Obstetrics & Gynecology:
Sexual Function in Older Women After Oophorectomy
Erekson, Elisabeth A. MD, MPH; Martin, Deanna K. MPH; Zhu, Kejia BS; Ciarleglio, Maria M. PhD; Patel, Divya A. PhD; Guess, Marsha K. MD; Ratner, Elena S. MD
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, and the Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, Connecticut.
Dr. Patel is supported by a career development award from the National Cancer Institute (NCI) (K07 CA120040). Dr. Ratner is supported by a career development award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (K12 HD047018).
Corresponding author: Elisabeth A. Erekson, MD, MPH, Yale University School of Medicine, Section of Urogynecology and Reconstructive Pelvic Surgery, 333 Cedar Street, PO Box 208063, New Haven, CT 06519; e-mail: firstname.lastname@example.org.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To compare the sexual function of older women who had bilateral oophorectomy with that of older women who had retained their ovaries.
METHODS: This cross-sectional study involved analysis of 1,352 women aged 57 to 85 years from the National Social Life, Health, and Aging Project. Women with previous bilateral oophorectomy were compared with women who retained their ovaries. The primary outcome of interest was self-report of sexual ideation, chosen because having thoughts about sexual experiences is not prohibited by either a partner or a woman's own physical limitations.
RESULTS: Three hundred fifty-six (25.8%) women reported previous bilateral oophorectomy. Our analysis achieved 90% power to detect a difference of 10% in sexual ideation. No significant difference in the report of sexual ideation was found between women with previous bilateral oophorectomy and women who retained their ovaries (54.5% and 95% confidence interval [CI] 48.1–61.0 compared with 49.9% and 95% CI 45.3–54.5, P=.230), even after adjusting for current hormone therapy, age, education, and race (adjusted odds ratio 1.32, 95% CI 0.96–1.80).
CONCLUSION: Bilateral oophorectomy may not play a pivotal role in sexual ideation and function among older women.
LEVEL OF EVIDENCE: II
Hysterectomy is the most commonly performed gynecologic surgical procedure, with more than 600,000 hysterectomies performed annually in the United States.1,2 The majority of hysterectomies are performed for benign indications. This leaves the choice to undergo concomitant prophylactic bilateral oophorectomy at the time of hysterectomy between a woman and her surgeon. Currently, 25% to 55% of benign hysterectomies are performed with concomitant elective oophorectomy.3–5 Elective oophorectomy is offered to women to reduce the risk of future ovarian cancer and adnexal surgery. However, ovarian conservation has been demonstrated to increase overall life-expectancy and decrease coronary heart disease.6,7
Postmenopausal ovaries have been demonstrated to produce both testosterone and androstenedione that are peripherally converted to estrogens in adipose cells.8 Postmenopausal women maintain serum testosterone levels even two to three decades after menopause.9,10 In postmenopausal women, removal of the postmenopausal ovaries generally results in a 50% decline in circulating androgen levels.8,11,12 Serum androgens are believed to be important in the maintenance of libido and sexual function in postmenopausal women.13 However, the effect of elective oophorectomy on sexual function, including ideation, partnerships, activity, frequency, attitudes, and problems in older women, has not been well-studied. The primary objective of this study was to compare sexual ideation and function of older women who underwent bilateral oophorectomy with that of older women who had retained their ovaries.
MATERIALS AND METHODS
We performed a cross-section analysis of the 2005–2006 National Social Life, Health, and Aging Project dataset to examine the sexual function in older women.14–16 The National Social Life, Health, and Aging Project survey was conducted to investigate sexuality in a nationally representative probability sample of community-dwelling older adults in the United States aged 57 to 85 years old. Adults were targeted for possible participation in the National Social Life, Health, and Aging Project study from a previous population-based study.17 A unique aspect of the National Social Life, Health, and Aging Project is adequate representation via oversampling of previously understudied minority populations (black and Hispanic women) within the dataset.17 The overall survey response rate was 75.5%, with 3,322 adults participating in the National Social Life, Health, and Aging Project between July 2005 and March 2006. Information in the National Social Life, Health, and Aging Project was obtained from in-home interviews of trained professional interviewers in both English and Spanish using computer-assisted personal interview methods.18 Data were collected by the National Opinion Research Center through the University of Chicago and were maintained by the Institute for Social Research at the University of Michigan to ensure the quality of the dataset.18,19 The current study is a secondary database analysis focused solely on women without cancer with known oophorectomy status. Male participants (n=1,455, 43.8%) and women with a previous cancer diagnosis (n=198, 6%) were excluded from our analyses. This study was exempt from review by the Yale University Institutional Review Board because it involves research of an existing dataset from a public source.
The purpose of this study was to compare sexual function of older women who reported previous bilateral oophorectomy with that of older women who had retained their ovaries. Women reporting no previous oophorectomy or unilateral procedure were considered as women who retained their ovaries. The primary outcome of interest was self-report of sexual ideation at least once monthly. We chose sexual ideation as our primary outcome because having thoughts about sexual experiences should not be affected by either the woman's own physical limitations or the partner's issues (lack of partner or partner's physical limitations). Because sexual function is known to change with age, women were stratified into the age categories of 57–64 years, 65–74 years, and 75–85 years to obtain percentage estimates and 95% confidence intervals (CI).16–18 Finally, we examined the difference between women who underwent oophorectomy before self-reported menopause and women who underwent oophorectomy after menopause.
Secondary outcomes included current sexual partnerships, sexual frequency within the past 12 months, types of sexual activities, sexual attitudes, and sexual problems. A current partner was defined as the woman reporting being currently married, cohabitating, or having an intimate partner. Women reporting no current sexual partner were not asked questions about sexual frequency or types of sexual activity (except for masturbation). Sexual frequency included the participation in any sexual activity within the past 12 months. Sex was defined as “any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs.” Types of sexual activity reported including foreplay, vaginal coitus, receiving or performing oral sex, and masturbation. All women were asked questions about their own sexual attitudes, values, and beliefs. For women reporting a current sexual partner, women were asked about sexual problems, including interest, lubrication, anorgasmia, dyspareunia, and avoidance of sexual activity because of problems.
Statistical analyses, including descriptive and inferential statistics with percentage estimates and 95% CI, were performed as appropriate. The National Social Life, Health, and Aging Project dataset allowed data to be weighted to provide an estimate of population characteristics representative of community-dwelling older Americans aged 57 to 85 years. Not all women answered all questions. Survey weights were used to account for the differential probability of inclusion in the sample and differential probability of nonresponse in all the analyses. Percentage estimates and 95% CI were obtained to report weighted frequencies. Model fitting and variance estimates used in the construction of CI account for the stratified and clustered nature of the design to produce unbiased estimates of standard errors. Logistic regression analysis was used to assess the association between sexual ideation (primary outcome) and oophorectomy status, current hormone therapy, demographic characteristics, and clinical characteristics. Potential confounders were considered for inclusion in the final model based on their significance in univariable analysis (P≤.1). Significant confounders were included in the final adjusted model if they continued to affect the final model (P≤.05). Oophorectomy status and current systemic hormone therapy were included in the final model because these were our main independent variables of interest. Statistical analyses were performed using SAS 9.2. Assuming a prevalence of sexual ideation of 52.8% (based on Lindau et al20), our analysis achieved 90% power to detect a difference of 10% in sexual ideation with a significance level (α) of 0.05 (two-sided).
In total, 1,352 women were included in this analysis: 356 (25.8%) women who reported previous bilateral oophorectomy and 996 (74.2%) women who had retained their ovaries. No women were missing data on oophorectomy status.
Demographics and clinical characteristics were similar between the two groups, although women with a previous bilateral oophorectomy were more likely to report current hormone therapy (59.1%, 95% CI 52.9–65.3) and more likely to report previous hysterectomy (97.0%, 95% CI 94.9–99.2) compared with women who retained their ovaries (current hormone therapy: 47.2%, 95% CI 43.7–50.6; previous hysterectomy: 23.3%, 95% CI 20.0–26.5) (Table 1). Mean age (68.7±0.5 compared with 68.0±0.3, P=.17) and self-reported health (very good or excellent: 41.6% compared with 46.2%, P=.70) were similar between women with previous bilateral oophorectomy and women who had retained their ovaries. Among women with previous bilateral oophorectomy, 75.4% (95% CI 69.4–81.4) had their ovaries removed before menopause.
Our primary outcome of interest was self-report of sexual ideation at least once monthly. No differences were observed between women with previous bilateral oophorectomy and women who had retained their ovaries (54.5% and 95% CI 48.1–61.0 compared with 49.9% and 95% CI 45.3–54.5, P=.23) (Table 2). Women who retained their ovaries did not demonstrate significantly increased odds of sexual ideation compared with women with previous bilateral oophorectomy (adjusted odds ratio 1.32, 95% CI 0.96–1.80) after adjusting for current systemic hormone therapy (estrogen or progesterone) age group, education, and race (Table 3). Age group, education, and race were found to be significant in univariable analysis (P<.1) and to affect the final logistic regression model (P<.05). On univariable analysis, hysterectomy status, menopausal status at the time of oophorectomy, and years since oophorectomy did not affect the model (P>.1) and were not included in the final logistic regression model. Sexual ideation varied by age, with decreasing sexual ideation reported by increasing age group, with 64.4% (95% CI 58.3–70.6%) of women aged 57–64 years, 48.3% (95% CI 43.2–53.5%) of women aged 65–74 years, and 32.3% (95% CI 26.8–37.8%) of women aged 75–85 years reporting sexual ideation.(Table 4) Pair-wise comparisons demonstrated a significant difference between women aged 65–74 years compared with women 57–64 years (P<.001) and women aged 75–85 years compared with women 57 to 64 years (P<.001) (Table 4).
No differences were observed in the number of women reporting a current partner between women with previous bilateral oophorectomy and women who had retained their ovaries (59.6% and 95% CI 53.8–65.3 compared with 63.6% and 95% CI 60.3–66.9, P=.22). The prevalence of a current partner again decreased with increasing age category.
No differences were observed in the percentage of women reporting sexual activity in the past 12 months between women with previous bilateral oophorectomy and women who had retained their ovaries (42.2% and 95% CI 34.2–50.2 compared with 44.5% and 95% CI 40.8–48.3, P=.61). Further comparisons of sexual frequency of once monthly or less, two–three times per month, and 1–2 times per week or more did not demonstrate a statistically significant difference (P=.18) (Table 2).
Among all women with current sexual partners, women who reported previous bilateral oophorectomy were more likely to report vaginal intercourse (90.1% and 95% CI 84.7–95.5 compared with 82.3% and 95% CI 78.2–86.5, P=.04) compared with women who had retained their ovaries; however, foreplay (90.2% and 95% CI 85.4–94.9 compared with 87.3% and 95% CI 83.4–91.3, P=.35), receiving oral sex (8.3% and 95% CI 1.0–15.5 compared with 9.7% and 95% CI 6.5–12.8, P=.74), performing oral sex (11.6% and 95% CI 3.3–20.0 compared with 11.2% and 95% CI 6.1–16.2, P=.90) were similar.
Women with previous bilateral oophorectomy were significantly more likely than women with retained ovaries to find a “married person having sex with someone other than partner” to be “always wrong” (P=.002), “always wrong even if partner has dementia” (P=.02), and “always wrong even if partner is physically ill” (P=.003). Otherwise, no significant differences were observed between the two groups in other sexual attitudes and beliefs, including religious beliefs guiding sexual behavior (P=.30) and sex being essential to maintain a relationship (P=.94).
Report of sexual problems were similar between women with previous bilateral oophorectomy compared with women with retained ovaries, including lack of interest (P=.88), vaginal lubrication (P=.90), premature climax (P=.94), inability to climax (P=.09), pain with intercourse (P=.60), lack of pleasure (P=.14), performance anxiety (P=.50), and avoidance of sex because of problems (P=.86).
Among women with previous bilateral oophorectomy, 75.4% (95% CI 69.4–81.4) had their ovaries removed before menopause. There was no significant difference in sexual ideation between women undergoing premenopausal oophorectomy and postmenopausal oophorectomy (57.5% and 95% CI 50.0–64.7 compared with 49.1% and 95% CI 35.8–62.5%, P=.12). There were no significant differences in the report of sexual problems between women undergoing premenopausal compared with postmenopausal oophorectomy, including lack of interest (P=.97), vaginal lubrication (P=.45), inability to climax (P=.84), pain with intercourse (P=.23), lack of pleasure (P=.21), and avoidance of sex because of problems (P=.26).
We found sexual ideation and function were similar among community-dwelling older women with previous bilateral oophorectomy compared with women who had retained their ovaries. Lindau et al16 previously reported on the sexual activity, frequency, attitudes, and problems of both women and men from this project. Their report shows that sexual function decreases with increasing age. However, hormonal status was not considered in their work.
One reported drawback of prophylactic oophorectomy women is decreased sexual function and hypoactive sexual desire disorder.21–24 In one small prospective study conducted in Turkey, sexual function scores were found to significantly decrease in postmenopausal women 6 months after hysterectomy with bilateral oophorectomy when compared with preoperative scores.22 The short length of this study and a lack of a control group of women with retained ovaries limit our knowledge of how oophorectomy affects sexual function in postmenopausal women in the long-term. Finch et al21 reported that premenopausal women with BRCA mutations undergoing prophylactic oophorectomy report a decrease in sexual functioning compared with postmenopausal women with BRCA mutations undergoing the same procedure; however, this study was limited to follow-up of 1 year after surgery. Finally, Leiblum et al23 reported hypoactive sexual desire disorder was more common among women younger than age 50 years who were surgically menopausal compared with their intact counterparts; however, no difference was seen in sexual desire in women older than age 50 years who had undergone surgical menopause. Although evidence suggests that premenopausal bilateral oophorectomy has a negative effect on sexual function, our findings and those of Leiblum et al23 suggest the effect diminishes with increasing time from menopause. It is possible that the effects of bilateral oophorectomy on sexual function decrease as women age; therefore, age, rather than oophorectomy, is the main contributor to sexual dysfunction in older women.
Limitations of our study include the self-report of oophorectomy. However, because women with one or more retained ovary may have mistakenly reported bilateral oophorectomy, and women mistakenly reporting to have intact ovaries may have undergone bilateral procedure, we believe misclassification would be nondifferential. Our study is also limited by its cross-sectional design. Women were not asked about sexual function before and after oophorectomy; therefore, causality cannot be determined. However, our findings suggest that oophorectomy status is not associated with a permanent and lasting effect on sexual function in older women. Our study is limited by being a secondary database analysis. Further information on certain variables was not collected. Specifically, we only have information on sexual ideation at least once monthly. No information about the monthly frequency of sexual ideation was available. Finally, this study discusses a sensitive topic and is limited by participant nonresponse to certain questions. As reported by Lindau et al,16 overall 2% to7% of respondents declined to answer questions about sexual activity and 14% declined to answer questions about masturbation. To account for nonresponse, weights were used to adjust for the bias of differential nonresponse. Our study is also strengthened by the large sample size representative of the community-dwelling older women in the United States and detailed information on numerous aspects of sexual function in this older population, enhancing the study's external validity. In brief, our findings suggest that elective oophorectomy may not play a long-term pivotal role in the sexual ideation and function of older women.
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© 2012 The American College of Obstetricians and Gynecologists
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