African Woman Sexuality: Assessment after Hysterectomy for Uterine Benign Disorders Based on Two Scales; PISQ 12/DFSI

Background: Several authors are studying sexual activity of hysterectomies women. However, the review of literature reveals few data in sub-Saharan Africa on the psychological and sexual impact of this treatment option. Objective: To assess sexual activity and sexual satisfaction of women after hysterectomy for benign disorders. Methods: Single center analytical study based on patient opinion. It was conducted in a five-year period: from January 2012 to December 2016 at the Yopougon teaching Hospital. 53 patients who answered two questionnaires, on sexuality by Pelvic organ prolapse-urinary Incontinence Sexual Questionnaire (PISQ-12) and sexual satisfaction by Derogatis Sexual Functioning Inventory (DSFI). Results: Hysterectomy accounted for 15.9% of gynecological surgical activities. Hysterectomy for benign pathology accounted for 3.3% of hysterectomies. The average age was 47.6 years old. The indications were dominated by uterine fibroid (88.68%). Hysterectomy was performed by the abdominal route in 86.79% of cases. Sexual activity was resumed in the second trimester post-operative in 69.81%. After hysterectomy, dyspareunia was reduced (p < 0.05), orgasm was more intense (p < 0.05) with a greater sexual satisfaction (p < 0.05). Conclusion: This study shows that there is no significant difference for women’s sexuality before and after hysterectomy.

uterus diseases, because of the role of this organ in procreation. Thus, hysterectomy may have sexual impact [1] [2].
In recent decades, the functions of the uterus and cervix remain controversial in sexual and orgasmic function. Master andJohnson in 1966, andCrepault in 1989 described two orgasms: clitoral and vaginal with uterine movements. For others, orgasm involves the pelvic floor and the anterior wall of the vagina [3] [4].
More recently, it would be a complex neuro-psycho-physiological process that activates the autonomic nervous system involving an anatomo-functional entity connecting the vagina, clitoris, urethra and anus [5] [6]. Sometimes, female reproductive system refers to psychic suffering that hysterectomy can destabilize, requiring prevention efforts [7] [8]. With correct indication, hysterectomy improves quality of life and sexuality, and does not alter erotic function [9].
Hysterectomy is a frequent surgical procedure (70,000 per year in France for 20 years, second gynecological intervention throughout the world) mainly for benign pathologies. Laparotomy accounted 40% despite simpler follow-up and less complications for the other pathways: vaginal (39%), pure laparoscopies (10%) [2] [10] [11]. Assessment of women sexuality with hysterectomies has been the subject of numerous studies. Negative consequences directly related to hysterectomy have not been identified, regardless of the pathway or the surgical technique used [8] [12] [13].
In sub-Saharan Africa, hysterectomy is also performed but its impact on the quality of women's sexual life remains poorly documented. We therefore decided to initiate this study to assess the psychosexual impact of hysterectomy.
More specifically, to determine the epidemiological profile of patients, specify different types and indications of hysterectomy and sexual behavior of women before and after hysterectomy.

Study Design
This is a single center analytical study based on patient opinion. The opinion on their sexuality was made by phone call mainly. It concerned patient who underwent hysterectomy in a period of five years: from January 2012 to December 2016 in the gynecology-obstetrics department of the Yopougon; Teaching Hospital (Abidjan-Côte d'Ivoire). The sexuality 6 months before and 6 months after the hysterectomy had been assessed.
We used 2 judgments criteria: sexuality (sexual behavior) and sexual satisfaction. Each of these criteria was assessed through two randomized questionnaires.
-For sexual behaviour, we have chosen the validated questionnaire PISQ-12 (Pelvic organ prolapse-urinary Incontinence Sexual Questionnaire, 12 questions) which is a short version of PISQ-31. The French version of PISQ-12 is a measurement tool of sexuality, validated linguistically in French, specifically developed for women with genital prolapse and/or urinary incontinence. PISQ-12 assesses the impact of certain symptoms on sexual satisfaction and Open Journal of Obstetrics and Gynecology includes 12 items rated from 0 (never) to 4 (always) [14]. An average, then comparison for item had been done. Higher score meaning depends of each item, it can be better or worse.
-For sexual satisfaction, we have chosen the DSFI questionnaire "Derogatis Sexual Functioning Inventory". The DSFI is a sexual behavior assessment questionnaire of 254 items, divided into 10 groups. One of the groups (section X) of the DSFI allows the evaluation of sexual satisfaction with 10 items (1 point per response according to the adapted correction grid [15]. DSFI is often used in studies on effects of treatments and has been subjected to several psychometric tests [16]. There was ten items and an average one ten for each group before and after hysterectomy was made. Higher score means better sexuality.
Sources of information used to complete the survey forms were: Survey of patients by telephone interview, or physical meeting sometimes or if need be, the register of operating report, hospitalization register of the gynecology unit, patient record. Other parameters studied were socio-demographic characteristics, antecedents, indications and type of hysterectomy.
The research protocol had been submitted for consideration, comment, guidance and approval to a research ethics committee (doctors, professors) before the study begins.

Population
Premenopausal women who underwent a hysterectomy for benign disorders of the uterus were recruited those who had undergone a hysterectomy for benign uterine disease, without an adnexectomy, regardless of the pathway and having resumed sexual activity was included. Women who have undergone hysterectomy for benign uterine diseases without sexual activity, patients with endometriosis, all other causes of hysterectomy and other diseases that may impact the sexual life have not been selected ( Figure 1).

Analysis and Statistic Tests
A preliminary descriptive study has been carried out. During this one, the distribution of each studied parameter was described. Subsequently, an analytical study during which we studied the variations of each item of questionnaires before and after hysterectomy was performed. We used the t-Student test, Fisher's exact test and Pearson's Chi2 for the comparison of the variability with a threshold of significance of 5%. Data processing and analysis was done using the Stata 13 software.

Results
Mean age was 45.68 + −3.47 36 -50. Socio-demographic and clinical aspect were reported in Table 1. Dyspareunia was lower (p = 0.0044) and orgasm was more intense after hysterectomy (p = 0.0044). Comparison of sexuality before and after surgery has been reported in Table 2 and Table 3.  However, sexual satisfaction did not vary after hysterectomy (p = 0.3878).
Most patients returned to sexual activity in the second trimester, 69.81% (n = 37). Delay in resuming intercourse was also not significantly associated with the surgical pathway (p = 0.6823). Table 2 presented analysis of sexuality. Open Journal of Obstetrics and Gynecology

Indications, Surgical Pathway and Type of Hysterectomy
Uterine fibroid was the most common indication with a frequency of 88.69%.  [20].
Laparotomy is the most commonly used pathway for uterine fibroids. Melis et al. [21] reported a frequency of 58.4% vaginal route for uteri weighing on average 249.4 g (range: 93 and 1149 g), 37.6% vaginal and laparoscopic route for uteri weighing an average of 348 g, and finally 4% of abdominal pathway for uteri weighing an average of 586.2 g [21]. In a previous study of uterine fibroid surgery in Côte D'Ivoire in 2013, Koffi [22] found that 85% of uteri from hysterectomy had a size greater than 16 cm, hence the predominance of laparotomy as a pathway the most frequent [22].

Sexual Activities
Disorders Gynecological provides various effects on the quality of woman life, including sexual life. Female sexuality doesn't only concern sexual activity, but also the perception of its own image of itself and the relationship with others.
Gynecological disorders can have an impact on sexual function: women can avoid intercourse because of dyspareunia caused by prolapse, urinary incontinence, bleeding disorders or recurrent urinary tract infections [20] [23].
Questions about sexuality remain very little discussed in the preoperative interview. Bradford observes that 35% of patients talk about it before surgery. The results of a preliminary study indicate that preoperative sexual counseling can positively influence sexual satisfaction after hysterectomy. When negative sexual outcomes are reported, the impact of adverse sexual side effects may be lessened after surgery. We noted that main of patients experienced sexual desire at least once a week, despite the uterine pathology with excitement during sexual activities and a normal orgasm during intercourse. 60.38% of the patients never felt pain during sex before surgery, but after the surgery, there was an improvement in the ratio of the patient without pain. Hysterectomy improved sexual function with regression of pelvic pain and dyspareunia [2] [23] [24]. Before surgery, pain, fibroid-related bleeding are the common causes of disruption of sexual function. Only 52.83% of patients had an orgasm as intense as in the past. The information and the sensitization before surgery would certainly have improved the sexual pleasure. Open Journal of Obstetrics and Gynecology Regarding the time to resume intercourse, most patients resumed sexual activity in the second trimester (69.81%) and earlier for the vaginal route. Gueye in Sénégal [18] reported a higher proportion of women who returned to sexual activity in the first trimester and those who underwent vaginal hysterectomy regained sexual activity faster [25] [26] [27]. In the Sahana G study [28], resumption of sexual activity was shorter after vaginal hysterectomy (45 days) than after abdominal hysterectomy (62 days) [28]. The absence of abdominal scar, the short period of convalescence and resumption of professional activities, would be the reasons. In addition, other patients reported that this issue of sexuality was more discussed during preoperative counseling when the vaginal route was the option chosen.
In our study, concerning the main criteria (sexuality and sexual satisfaction), there is no statistically significant difference before and after hysterectomy. For the secondary criteria we find a significant reduction of the pain and a significant improvement of the orgasm after the hysterectomy (p < 0.05). Mokate's review of the literature in 2006 [25] did not find any difference for the feeling of sexuality according to operative techniques. They looked at the influence of the pathway (abdominal, vaginal and laparoscopic) or the type of hysterectomy [29].
In 2015, in France, Gé [13] concluded improvement of sexual function after hysterectomy. Despite the lack of evidence of the interest of cervix preservation in the literature, his study seemed to show an improvement on some of the criteria for the evaluation of sexuality in the subtotal hysterectomy group, especially on orgasm. For some authors, there is no advantage in retaining the cervix for sexuality, and they recommend considering the patients' preference for operative choice because of their psychological impact [12]. Uterus is it a sexual organ? Thakar [26] thinks that women can be positively reassured that hysterectomy does not negatively affect sexuality. Health professionals need to know that a minority of women may develop adverse effects after the operation [26]. Preoperative education about potential negative sexual outcomes after surgery can improve the satisfaction of hysterectomy, regardless of whether negative sexual outcomes are known. Preoperative deterioration of desire and intercourse has no correlation with sexuality after surgery [19] [26].
Regarding the surgical pathway, according to Sahana Gupta [28], deterioration of sexual function occurred more frequently after abdominal route (24%) than after vaginal route (13.5%) or laparoscopic route (8.5%). All agree on the positive impact of vaginal and laparoscopic hysterectomy on women's sexuality as that of abdominal hysterectomy. It has been difficult to compare our pathways first because they remain dominated by laparotomy; frequent practice of the vaginal route may allow for more in-depth studies in our context.
Overall, sexuality after hysterectomy remained unchanged in more than half of cases and respectively improved or decreased by 21.3% and 18.3% [25] [26] [29]. Helstrom [30] estimates that best indicators of sexuality after surgery were pre-surgical frequency of intercourse, excitement cycle, frequency of desire, and K. Abdoul et al. Open Journal of Obstetrics and Gynecology frequency of orgasm. Multiplicity of orgasm, cycle of desire and attitude towards sexual partner are also related to postoperative sexuality [29] [30] [31]. Fernandes [10] after review of literature in 2014 summarizes in these terms: sexual functioning improves overall after a hysterectomy. Frequency of sexual activity increases and problems of sexual functioning decrease [10] [30] [31].

Conclusion
At the African woman, as somewhere else in the world (Europe, Asia, America) results on the primary endpoint reveal that there is no significant difference for women's sexuality before and after hysterectomy. Regarding secondary endpoints, we significantly noted a regression of pain and an improvement in the intensity of orgasm after hysterectomy. The information and the sensitization about hysterectomy and sexuality before surgery would certainly have more improved the sexual pleasure.

Conflicts of Interest
The authors declare that they do not have any conflicts of interest.