospective cohortFSFI47.92±1.1Mixed(55.3)6Not reportedNot reported
      Goktas (28)2015Turkeyprospective cohortFSFI46.94±3.9BSO(100)6totalAbdominal
      Radosa (29)2014Germanyprospective cohortFSFI46.41±8.17Ovarian preservation (0)6

      Supracervial /total
      vaginal/ laparoscopic
      Eken (30)2016Turkeyprospective cohortASEX41.95±2.5Ovarian preservation (0)6totalAbdominal/ laparoscopic
      Kayatas (18)2017Turkeyprospective cohortFSFI45Ovarian preservation (0)6Not reportedAbdominal/ laparoscopic
      *bilateral salpingo-oophorectomy

       Risk of bias within studies

      Risk of bias assessment within studies was performed using the NOS checklist. The quality assessment results of each study are shown in Appendix 2. The results of the risk of bias assessment showed that a small number of studies had reported the method of calculating the sample size and the information used in it. In addition, in none of the studies were the results completely reported. In a small number of them, the intervention of the interveners was not performed.

       Outcome assessment

      Overall SMD estimation: A meta-analysis of the studies was used to calculate the SMD of women's sexual function. Figure 2 shows the Forest plot SMDs of sexual function in individuals who underwent hysterectomy versus those who did not with a total pooled SMD of .08 (CI95%: -.38 to .55; I2 = 96.8%; χ2 = 307.94, p-value <.001; τ2 = .59).
      Figure 2
      Figure 2Forest plot of overall SMD for sexual function among women underwent hysterectomy
      Publication bias: The publication bias, checked using a funnel plot (Figure 3) and the Begg (z =.31, p-value =.75) and Egger (t = -.81, p-value =.44) tests, indicates the low probability of publication bias in the included studies.
      Figure 3
      Figure 3Funnel plots for assessing publication bias within studies related to sexual function
      Sensitivity analysis: The Jack-Knife method was used to evaluate the small study effects. The sensitivity analysis showed that the estimated pooled SMD was not affected by the small number of studies (figure 4).
      SMD estimation for FSFI domains: Meta-analysis of different dimensions of FSFI questionnaire was also performed (Table 2). The results showed that there was no statistically significant relationship between sexual function scores in different dimensions with hysterectomy, and that the reported SMDs were in the trivial area of interpretation.
      Table 2Result of overall SMD of 6 domains of FSFI (7 studies)
      domainI-squared %Waited methodHedges' g95% CI Hedges' g
      desire95.8D+L.19-.37 to .76
      Arousal92.2D+L.01-.38 to .41
      Lubrication91.3D+L-.08-.45 to .28
      Orgasm88.2D+L-.08-.40 to .23
      Satisfaction96.8D+L.15-.53 to .82
      pain86.5D+L.06-.24 to .36
      Sub-group analysis and meta-regression: Subgroup analysis (Table 3) and meta-regression (Table 4) were used to determine the potential source of heterogeneity and variables that affect the pooled effect size. The results of the subgroup analysis showed that one of the possible sources of heterogeneity is the World Bank countries’ classification so that high-income countries had less heterogeneity than upper-middle-income countries (67.7% I2 = vs. I2 = 97.2%). Another source of heterogeneity was type of hysterectomy; in which women with supra-cervical or total hysterectomy had lower I2 levels (67.7% vs. 93.6%) than those with total hysterectomy.
      Table 3Sub-group analysis
      Potential factorsSMD (CI95%)No of studiesHeterogeneity X2p-valueI2Interaction p-value
      Type of sexual function scalePISQ-12-1.35

      (-1.74 to -.96)
      1---<.001
      FSFI-.30

      (-.017 to .77)
      9220.81<.00196.4%
      ASEX-.45

      (-.76 to -.14)
      1---
      World Bank countries classificationhigh-income.41 (.19 to .63)23.09.0867.7%<.001
      upper-middle-income.01 (-.64 to .66)9286.31<.00197.2%
      Type of hysterectomytotal-.23

      (-.77 to .31)
      678.73<.00193.6%<.001
      Supra-cervical or total (the type of hysterectomy was not specified separately for the study groups).41

      (.19 to .63)
      23.09.0867.7%
      Ovary statusBSO
      bilateral salpingo-oophorectomy
      -.12

      (-.70 to .45)
      317.62<.00188.7%<.001
      BSO or ovarian preservation (ovary status was not specified separately for the study groups)1.11

      (-.05 to 2.27)
      256.19<.00198.2%
      ovarian preservation.04

      (-.42 to .50)
      317.43<.00188.5%
      Reproductive statusmenopause-.61

      (-1.03 to -.19)
      1---<.001
      mixed-.18

      (-.81 to .44)
      326.73<.00192.5%
      Perimenopause.26

      (-.22 to 074)
      428.05<.00189.3%
      All studies.08

      (-.36 to .52)
      11263.84<.00196.2%-
      low asterisk bilateral salpingo-oophorectomy
      Table 4meta-regression analysis
      variableΒ (CI95%)p-valueI2Residual (%)Adjusted R2 (%)Tau2
      Quality of studies (NOS).34 (-.86 to 1.55).5397.07-6.65.78
      Age (year)-.08 (-.27 to .12).3797.05-1.98.75
      BMI.30 (-.73 to 1.33).4997.95-8.371.00
      Parity-.51 (-2.15 to 1.13).3998.25-.801.53
      Evaluation time after surgery (month).18 (-.01 to .36).0695.6026.14.54
      Appendix 1Search syntax adopted for each database
      DatabaseSearch dateretrieved studiescustomized syntax
      PubMedFebruary

      20-2021
      509(Hysterectomy[title/abstract] OR Hysterectomies[title/abstract]) AND ((Dysfunction AND “Psychological Sexual”)[title/abstract] OR (Dysfunctions AND “Psychological Sexual”)[title/abstract] OR “Psychological Sexual Dysfunction”[title/abstract] OR “Psychological Sexual Dysfunctions”[title/abstract] OR (“Sexual Dysfunction” AND Psychological)[title/abstract] OR “Psychosexual Dysfunctions”[title/abstract] OR (Dysfunction AND Psychosexual)[title/abstract] OR (Dysfunctions AND Psychosexual)[title/abstract] OR “Psychosexual Dysfunction”[title/abstract] OR “Psychosexual Disorders”[title/abstract] OR (Disorder AND Psychosexual)[title/abstract] OR (Disorders AND Psychosexual)[title/abstract] OR “Psychosexual Disorder”[title/abstract] OR “Hypoactive Sexual Desire Disorder”[title/abstract] OR “Sexual Aversion Disorder”[title/abstract] OR (“Aversion Disorders” AND Sexual)[title/abstract] OR (Disorders AND “Sexual Aversion”)[title/abstract] OR “Sexual Aversion Disorders”[title/abstract] OR “Orgasmic Disorder”[title/abstract] OR (Disorders AND Orgasmic)[title/abstract] OR “Orgasmic Disorders”[title/abstract] OR “Sexual Arousal Disorder”[title/abstract] OR (“Arousal Disorders” AND Sexual)[title/abstract] OR (Disorders AND “Sexual Arousal”)[title/abstract] OR “Sexual Arousal Disorders”[title/abstract] OR “sexual function”[title/abstract] OR “sexual functions”[title/abstract] OR “sexual health”[title/abstract] OR “sexual activity”[title/abstract] OR “sexual performance”[title/abstract])
      ScopusFebruary 4, 20211142(TITLE-ABS-KEY (hysterectomy) OR TITLE-ABS-KEY (hysterectomies)) AND (TITLE-ABS-KEY (dysfunction AND "Psychological Sexual") OR TITLE-ABS-KEY (dysfunctions AND "Psychological Sexual") OR TITLE-ABS-KEY ("Psychological Sexual Dysfunction") OR TITLE-ABS-KEY ("Psychological Sexual Dysfunctions") OR TITLE-ABS-KEY ("Sexual Dysfunction" AND psychological) OR TITLE-ABS-KEY ("Psychosexual Dysfunctions") OR TITLE-ABS-KEY (dysfunction AND psychosexual) OR TITLE-ABS-KEY (dysfunctions AND psychosexual) OR TITLE-ABS-KEY ("Psychosexual Dysfunction") OR TITLE-ABS-KEY ("Psychosexual Disorders") OR TITLE-ABS-KEY (disorder AND psychosexual) OR TITLE-ABS-KEY (disorders AND psychosexual) OR TITLE-ABS-KEY ("Psychosexual Disorder") OR TITLE-ABS-KEY ("Hypoactive Sexual Desire Disorder") OR TITLE-ABS-KEY ("Sexual Aversion Disorder") OR TITLE-ABS-KEY ("Aversion Disorders" AND sexual) OR TITLE-ABS-KEY (disorders AND "Sexual Aversion") OR TITLE-ABS-KEY ("Sexual Aversion Disorders") OR TITLE-ABS-KEY ("orgasmic disorder") OR TITLE-ABS-KEY (disorders AND orgasmic) OR TITLE-ABS-KEY ("orgasmic disorders") OR TITLE-ABS-KEY ("sexual arousal disorder") OR TITLE-ABS-KEY ("Arousal Disorders" AND sexual) OR TITLE-ABS-KEY (disorders AND "Sexual Arousal") OR TITLE-ABS-KEY ("Sexual Arousal Disorders") OR TITLE-ABS-KEY ("sexual function") OR TITLE-ABS-KEY ("sexual functions") OR TITLE-ABS-KEY ("sexual health") OR TITLE-ABS-KEY ("sexual activity") OR TITLE-ABS-KEY (“sexual performance”))
      ProQuestFebruary 4, 202117ab((Hysterectomy) OR (Hysterectomies)) AND ab((Dysfunction AND “Psychological Sexual”) OR (Dysfunctions AND “Psychological Sexual”) OR (“Psychological Sexual Dysfunction”) OR (“Psychological Sexual Dysfunctions”) OR (“Sexual Dysfunction” AND Psychological) OR (“Psychosexual Dysfunctions”) OR (Dysfunction AND Psychosexual) OR (Dysfunctions AND Psychosexual) OR (“Psychosexual Dysfunction”) OR (“Psychosexual Disorders”) OR (Disorder AND Psychosexual) OR (Disorders AND Psychosexual) OR (“Psychosexual Disorder”) OR (“Hypoactive Sexual Desire Disorder”) OR (“Sexual Aversion Disorder”) OR (“Aversion Disorders” AND Sexual) OR (Disorders AND “Sexual Aversion”) OR (“Sexual Aversion Disorders”) OR (“Orgasmic Disorder”) OR (Disorders AND Orgasmic) OR (“Orgasmic Disorders”) OR (“Sexual Arousal Disorder”) OR (“Arousal Disorders” AND Sexual) OR (Disorders AND “Sexual Arousal”) OR (“Sexual Arousal Disorders”) OR (“sexual function”) OR (“sexual functions”) OR (“sexual health”) OR (“sexual activity”) OR (“sexual performance”))
      web of scienceFebruary 4, 2021858(TS=(Hysterectomy) OR TS=(Hysterectomies)) AND (TS=(Dysfunction AND Psychological Sexual) OR TS=(Dysfunctions AND Psychological Sexual) OR TS=(Psychological Sexual Dysfunction) OR TS=(Psychological Sexual Dysfunctions) OR TS=(Sexual Dysfunction AND Psychological) OR TS=(Psychosexual Dysfunctions) OR TS=(Dysfunction AND Psychosexual) OR TS=(Dysfunctions AND Psychosexual) OR TS=(Psychosexual Dysfunction) OR TS=(Psychosexual Disorders) OR TS=(Disorder AND Psychosexual) OR TS=(Disorders AND Psychosexual) OR TS=(Psychosexual Disorder) OR TS=(Hypoactive Sexual Desire Disorder) OR TS=(Sexual Aversion Disorder) OR TS=(Aversion Disorders AND Sexual) OR TS=(Disorders AND Sexual Aversion) OR TS=(Sexual Aversion Disorders) OR TS=(Orgasmic Disorder) OR TS=(Disorders AND Orgasmic) OR TS=(Orgasmic Disorders) OR TS=(Sexual Arousal Disorder) OR TS=(Arousal Disorders AND Sexual) OR TS=(Disorders AND Sexual Arousal) OR TS=(Sexual Arousal Disorders) OR TS=(sexual function) OR TS=(sexual functions) OR TS=(sexual health) OR TS=(sexual activity) OR TS=(sexual performance))
      EmbaseFebruary 4, 20212832('hysterectomy'/exp OR hysterectomy OR hysterectomies) AND (dysfunction AND 'psychological sexual' OR (dysfunctions AND 'psychological sexual') OR 'psychological sexual dysfunction' OR 'psychological sexual dysfunctions'/exp OR 'psychological sexual dysfunctions' OR (('sexual dysfunction'/exp OR 'sexual dysfunction') AND psychological) OR 'psychosexual dysfunctions'/exp OR 'psychosexual dysfunctions' OR (dysfunction AND psychosexual) OR (dysfunctions AND psychosexual) OR 'psychosexual dysfunction' OR 'psychosexual disorders'/exp OR 'psychosexual disorders' OR (('disorder'/exp OR disorder) AND psychosexual) OR (('disorders'/exp OR disorders) AND psychosexual) OR 'psychosexual disorder'/exp OR 'psychosexual disorder' OR 'hypoactive sexual desire disorder'/exp OR 'hypoactive sexual desire disorder' OR 'sexual aversion disorder'/exp OR 'sexual aversion disorder' OR ('aversion disorders' AND sexual) OR (('disorders'/exp OR disorders) AND 'sexual aversion') OR 'sexual aversion disorders' OR 'orgasmic disorder' OR (('disorders'/exp OR disorders) AND orgasmic) OR 'orgasmic disorders' OR 'sexual arousal disorder'/exp OR 'sexual arousal disorder' OR (('arousal disorders'/exp OR 'arousal disorders') AND sexual) OR (('disorders'/exp OR disorders) AND ('sexual arousal'/exp OR 'sexual arousal')) OR 'sexual arousal disorders'/exp OR 'sexual arousal disorders' OR 'sexual function'/exp OR 'sexual function' OR 'sexual functions' OR 'sexual health'/exp OR 'sexual health' OR 'sexual activity'/exp OR 'sexual activity' OR ‘sexual performance’/exp OR ‘sexual performance’)
      Science DirectFebruary 4, 2021229Title, abstract, keywords: Hysterectomy AND (sexual dysfunction OR sexual function OR sexual performance)
      Appendix 2Quality assessment of studies
      Study (year)SelectionComparabilityoutcomeTotal score
      Representativeness of the sampleSample sizeNon-respondentAscertainment of the exposureConfounding factors are controlledAssessment of outcomesStatistical test
      Ercan (2016)*-***-*-5
      Sukgen (2018)*-*****-6
      Bayram (2008)*******-7
      Celik (2008)*-*****-6
      Dedden (2020)*-*****-6
      Can (2020)*******-7
      Doganay (2018)*-*****-6
      Goktas (2015)*-*****-6
      Radosa (2014)*-*****-6
      Eken (2016)*-*****-6
      Kayatas (2017)*-*****-6
      SMD estimation was affected by all variables listed in Table 3. In a study using the PISQ-12 instrument, the relationship between hysterectomy and sexual function was reported to be much stronger (SMD = -1.35, N = 1) than those that used the FSFI instrument (SMD = -.30, N = 9) and ASEX (SMD = -.45, N = 1). In high-income countries, the relationship was stronger than in upper-middle-income countries (SMD = .41, N = 2 and SMD = .01, N = 9, respectively). Comparison of SMD by type of hysterectomy showed that studies reporting supracervical/total hysterectomy (in these studies, the type of hysterectomy was not specified separately for the study groups) had a stronger association between hysterectomy and sexual function than total hysterectomy alone (SMD = .41, N = 2 vs. SMD = -.23, N = 6). Evaluation of SMD by ovarian status showed that in studies in which a percentage of participants had BSO, the relationship was much stronger (SMD = 1.11, N = 2) than those in which all participants had BSO or ovarian preservation. In a study in which all participants were menopause, the association between sexual function and hysterectomy was stronger (SMD = -.61, N = 1) than that in which the participants were either pre-menopausal or mixed. The results of meta-regression analysis also showed that for each month of distance from hysterectomy, women's sexual function score increases by .18 (Table 4).

      Discussion

      The aim of this study was to compare sexual function among individuals who underwent hysterectomy and those who did not, and to determine the potential source of heterogeneity and factors related to sexual function in these women. The combination of the results of the studies showed that hysterectomy has no significant effect on sexual function in women.
      According to the results of subgroup analysis, some factors affected the sexual function of individuals who underwent hysterectomy. One of these factors was the tools used to measure the outcome. Among the tools used to assess sexual function, a study using the PISQ-12 reported a very strong association between hysterectomy and sexual function, and sexual function was significantly reduced in this study. Of course, the result is not consistent because there was only one study in this subgroup.
      The results of the subgroup analysis showed that in countries that were in the high-income group according to the World Bank (the Netherlands, Germany), hysterectomy led to poor improvement in sexual function. Due to the limited number of studies in this subgroup, the result has no consistency. It should be noted that all 9 studies included in the upper-middle-income subgroup were conducted in Turkey. A study in Philadelphia that examined socioeconomic variables affecting sexual function concluded that high income was associated with better sexual function in women (29). On the contrary, in a study conducted in Turkey, it was shown that there is no significant relationship between income and sexual function in women (30). In addition to economy, another reason for these differences may be differences in the cultural contexts of different societies. In the DSM-5, in addition to addressing 4 sexual dysfunctions in men and 3 sexual dysfunctions in women, a new group is included in this classification that includes cultural or religious factors (e.g., prohibitions on sexual activity or pleasure; attitude towards sex) (31, 32). Cultural and social factors play a role in sexual dysfunction, but depending on the level of acculturation, this contribution can be stronger or weaker (33).
      In the present study, sexual function was affected by the type of hysterectomy so that total hysterectomy/ supracervical hysterectomy had a weak and significant relationship with sexual function and led to poor improvement, but the number of studies in the subgroup was low, further studies in future might lead to changes in these results. In most of the studies included in our meta-analysis, there was no information on sexual function by type of hysterectomy, therefore, total and superacervical hysterectomy were not comparable. However, the results of meta-analysis studies in this field are also consistent with those of our study. A meta-analysis of clinical trial studies conducted by Lethaby et al. in 2012 found no difference in sexual, urinary, or intestinal function in the short term (up to two years after surgery) or in the long term (nine years after surgery) (5). In another meta-analysis of clinical trial studies, total and subtotal hysterectomies were evaluated for some outcomes including sexual function. Due to the fact that except for two studies (which used valid questionnaires to measure outcome), the rest of the studies were self-made questionnaires; therefore, the findings could not be combined, but the results of this study showed that in the follow-up 12 months after surgery, the two groups were similar in terms of sexual satisfaction (34).
      Among other factors examined in the subgroup analysis were ovarian conditions. Bilateral oophorectomy in premenopausal and postmenopausal women is expected to lead to a significant reduction in mean total and free testosterone levels (average approximately 50%) and decreased libido after bilateral oophorectomy which is likely to be due to androgen depletion (35). The results of the present study showed that removal or preservation of both ovaries had no effect on sexual function of individuals who underwent hysterectomy, and SMD of both subgroups was in the trivial area. However, due to the small number of studies in the subgroups and the low accuracy, the results obtained in the present study are not conclusive.
      According to the results of our study, sexual function was also affected by fertility status and decreased moderately in menopausal women, while in premenopausal women, sexual function increased slightly. Due to hormonal changes in the postmenopausal age and psychological problems such as stress, depression and fatigue, sexual function is expected to decrease during this period (36). Of course, due to insufficient number of studies in subgroups and lack of accuracy, these results are not conclusive.
      In the studies included in the present meta-analysis, women's sexual function was examined 3-12 months after surgery, and meta-regression results showed that sexual function improved over time, which could be due to adaptation to the current situation and improvement in the conditions for which the surgery was performed.
      One of the strengths of the present study was conducting extensive searches in reputable databases that increased the likelihood of retrieving related articles. Other strengths were subgroup analysis and meta-regression for heterogeneity and performing sensitivity analysis. One of the limitations of the present study was the small number of studies that led to inconclusive interpretation of the results, especially those of the subgroups. In some studies, it was not clear what type of hysterectomy was performed, and this led to sexual performance not being comparable to different types of hysterectomies. Another limitation was the lack of diversity at the study site, and most of the studies included in the meta-analysis were conducted in Turkey. It seems that more studies are needed in this field, different types of hysterectomies, fertility status, ovarian status, etc., in order to achieve conclusive results.

      Conclusion

      The results of the present study showed that hysterectomy does not change the sexual function of women due to benign diseases, but due to the instability in the results, more studies are needed.

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