Diabetes The majority of studies clearly identified a strong link between sexual dysfunction and comorbid depression but not with diabetic controls, duration of diabetes, or its complications. Data are limited in quality given that many studies do not clarify estrogen status, different assessments of sexual function are used, and many publications study only the women who do not remain sexually active—those who simply do not have a partner or may have discontinued activity as a result of severe dysfunction (69). Prevalence of low sexual desire is found to be similar in women with and without diabetes, whereas difficulties with lubrication are approximately two times more common in women with diabetes. Some but not all studies show increased prevalence of dyspareunia, orgasmic difficulties, and sexual dissatisfaction (70). A large study involving women enrolled in the long-term Epidemiology of Diabetes Interventions and Complications (EDIC) study neither compared patients with control women nor inquired about dysfunction in those who were not sexually active. Nevertheless, dysfunction was present in 35% of the active women with low desire, and more than half had problems with orgasm arousal and lubrication. In multivariate analysis, only depression and marital status predicted sexual dysfunction (69).
Simple Hysterectomy Despite speculation that there might be different sexual outcomes depending on whether hysterectomy was vaginal, subtotal, or total abdominal, this difference is not supported by study (71,72). In a large prospective observational study of 413 women undergoing three different types of hysterectomy (vaginal, supracervical, and total abdominal hysterectomy), sexual pleasure improved in most women, independent of the type of hysterectomy (72). The prevalence of one or more bothersome sexual problems 6 months after vaginal, supracervical, and total abdominal hysterectomy was 43%, 41%, and 39%, respectively. The results of another prospective trial of 158 women randomized to total abdominal hysterectomy and 161 to supracervical abdominal hysterectomy showed no difference in sexual outcomes (71). A retrospective study of 108 women undergoing classic intrafascial supracervical hysterectomy and 125 undergoing total hysterectomy did not find any sexual benefits of classic intrafascial supracervical hysterectomy over total hysterectomy (73). There was no difference between groups in time from surgery to first intercourse, change in libido, sexual frequency, or frequency or degree of orgasm. Overall, two-thirds of the women in the study experienced either no change or an improvement in sexual function, regardless of which procedure was performed. Both this study and a study comparing total laparoscopic hysterectomy with laparoscopically assisted vaginal hysterectomy found similar effects on sexual function (74).
Radical Hysterectomy Techniques were developed to avoid the portions of the inferior hypogastric plexus in the cardinal and broad ligaments, and preliminary studies suggest minimal reduction of vaginal congestion in response to sexual stimulation in a laboratory setting (75). Only one of two small clinical studies confirmed preservation of sexual function (76,77).
Cancer of the Cervix Sexual symptoms encountered in women with cancer of the cervix include reduced vaginal lubrication secondary to surgical menopause, radiation damage, and/or interruption of the autonomic nerves. A study conducted in Croatia showed the importance of fear of dyspareunia. Of 210 women treated with combinations of surgery, radiation, and chemotherapy, 50% reported a marked fear of pain. Only six patients identified actual dyspareunia and only three patients found penetration impossible (78).