Oophorectomy substantially impairs sexuality.[36] Substantially more women who had both an oophorectomy and a hysterectomy reported libido loss, difficulty with sexual arousal, and vaginal dryness than those who had a less invasive procedure (either hysterectomy alone or an alternative procedure), and hormone replacement therapy was not found to improve these symptoms.[37] In addition, testosterone levels in women are associated with a greater sense of sexual desire, and oophorectomy greatly reduces testosterone levels.[38] However, at least one study has shown that psychological factors, such as relationship satisfaction, are still the best predictor of sexual activity following oophorectomy.[39] Sexual intercourse remains possible after oophorectomy and coitus can continue. Reconstructive surgery remains an option for women who have experienced benign and malignant conditions.[40] :1020–1348