at the American College of
Obstetricians and Gynecologists 2000 meeting.
Winnifred B. Cutlera,
Ph.D., Norma L. McCoyb,
Ph.D., Millicent G. Zacherc
M.Ed.,D.O., F.A.C.O.G., Elizabeth Genovesed
M.D., and Erika Friedmanne
Ph.D.
View Complete
list of Dr. Cutler's published works
May, 2000. The
American College of Obstetricians and Gynecologists (ACOG) held its 48th
Annual Clinical Meeting (ACM) in San Francisco, CA.,at the Moscone Convention
Center. The meeting began Monday, May 22 and ran through Wednesday, May 24.
ACOG is a national medical organization which represents over 40,000
obstetricians and gynecologists throughout the United States. ACOG’s ACM is
one of the largest gatherings of women’s health care practitioners, drawing
thousands of physicians, experts, poster exhibitors, researchers, and
guests.
ABSTRACT
Objective: This research
examined the sexual activity, frequency, and orgasmic experience in: a)
132 women with an intact uterus undergoing assessment in the Athena
Institute's women's wellness program; b) 37 other patients with uterine
fibroid tumors; and c) 23 women from the wellness program who had had a
hysterectomy.
We compared these data to recently published data
on sexuality for women before hysterectomy1
and for women from the wellness program who had had a
hysterectomy.
Methods: Consecutive patients undergoing
comprehensive executive physical exams were offered perineometry tests
of pubococcygeal muscle strength and endurance and asked to complete
extensive questionnaires on genitourinary experience of incontinence and
sexual response including coital and orgasmic frequency. Women using
either oral contraceptives or Prozac were excluded from our final data
analysis because of recent studies showing sexual response deficiencies
in these groups2,3.
Informed consent was obtained to use their data. An unaffiliated
gynecologist provided the same questionnaires to the 37 patients with
fibroid tumors who mailed them to Athena
Institute.
Results: Confirming prior reports, clitoral and
vaginal sites were commonly recognized as sites contributing to orgasm.
A third site--the cervix---was reported by a substantial minority of
women. Both study groups showed similar responses. Cervical stimulation
was recognized as making a contribution to orgasm by 46% of the wellness
program women and 70% of the fibroid patients. Vaginal stimulation was
recognized in 86% and 91% respectively. Clitoral stimulation was
reported in 98% and 97%.
Although pelvic muscle strength and
endurance had previously been shown to be inversely related to
incontinence4
neither was related to these sexual findings. Parity also was an
independent factor; multiparous women were more sexually responsive than
primiparas or nulliparas.
Women who were scheduled for
hysterectomy showed both a statistically and clinically significant
reduction in sexual activity and orgasm compared to other
women.
Conclusions: Most women reported that clitoral
stimulation evoked their orgasms; many women also recognized that
vaginal stimulation would; fewer also perceived that cervical
stimulation could contribute to their orgasm.
More women with
fibroid tumors reported being sexually responsive than intact well women
at the vaginal and cervical sites.
Probably, hysterectomy
negatively impacts sexuality. We found intact well women more sexually
active and orgasmic than women scheduled for surgical removal of the
uterus. Recent studies1,5
using the preop period as a baseline have employed a distorted i.e.,
suppressed prehysterectomy measure of sexuality; those studies
incorrectly compared posthysterectomy sexuality at 2 years to support an
invalid conclusion that hysterectomy "improves" a woman's
sexuality.
Multiple child bearing appeared to improve perceived
sexual responsiveness at vaginal and cervical
sites.
We compared these data to recently published data on sexuality for women before hysterectomy1 and for women from the wellness program who had had a hysterectomy.
Methods: Consecutive patients undergoing comprehensive executive physical exams were offered perineometry tests of pubococcygeal muscle strength and endurance and asked to complete extensive questionnaires on genitourinary experience of incontinence and sexual response including coital and orgasmic frequency. Women using either oral contraceptives or Prozac were excluded from our final data analysis because of recent studies showing sexual response deficiencies in these groups2,3. Informed consent was obtained to use their data. An unaffiliated gynecologist provided the same questionnaires to the 37 patients with fibroid tumors who mailed them to Athena Institute.
Results: Confirming prior reports, clitoral and vaginal sites were commonly recognized as sites contributing to orgasm. A third site--the cervix---was reported by a substantial minority of women. Both study groups showed similar responses. Cervical stimulation was recognized as making a contribution to orgasm by 46% of the wellness program women and 70% of the fibroid patients. Vaginal stimulation was recognized in 86% and 91% respectively. Clitoral stimulation was reported in 98% and 97%.
Although pelvic muscle strength and endurance had previously been shown to be inversely related to incontinence4 neither was related to these sexual findings. Parity also was an independent factor; multiparous women were more sexually responsive than primiparas or nulliparas.
Women who were scheduled for hysterectomy showed both a statistically and clinically significant reduction in sexual activity and orgasm compared to other women.
Conclusions: Most women reported that clitoral stimulation evoked their orgasms; many women also recognized that vaginal stimulation would; fewer also perceived that cervical stimulation could contribute to their orgasm.
More women with fibroid tumors reported being sexually responsive than intact well women at the vaginal and cervical sites.
Probably, hysterectomy negatively impacts sexuality. We found intact well women more sexually active and orgasmic than women scheduled for surgical removal of the uterus. Recent studies1,5 using the preop period as a baseline have employed a distorted i.e., suppressed prehysterectomy measure of sexuality; those studies incorrectly compared posthysterectomy sexuality at 2 years to support an invalid conclusion that hysterectomy "improves" a woman's sexuality.
Multiple child bearing appeared to improve perceived sexual responsiveness at vaginal and cervical sites.
Figure 1: The Athena Institute questionnaire on
Orgasm
How
often during sexual intercourse do you reach orgasm ?
-------
-------
-------
-------
-------
never
rarely
occasionally
frequently
always
Please indicate
which of the following forms of stimulation enable you to reach
orgasm. (check all that apply)
____ clitoral stimulation
alone
____ vaginal stimulation alone
____ cervical tapping
(penis tapping at base of uterus) alone
____ clitoral and vaginal
stimulation
____ clitoral stimulation and cervical tapping
____
vaginal stimulation and cervical tapping
____ all these types of
stimulation
Please indicate how often each type of stimulation
contributes to orgasm
clitoral stimulation
-------
-------
-------
-------
-------
never
rarely
occasionally
frequently
always
vaginal
stimulation
-------
-------
-------
-------
-------
never
rarely
occasionally
frequently
always
cervical
tapping
-------
-------
-------
-------
-------
never
rarely
occasionally
frequently
always
Date of
Birth:_________________;
Figure 2: Age distribution of the Intact Wellness, Intact Uterus with Fibroid Group, and Post Hysterectomy Wellness Patients
Mean ages for 132 intact women (M = 47.0, SD = 7.1), 37 women
with fibroids (M = 48.3, SD = 6.4), and 23 women who had had a
hysterectomy (M = 48.7, SD= 7.2) were not significantly different (F
< 1)
Background
Sexual stimulation
of the clitoris is well established as a trigger for orgasm for most women.
Vaginal stimulation also has been reported to trigger orgasmic inevitability
if the rhythm and pressure are individualized6.
Work
in rats has established a significant role of cervical stimulation in
triggering hypothalamic-pituitary neural pathways that trigger GNRH release.
Work in spinal-injured women with intact uteri has demonstrated that cervical
and vaginal stimulation applied differentially triggered disparate orgasmic
perceptions in these women7.
Recent
studies of women immediately before, and up to 2 years after, their
hysterectomy have concluded that the increase in several measures of sexual
behavior that they reported provide evidence that hysterectomy improves the
sexual life of women1,5.
Unfortunately, this seemingly welcome conclusion could be marred by a faulty
choice of baseline for comparison to the postoperative era, and the omission
of a comparison group of intact women.
We arrayed the most widely cited
pre and post hysterectomy data1 and compared them to our samples of well
women, and women with fibroid tumors. Our Tables 1, 2, and 3 demonstrate that
presurgery sexual life is depressed in comparison with all other groups
studied. Hence, the studies purporting to describe a posthysterectomy
improvement in sex life are crippled by their defective choice in baseline. If
questions are asked about her recent sexual behavior, AFTER a woman has agreed
to be scheduled for a hysterectomy, one can expect to learn she is not very
sexual just before genital surgery.
Influences of parity were
previously suggested for sexual arousal and orgasm8.
The anatomical and physiological changes of pregnancy and parturition, and the
related variations in sexual arousal were initially described by Masters and
Johnson. Therefore, it was relevant to search for an influence of parity on
the measures of sexual arousal being reported here.
Fibroid tumors had
not previously been studied for their relationship to sexual response.
However, the earlier reports8
of the role of uterine engorgement on sexual arousal and orgasm imply a
potential enhancement of sexual response in women with fibroid
tumors.
Results
Table 1: Proportion of Women Reporting They Are Sexually Active
Group
Total Number
Sexually Active
1. Intact
Uterus
Athena
121
78%
2. Intact Uterus with
Fibroids
Smith
36
78%
3. Post Hysterectomy .5-20
yrs
Athena
23
83%
4. Post Hysterectomy @ 2
yrs
Rhodes et al.
1101
77%
5. Scheduled for
Hysterectomy
Rhodes et al.
1101
70%
Athena
Smith
Athena
Rhodes et al.
Rhodes et al.
A significantly lower proportion of women are sexually active before their hysterectomy than two years later1.
Table 2: Proportion of Women Reporting Frequent Sexual Activity
Group
Total Number
Sexual Activity
>
5 Times/Month
1. Intact
Uterus
Athena81
58%
2. Intact Uterus with
Fibroids
Smith30
57%
3. Post Hysterectomy .5-20
yrs
Athena22
45%
4. Post Hysterectomy @ 2
yrs
Rhodes et al.1101
41%
5. Scheduled for
Hysterectomy
Rhodes et al.1101
31%
Comparison of women
reporting frequent sexual activity was tested for Groups 1,2,3,and 5.
X2(3,N = 1234) = 33.87, p <. 005.
Because Groups 4 and
5 are the same women, they are not independent, and therefore group 4 was
excluded from comparisons.
A significantly
lower proportion of women are FREQUENTLY sexually active before their
hysterectomy than themselves two years later1,
or than women with fibroid tumors (X2(3,N = 1234) = 9.0, p
< .025) or women with an intact uterus X2(3,N = 1234) =
25.5, p < .0005.
Table 3: Proportion of Women Reporting Frequent Orgasm
Group
Total Number
Frequent Orgasm
1. Intact Uterus
Athena
118
61%
2. Intact Uterus with Fibroids
Smith
34
58%
3. Post Hysterectomy .5-20 yrs
Athena
21
61%
4. Post Hysterectomy @ 2 yrs.
Rhodes et al
1095
55%
5. Scheduled for Hysterectomy
Rhodes et al.
1095
46%
Athena
Smith
Athena
Rhodes et al
Rhodes et al.
Comparison of women
reporting frequent orgasm was tested for Groups 1,2,3,and 5.
X2(3,N = 1268) = 13.76, p < .005.
A significantly
lower proportion of women are frequently orgasmic before their hysterectomy
than intact well women (X2(3,N = 1268) = 10.19, p < .01)
or than themselves two years after hysterectomy1.
Table 4: How Often
Each Type of Stimulation Contributes to Orgasm
among Intact Well
Women
Clitoral Stimulation
Vaginal Stimulation
Cervical Tapping
Almost Always or Always
82%
39%
17%
Rare or Occasionally
16%
47%
29%
Never
02%
14%
54%
Number who provided an answer
110
109
106
Clitoral stimulation is the most commonly perceived form of stimulation contributing to orgasm, vaginal stimulation the next most common, and cervical tapping the least common.
Table 5: Frequent Contribution to Orgasm by Site
Hysterectomy appears to compromise
sexual sensitivity at both the vaginal and cervical sites. Comparison of the
frequency of women reporting that vaginal stimulation frequently contributed
to orgasm revealed differences among the three groups of
patients.
Group
Clitoral Stimulation
Vaginal Stimulation
Cervical Tapping
Intact Uterus
Athena82% (of 110)
39% (of 109)
17% (of 106)
Intact Uterus with Fibroids
Smith74% (of 35)
48% (of 33)
33% (of 30)
Post Hysterectomy .5-20 yrs
Athena86% (of 21)
19% (of 21)
10% (of 20)
Women with fibroid tumors appear to experience a heightened
vaginal sensitivity. X2(2,N = 163) = 4.08, p <
.07.
Similar analysis for cervical sensitivity also revealed a
significant difference X2(2,N = 156) = 5.29, p <
.05.
Table 6A: Recognition of a Contribution to Orgasm by Site in Relationship to Parity among Intact Well Women
Percentage of women
who recognize that during their coital activities this form of stimulation
contributes to orgasm.
Group
Clitoral Stimulation
Vaginal Stimulation
Cervical Tapping
Multiparous
96% (of 59)
75% (of 58)
43% (of 58)
Primiparous
92% (of 13)
46% (of 13)
15% (of 13)
Nulliparous
93% (of 32)
50% (of 32)
30% (of 30)
Comparison of the frequency of women reporting
that vaginal stimulation contributed to orgasm revealed differences among
the three groups of patients (for vaginal sensitivity,
X2(2,N = 103) = 8.04, p < .001.
Similar analysis
for cervical sensitivity also revealed a trend toward a significant
difference X2(2,N = 101) = 4.15, p <
.07.
Multiparous women appear to be more sensitive to vaginal and
cervical stimulation than primiparous and nulliparous women.
Table 6B: Frequent Contribution to Orgasm by Site in Relationship to Parity among Intact Well Women
Percentage of women
who record that coital stimulation frequently contributes to their orgasm at
specified anatomical site. Comparison of the frequency of women reporting
that cervical tapping stimulation frequently contributed to orgasm revealed
differences among the three groups of women.
Group
Clitoral Stimulation
Vaginal Stimulation
Cervical Tapping
Multiparous
84% (of 59)
44% (of 58)
24% (of 58)
Primiparous
84% (of 13)
30% (of 13 )
0% (of 13)
Nulliparous
78% (of 32)
34% (of 32)
10% (of 30)
Significantly more
multiparous women experienced frequent orgasms from cervical tapping than
nulliparous or primiparous X2(2,N = 101) = 5.80, p <
.05.
Conclusions:
1) These data suggest a hierarchy of sites for sexual response. Most women recognize that clitoral stimulation evokes orgasm. Many of these recognize vaginal stimulation, with a smaller proportion recognizing cervical stimulation.
2) Women with fibroid tumors are more sexually responsive, at the vaginal site and appear more sexually responsive at the cervical site, than intact well women.
3) Hysterectomy can be expected to impact sexuality. Contrary to previous assertions, our data contradict the conclusion that hysterectomy enhances the sexuality of women. The sexual lives of women who have been scheduled to undergo a hysterectomy were depressed compared with intact women; and according to Rhodes, et al., themselves posthysterectomy. Our data indicated that intact well women were more sexually active and more sexually responsive than women scheduled for hysterectomy.
Thus, we conclude that the data collected in the last 30 days before hysterectomy cannot provide a valid measure of prehysterectomy sexuality. The data from several recent studies1,5 that compared post-hysterectomy sexuality to that period immediately preceding surgery are not valid indicators of the effects of hysterectomy on sexuality.
4) The event of multiple child bearing appears to enhance the ability to respond sexually.
REFERENCES
1. Rhodes
JC, Kjerulff KH, Langenberg PW, Guzinski GM (1999) Hysterectomy and sexual
functioning. JAMA 282:1934-1941
2. McCoy NL and Matyas JR (1996) Oral
contraceptives and sexuality in university women. ArchSexBehav
25:73-90.
3. PROZAC (fluoxetine HCL) prescribing information by
Dista/Eli Lilly, pp. 859-863, PHYSICIANS DESK REFERENCE 52nd Ed (1998),
Medical Economics Company, Inc. Montvale, NJ 07645.
4. Cutler WB,
Friedmann E, Genovese-Stone E, and Felmet K (1992) Urinary stress
incontinence: a pervasive problem among well women. J Wmns Health Vol
1:259-266.
5. Carlson KJ, Miller BA, Fowler FJ (1994) The Maine Women's
Health Study: I. Outcomes of hysterectomy. Obstet Gynecol 83:556-65.
6.
Alzate H (1985) Vaginal eroticism: a replication study. ArchSexBehav
14:529-537. and for example, Alzate H (1985) Vaginal eroticism and female
orgasm: a current appraisal Journal of Sex and Marital Therapy
11:271-284.
7. Komisaruk B, Whipple B (1986) Vaginal stimulation -
produced analgesia in rats and women. Annals NY Acad. Sciences 467:30-39. and
Komisaruk BR, Gerdes C, Whipple B (1997) Complete spinal cord injury does not
block perceptual responses to genital self stimulation in women. Archives of
Neurology 54:1513-1520.
8. Master WH and Johnson VE (1966) Human Sexual
Response Little, Brown, Boston
AUTHORS’ AFFILIATIONS
a. President
and Founder, Athena Institute for Women's Wellness,
www.AthenaInstitute.com
b. Professor of Psychology, San Francisco State
University, SFO, CA
c. Director, Div of Reproductive Endocrinology,
Albert Einstein Medical Center, Phila. PA
d. Medical Director, IMX,
Bala Cynwyd, PA
e. Professor of Biology, Chair, Dept Health and
Nutrition Sciences, Brooklyn College, Brooklyn, NY
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