Assessment of sexual function following hysterectomy: A systematic review and meta-analysis

Background: Hysterectomy is among the most commonly performed major gynecological surgical procedures; however, its impact on sexual quality of life remains incompletely characterized. The use of heterogeneous instruments and outcome definitions has contributed to variability and inconsistency in reported findings.

Objective: To evaluate changes in sexual quality of life following hysterectomy and determine whether preservation of the cervix is associated with improved postoperative sexual function.

Methods: A systematic literature search was conducted in PubMed/MEDLINE, Web of Science, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception through February 2026. Reference lists of eligible studies were also screened. Studies reporting preoperative and postoperative sexual quality-of-life outcomes after hysterectomy were eligible. Studies using non-validated questionnaires, radical hysterectomy, or concomitant bilateral salpingo-oophorectomy were included in the qualitative synthesis but excluded from quantitative synthesis. Risk of bias was assessed using RoB 2 for randomized controlled trials and ROBINS-I for non-randomized studies. Random-effects meta-analyses and meta-regression were performed within a frequentist framework, accounting for repeated measurements; cluster-robust standard errors were applied, and certainty of evidence was assessed using GRADE.

Results: Seventeen studies comprising 2,483 patients were included in the quantitative synthesis, including four randomized controlled trials and thirteen observational studies. The Female Sexual Function Index was the most frequently reported outcome measure. No clinically or statistically significant improvement in postoperative sexual function was observed across total, subtotal, abdominal, laparoscopic, or vaginal hysterectomy. The pooled mean change in Female Sexual Function Index total score was 3.48 points after laparoscopic subtotal hysterectomy (95% confidence interval, -5.52 to 12.47; p=0.237), 0.1921 points after total laparoscopic hysterectomy with defined follow-up intervals (95% confidence interval, -1.3507 to 0.9665; p=0.57), 2.07 points after total abdominal hysterectomy without defined follow-up intervals (95% confidence interval, -1.50 to 5.64; p=0.21), and 0.99 points after vaginal hysterectomy (95% confidence interval, -5.54 to 7.52; p=0.71). Female Sexual Function Index total scores were consistent with sexual dysfunction at baseline and remained below the established cutoff of 26.55 during follow-up. Subtotal hysterectomy did not demonstrate a meaningful advantage over total hysterectomy.

Conclusion: Across hysterectomy types, postoperative changes in sexual function scores were small and did not reach statistical significance at the pooled level. No surgical route, including subtotal hysterectomy, demonstrated a consistent advantage over others. Preservation of the cervix does not confer a measurable benefit in sexual quality of life. Surgical approach selection should not be guided by expectations of improved sexual outcomes.