Is the Uterus Necessary After Childbearing is Completed?
Frederick R. Jelovsek MD
"What are the advantages of keeping your uterus over a lifetime? Does the uterus perform any functions past child-bearing years? Some sources say the uterus continues to produce needed hormones during a woman's entire life; that it is part of the endocrine system; and that the loss of the uterus decreases sexual enjoyment.
I am 50 and still having regular periods. In the 1960's my mother had a hysterectomy. Those years seemed to be the start of an epidemic of hysterectomies similar to tonsillectomies, which now are being thought to be often unecessary. Thanks!". z at aol
This is certainly a loaded question that gets to the multiple different effects that have been attributed to having a hysterectomy. The issue gets quite confused if the ovaries are removed at the same time as the hysterectomy because then you have a sudden menopause superimposed upon the surgery itself. I assume that the above question is directed at the independent effect of a hysterectomy and not that of both removal of the ovaries and the uterus before menopause. However, at age 50, it is likely that the surgery will also include removal of the ovaries and if you are not yet menopausal, this will add additional menopausal effects.
Popular Questions About The Uterus
Does the uterus secrete proteins or hormones independent of ovarian function?
The uterus secretes hormones and proteins but they are almost always in response to the cyclical hormonal changes from the ovaries or the prolonged high levels of hormones during pregnancy. Various prostaglandin hormones, cellular growth factors and other compounds are made in response to the changing hormones and the lining of the uterus (endometrium). After the ovaries are non functional such as with surgical or natural menopause, there are no hormones or proteins that are secreted into the body's blood stream that I am aware of. Certainly the muscle cells of the uterus secrete enough local substances that have to do with keeping the cells alive but those substances are pretty much confined locally and do not have any systemic effect.
With the above general comments about the lack of any general hormone secretion from the uterus after menopause already expressed, there are some notable exceptions. It is likely that the local effects of some of the uterine proteins are perceived under special circumstances after menopause. The main one I am aware of is in response to sexual stimulation and intercourse. The physiologic response of blood vessels swelling full of blood during sexual arousal is likely a systemic response of nerves going directly to the blood vessels and not from secretions of the uterus, however there are more blood vessels to become swollen if the uterus is still in place. The substances that cause uterine contractions during orgasm probably do come from the uterus even after menopause. If the uterus is removed, not only do the secreted substances fail to be produced but also their target organ, the muscles of the uterus are gone. Thus the feeling of light uterine cramps during orgasm is gone after hysterectomy.
Does the uterus contribute to sexual response or desire?
As described above, the uterus definitely plays a role in sexual response. It undergoes vascular congestion during arousal and then rapid drainage of the vascular congestion after orgasm (climax). Also there are rapid small amplitude contractions of the uterine muscle during orgasm as well as contractions of the vagina and urethral muscles. After hysterectomy those uterine contractions with orgasm disappear although some contractions are still present in the lower genital tract. Most women will report a difference in orgasm after hysterectomy but not necessarily less enjoyable. There is a current trend among some physicians and patients to perform or request a subtotal hysterectomy in which the main uterine muscle and lining are removed (body of uterus) while leaving the cervix. As you can imagine, it is very difficult to study whether the small amount of muscle in the cervix (it is mostly just connecting tissue and not as much muscle) preserves any degree of uterine contractions during orgasm. I would guess that the cervix alone would not contribute that much.
The genital changes that take place during a sexual response according to the Masters and Johnson classification are:
- Excitement phase - vaginal lubrication, vasocongestion, separation of the lips of the vaginal opening (labia majora), vaginal walls thicken, early uterine elevation, lengthening of the vagina
- Plateau phase - uterine elevation, clitoral elevation, vaginal expansion, maximum lubrication, outer third of vagina forms orgasmic platform
- Orgasm phase - uterine contractions, tenting effects of vagina, orgasm contractions
- Resolution phase - sexual flush disappears, changes go in reverse
As you can see, most of the same changes will take palce after hysterectomy as before hysterectomy except uterine elevation and uterine contractions and the vasocongestion that takes place in the pelvis above the vagina.
The problem with most of the scientific studies that have been done on the effect of hysterectomy on sexual response, is that the investigators often lumped together many situations which confuse whether or not a postoperative change is due to the removal of the uterus alone or due to other factors. For example it is well known that menopause itself reduces sexual desire and sexual response because of the loss of estrogen. Even if estrogen is replaced, it can be less than perfect at restoring preoperative sexual desired and response.
One study looked at body image and sexuality in three groups, a control group with no surgery, a hysterectomy group and women having removal of the ovaries with and without hormone replacement. They found NO differences in mood (measured by patient questions) or vaginal blood flow (measured by instruments) and a woman's subjective arousal to an erotic stimulus. They did however find that women who had had an oophorectomy and either had no estrogen replacement or estrogen replacement without testosterone had significantly lower self-reported desire and arousal than any of the remaining groups. This study and others imply that the main problem after hysterectomy is lack of desire (libido) if the ovaries are removed, but not the ability to undergo sexual arousal in response to an erotic stimulus. This may be able to be overcome by adequate testosterone replacement along with estrogen replacement. (See also testosterone article)
Another factor often forgotten in clinical studies is what was the degree of satisfaction with one's sexual partner and sexual desire prior to the surgery. An interesting Scandinavian study looked at 104 women having subtotal hysterectomies. Sexual desire, activity, satisfaction and dysfunction were compared between women without, with a poor, and with a good partner relationship prior to the surgery. They found an improved sexuality, one year post hysterectomy, in 61% of women with a good partner relationship, in 17% of those with a poor relationship but no improvement was seen in women who had no regular partner relationship. Therefore it is extremely important in your judging of medical data that purports to show either positive or negative change with hysterectomy, that the study took into account preoperative partner satisfaction. This study concluded that "women with no or with ambivalent partner relationships are more at risk for deterioration of sexuality after hysterectomy. "
Does the uterus help support the pelvic structures and its removal cause prolapse?
The uterus and top of the vagina are supported in the pelvis by several attachments to the strong tendons and ligaments of the pelvis bone. I do not know if the scientific names of these areas are important to you -- pubovesicocervical fascia, rectovaginal fascia, uterosacral ligaments and cardinal ligaments -- but the concept is important to grasp. All of these attachments are cut during hysterectomy and as long as they are reattached to the end of the vagina, prolapse should not occur very frequently. You would think that this is a very easy task surgically but those support ligaments are not visable most of the time. They are below a layer(s) of tissue and there may be breaks in those connections at invisible places other than their attachments to the uterus and vagina.
For example a common instance of prolapse occurs after hysterectomy for uterine fibroids. The uterus is enlarged and the size alone may support the uterus in the pelvis so that breaks in the ligaments are not appreciated before surgery. Then within 3-12 months after surgery, the vaginal vault and the bladder drop down. This causes many women to conclude that hysterectomy "causes" prolapse when in fact a better term would be that potential prolapse was being prevented by the enlarged uterus. This can happen to all surgeons such that even with appropriate surgical repair, the abdominal pressures shift from the repaired points to the weakest anatomical points in the lower pelvis. Thus different areas seem to "fall down" even after successfull surgical repair.
Are there a lot of unnecessary hysterectomies performed?
I'm sure there are many "unnecessary" hysterectomies performed. How many is unknown by anyone. Ever since the mid 1950's there has been criticism of doctors performing too many uterine removals. The rate of hysterectomy in the U.S. varies from geographical region to region but on the whole is about twice that of other industrialized countries. Therefore you would think there would be quite a few unnecessary procedures. The problem becomes the definition of "unnecessary". In whose eyes is a procedure deemed as "needed" versus "unnecessary". There seems to be disagreement about this. The only unnecessary hysterectomy is the one that I or you or someone else disagrees with!
For example in insurance programs requiring 2nd opinions, about 8% of hysterectomies are recommended as not needed at the time (6) In an interesting note, this study mentioned that in the Northeast region of the U.S., women whose second opinion thought the hysterectomy was unnecessary did not go on and have the procedure done. Whereas in the South and North Central regions, women chose to have the hysterectomy even though it was not recommended. This means that they thought it was in their best interest even though the 2nd physician did not. Even 8% unnecessary hysterectomies by that study does not explain the higher rate in the U.S.
I am sure there are doctors who tend to overuse hysterectomy especially for pain and abnormal bleeding problems. They see the procedure as the solution to a problem that may be difficult to manage. Many women look at these symptoms as a quality of life problem. In putting up with pain or bleeding, there can be a moderate amount of inconvenience in work, school or leisure activities. Hysterectomy may be looked at as the quick, long term medication-free answer. We live in an impatient world. On the doctor's part, there may be the perception without thoroughly discussing with the patient, that the woman is unlikely to tolerate the medical therapy, frequent office visits and sometimes minor biopsy procedures that would be needed for the condition complained about.
The best protection a woman has from an unnecessary hysterectomy is an informed education and consideration of all of the treatment options.
What can I expect after hysterectomy aside from the effects of whether the ovaries are functioning?
As best I can tell from both experience and the medical scientific literature, hysterectomy alone, without ovarian removal in the premenopausal woman, or with ovarian removal in the menopausal woman will result in:
- a change in sexual response during orgasm, but not an adverse change
- increased tiredness for several months after the hysterectomy
- in general a recovery time of almost 6 months be complete return to preoperative function.
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