Dear Dr. Pat,

I am 50 years old, happily unmarried and childless. I have had human papilloma virus (HPV) for many years, with abnormal Pap smears and one cone biopsy that showed some mild cell changes several years ago. I had normal Pap smears for two years, and then I was posted abroad with my work in a non-governmental organization (NGO). I didn’t get back to my gynecologist for 18 months and then found that I had developed carcinoma in situ of the cervix. and have no choice but to have a hysterectomy. This diagnosis was made with a cone biopsy, and I had it reviewed by two other hospital pathology departments because I just could not believe it. I do smoke, haven’t always used condoms, and have had a lot of partners—more than 50. But this has really changed my mind about my careless behaviors. I have stopped smoking and right now the last thing I am interested in is a new sexual contact.

My gynecologist has a good reputation as a surgeon and has taken very good care of me for 20 years. She told me that I need a hysterectomy. She says that she can do this laparoscopically so that the healing time is much quicker and I won’t have a big scar on my stomach.

I have done some reading about sexual dysfunction after hysterectomies, and found reports of some doctors actually shortening the vagina, and how that can change the ability to achieve orgasm. Is there a nerve supply to the clitoris that’s disrupted with the removal of the uterus and the cervix, or is this just Internet chatter? What should I ask my surgeon to do to avoid unnecessary shortening of the vagina from a hysterectomy? More importantly, how do I know if HPV will show up in the vagina that’s left, along with the other genital tissue and the anus? (I have occasionally had anal sex.)

Thanks,

Linda

Dear Linda,

This is such an important question for many reasons. The past behaviors you describe—smoking, unprotected intercourse and many sexual partners—are the classic risks for cervical cancer.

In addition, you have acquired the very common HPV (human papilloma virus), which is now understood to be the cause of cervical, vaginal, vulvar, and some anal cancers.

The last issue that you describe is not having had Pap smears on a regular basis, even though you had been told that you were at high risk for developing these cancers.

I do believe that you understand you have an opportunity, even now, to be healthy and to find future abnormalities early. You will need colposcopy of the vulva, vagina, and anus on a regular basis. Find any abnormality early and it can be treated.

Your question may save another woman’s life. Thank you so much for writing to us.

I have asked Dr. Lauri Romanzi, a uro-gynecologist who specializes in pelvic floor and pelvic reconstructive surgeries, and Dr. Elizabeth Poynor, a gynecologic cancer surgeon, to answer your often-asked questions about the relationship between simple (not radical) hysterectomy and change in orgasmic function and sexual comfort. Their answers are below, and we can all learn from them.

Best,

Dr. Pat


From Lauri Romanzi, M.D., WVFC Medical Advisory Board Member:

Your concerns are valid ones, and the world of gynecologic oncology has been busy over the past five years, taking your concerns very seriously.

With regard to vaginal shortening, this is mandatory when surgery is done for frank cervical cancer, as the top third of the vagina is at high risk for metastatic spread of cervical cancer. If surgery is done for pre-cancerous carcinoma in situ (your diagnosis), the entire vaginal length may be preserved, whether the surgery is done vaginally, laparoscopically, or with an abdominal incision.

You may wish to consider vaginal hysterectomy, which is scar-free (all incisions inside the vagina), is least likely to damage the mechanics of the upper urinary tract, and allows a choice of anesthesia: regional (spinal or epidural) done with intravenous sedation, or full general anesthesia. With laparoscopic hysterectomy, general anesthesia is the only option. By all means, have a discussion with your gynecologist about your desire to preserve maximal vaginal length, the various methods of hysterectomy, and anesthesia options.

When conventional radical hysterectomy is done for frank cervix cancer (not carcinoma in situ), removal of lymph nodes to evaluate and prevent the spread of the disease is absolutely crucial. However, the deep roots of the pelvic nerves that control bladder, bowel, and sexual function may be affected, as they are located in the same area as these at-risk lymph nodes.

These nerves that function during orgasm start deep in the pelvis and work their way out onto the inner buttock and groin, sending sensory branches to the labia, clitoris, perineum, and anus. Without radical excision of lymph nodes, your nerves are, by definition, “spared.”

For less fortunate women in need of a radical cervical cancer hysterectomy. This is a truly amazing time! For several years now, new nerve-sparing techniques for cancer hysterectomy have been investigated, which may minimize impact on bladder, bowel, and sexual function. To quote a recent study that evaluated sexual arousal before and after radical hysterectomy for cervix cancer (link to study here): “Conventional laparoscopic radical hysterectomy is associated with an overall disturbed vaginal blood flow response compared with healthy controls. Because it is not observed to the same extent after nerve-sparing laparoscopic radical hysterectomy, it seems that the nerve-sparing technique leads to a better overall vaginal blood flow caused by less denervation of the vagina.”

Have a talk with your gynecologist about pelvic nerves, vaginal length, and sexual function, and your very important concern about monitoring the surrounding cancer-vulnerable tissues of the vagina, vulva, clitoris, and anus with in-office colposcopy, and HPV and Pap screening. I am certain your gynecologist will warmly receive your concerns during your peri-operative visits. Ask her the questions you’ve asked here. And don’t be shy about second-opinion evaluations. Finding a surgeon who shares your concerns and is willing to discuss them before surgery allows for better recuperation and management of complications that may occur even with the best of surgical techniques.


From Elizabeth Poynor, M.D., Co-chair of WVFC Medical Advisory Board:

The supra-cervical hysterectomy  is now being offered to women as an alternative to a total hysterectomy by many gynecologists. However, there is no information to support that this is a better operation for women. There are some instances, such as yours, when the cervix must be removed. In the past, before the use of the Pap smear, the cervix was always removed in order to prevent cervical cancer. Since the use of newer Pap smear technologies has made cervical pre-cancers easier to detect, the routine removal of the cervix has been called into question.

The cervix is always removed at the time of hysterectomy for cervical pre-cancers such as yours, and for cancers of the uterus, ovary and cervix, as well as for other conditions such as endometrial hyperplasias. Proponents of the supra-cervical hysterectomy argue that the advantages to leaving the cervix behind include possibly better sexual functioning, improved pelvic floor support, and less bladder prolapse after surgery, along with fewer surgical complications.

The study of sexual function in women is tremendously complex because of the many factors that influence sexual behavior in women. The thought that leaving the cervix behind results in better sexual functioning arises from the idea that the supra-cervical hysterectomy theoretically leads to the preservation of important nerves, and less vaginal scarring and shortening. However, these theoretical advantages have not been proven in rigorous scientific studies. In a large randomized trial from England, women who had a total hysterectomy had similar sexually functioning when compared to women who had retained their cervix. These results have been confirmed in a larger Danish study.

Proponents of the supra-cervical hysterectomy also argue that there is improved pelvic floor support and less urinary incontinence post-operatively. While this is an intuitive assumption, the scientific evidence does not support this view. Indeed, a number of studies have demonstrated that urinary incontinence is increased after supra-cervical hysterectomy, when compared to total hysterectomy. Prolapse of the cervical stump can also occur with the supra-cervical approach.

Fewer complications have been theorized to occur during a supra-cervical hysterectomy. Indeed, studies have demonstrated that there are shorter operating times, less blood loss, and a reduction in post-operative fevers with the supra-cervical approach. However, when the cervix must be removed for a pre-malignant or malignant condition, it is reasonable to accept these very slightly elevated surgical risks, as the benefit to removing the cervix outweighs the risk.

Whether you have your cervix left in or not, your sex life should be good if it was before your hysterectomy. If performed properly, a total hysterectomy should not in itself disrupt sexual functioning, if you have no sexual dysfunction or anatomical issues pre-operatively. A total hysterectomy does not in itself lead to an increased risk of vaginal and bladder prolapse. While a total hysterectomy may be a slightly longer operation, it can be performed safely with few complications if performed by a skilled gynecologic surgeon.