The Postmenopausal Ovary and Sexual Function
Abstract & Commentary
By Jeffrey T. Jensen, MD, MPH , Leon Speroff, Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, is Editor for OB/GYN Clinical Alert.
Synopsis: A history of bilateral oophorectomy was not associated with a decrease in self-reported sexual ideation or function among postmenopausal women.
Source: Erekson EA, et al. Sexual function in older women after oophorectomy. Obstet Gynecol 2012;120:833-842.
Although the incidence of hysterectomy has declined in recent years, it remains the most common major gynecologic procedure, and many women are offered or consider elective bilateral oophorectomy (BSO) at the time of hysterectomy to reduce ovarian cancer risk. Since postmenopausal ovaries continue to produce testosterone, and oophorectomy is associated with a decline in circulating androgen levels, many clinicians and patients question whether oophorectomy is associated with a reduction in libido and waning of sexual function. To address the hypothesis that BSO results in a decline in sexual function, the authors analyzed data from the 2005-2006 National Social Life, Health, and Aging Project, a cross-sectional and nationally representative probability sample of community-dwelling older adults in the United States aged 57-85 years old. The overall survey response rate was 75.5%, and this subanalysis of sexual function involved 1352 women. Women self-reporting no previous oophorectomy or a unilateral procedure were considered as having retained their ovaries. The primary outcome of interest was self-report of sexual ideation at least once monthly; this outcome was selected because having thoughts about sexual experiences should not be affected by either the woman's own physical limitations or the partner's issues. Secondary outcomes included sexual behaviors and frequency. Because sexual function is known to change with age, responses were stratified into three age categories (57-64 years, 65-74 years, and 75-85 years), and comparisons were adjusted for known confounders such as current hormone therapy, age, education, and race. The sample size provided 90% power to detect a difference of 10% in sexual ideation.
A total of 356 (25.8%) women reported previous BSO. Overall, there was no significant difference in the report of sexual ideation found between women who retained their ovaries (54.5%, 95% confidence interval [CI] 48.1-61.0) compared with women with previous BSO (49.9%, 95% CI 45.3-54.5, adjusted odds ratio 1.32, 95% CI 0.96-1.80). There also were no differences observed in the percentage of women reporting sexual activity in the past 12 months (42.2% BSO, 44.5% retained, P = 0.61) or in sexual frequency. Among all women with current sexual partners, women who reported previous BSO were more likely to report vaginal intercourse (90% compared with 82%). These data support a conclusion that BSO does not play a pivotal role in sexual ideation and function among older women.
Commentary
Although alternatives to hysterectomy have reduced the number of operations performed for benign indications, recent estimates from hospital discharge data support that more than 600,000 hysterectomies are performed each year. The decision to perform a BSO at the time of benign surgery is common among women who have completed childbearing. A recent study from Belgium found that the physician's recommendation to perform an elective BSO at the time of a hysterectomy for a benign condition is strongly influenced by the patients' age and that 83% of women over age 51 underwent the procedure at the time of hysterectomy.1 The primary concern for most of these clinicians and patients is that the non-reproductive ovary might later develop into ovarian cancer, and that oophorectomy can prevent this. A strong argument to avoid oophorectomy in premenopausal women is that compliance with estrogen replacement therapy is low, and that the premature "surgical" onset of menopause has adverse long-term health effects.2
But what about the postmenopausal ovary? These ovaries no longer produce estradiol, but are a major source of androgens (testosterone and androstenedione). Although these steroids are capable of aromatization to estrogens in peripheral tissue, the amount is insignificant in most women. This leaves us to consider whether ovarian androgens themselves have a central role in the maintenance of health, including normal sexual function in postmenopausal women. The issue is clouded by the high baseline prevalence of sexual problems in mature women (and men), the complexity of diagnoses (e.g., arousal, desire, or combination), and inconclusive clinical data linking testosterone replacement with benefit.3
The study by Erekson and colleagues uses a population approach to address the question of oophorectomy. The authors selected the correct outcome of sexual ideation as a close proxy to sexual desire, one sexual domain that may be influenced by androgens. They found that BSO was not associated with a difference in sexual ideation or in reported sexual activity. This finding contributes to past research showing that serum androgen levels are not correlated with more favorable sexual outcomes in women. Their data are robust in that the sample was nationally representative. The absence of any effect of oophorectomy across any of the three age strata support that declining ovarian androgen production with age did not account for this lack of difference. In other words, ovarian androgen production alone does not explain differences in sexual behavior in this large group.
This study provides valuable information to clinicians counseling women regarding the pros and cons of elective oophorectomy during benign gynecologic surgery at or after menopause. It also provides guidance when we see women presenting with sexual complaints years after surgery. Since sexual concerns are common among women of all ages, this history should be solicited during routine wellness visits. But one needs to be prepared when a concern about sexual function emerges. In general, a referral to a competent sexual therapist will provide more benefit than testosterone replacement.
References
- Plusquin C, et al. Determinants of the decision to perform prophylactic oophorectomy in association with a hysterectomy for a benign condition. Maturitas 2012;73:164-166.
- Speroff T, et al. A risk-benefit analysis of elective bilateral oophorectomy: Effect of changes in compliance with estrogen therapy on outcome. Am J Obstet Gynecol1991;164(1 Pt 1):165-174.
- Simon JA. Identifying and treating sexual dysfunction in postmenopausal women: The role of estrogen. J Women's Health 2011;20:1453-1465.
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