Objective assessment of sexual arousal in women with a history of hysterectomy C.P. Maas a,1 , M.M. ter Kuile a , E. Laan b , C.C. Tuijnman a , Ph.Th.M. Weijenborg a , J.B. Trimbos a , G.G. Kenter a, * Objective The potential contribution of psychological and anatomical changes to sexual dysfunction following hysterectomy is not clear. Radical hysterectomy for cervical cancer causes surgical damage to the autonomic nerves which are responsible for the increased vaginal blood flow during sexual arousal. Simple hyster- ectomy causes more limited nerve disruption. Photoplethysmographic assessment of vaginal pulse amplitude objectively measures vaginal blood flow during sexual arousal. We hypothesised that damage of the autonomic nerves results in a disrupted vaginal blood flow response during sexual stimulation. Design Between-groups comparison of vaginal pulse amplitude. Setting University hospital. Sample Twelve women with a history of radical hysterectomy, 12 women with a history of simple abdominal hysterectomy and 17 age-matched controls. Methods Photoplethysmographic assessment of vaginal pulse amplitude during sexual stimulation by erotic films. Self-reported ratings of subjective sexual arousal were collected after each erotic stimulus condition. Main outcome measure Maximum vaginal pulse amplitude. Results Maximum vaginal pulse amplitude differed between the three groups (P ¼ 0.043). Women with a history of radical hysterectomy had a lower response than controls (P ¼ 0.015). Women in the radical hysterectomy group and controls reported an equally strong subjective arousal. Women with a history of simple hysterectomy showed an intermediate maximum vaginal pulse amplitude. Conclusions Radical hysterectomy seems associated with a disturbed vaginal blood flow response during sexual arousal. This cannot be explained solely by uteric extirpation, since it was not observed to the same extent after simple hysterectomy, but might be related to a denervation of the vagina which increases with increasing radicality of surgery. INTRODUCTION The traditional view of women’s sexual response and the nature of their sexual desire has been questioned recently, and alternatives have been suggested. 1 Being an emotion, sexual desire is a psychological entity, but it also has a biological basis and women expect their gynaecologists to accept their sexual difficulties as a legitimate women’s health issue and be prepared and able to address it. 1,2 Women with a history of radical hysterectomy for cervical cancer report a decrease in lubrication and genital swelling during sexual arousal, which compromises sexual activity and results in considerable distress. 3–5 It is thought that surgical damage to the pelvic autonomic nerves during radical hysterectomy disrupts the nerve supply to the blood vessels of the vaginal wall which is responsible for the neural control of the lubrication response. 5–8 Sexual dys- function after simple total abdominal hysterectomy for treatment of benign disease is milder, which could be explained by more limited nerve disruption due to a less radical surgical procedure. 8,9 However, in attempts to clarify the aetiology of female sexual dysfunction after hysterectomy, it has proven difficult to design clinical research protocols which adequately address the potential contribution of both psychological and anatomical changes. Psychophysiological assessment using photoplethysmo- graphic vaginal pulse amplitude 10 is reliable in assessing the increase in vaginal blood flow during sexual arousal. 11 This increased vaginal blood flow reflects a highly automa- tised genital response mechanism, occurring irrespectively of subjective appreciation of the sexual stimulus. 12,13 The genital physiological response is an involuntary reflex me- diated by the (unconscious) autonomic nervous system. 1,14 We tested the hypothesis that surgical damage of the pel- vic autonomic nerves during radical hysterectomy results BJOG: an International Journal of Obstetrics and Gynaecology May 2004, Vol. 111, pp. 456–462 D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology www.blackwellpublishing.com/bjog a Department of Gynaecology, Leiden University Medical Center, The Netherlands b Department of Clinical Psychology, University of Amsterdam, The Netherlands * Correspondence: Dr G. G. Kenter, Department of Gynaecology, K6p-76, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. 1 C. P. Maas was supported by the Dutch Cancer Society. DOI:10.1111/j.1471-0528.2004.00104.x