Health: But what about my orgasms?: It is a question that women should put to consultants who advise them to undergo a total hysterectomy. Barbara Baker is glad she asked

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I DIDN'T know I had fibroids until I went to a health farm and the masseuse felt a lump in my abdomen. I went to my GP for a check- up and as soon as an ultrasound scan confirmed his diagnosis, I was referred to a consultant. 'You need a hysterectomy,' he said. 'But I'm only 40,' I replied. 'And anyway, I haven't got any symptoms. Isn't it a bit drastic?'

But he insisted it was for the best and said that while he was at it, he might as well whip out my cervix (the neck of the womb) and ovaries, as well as the womb. 'Save you getting cancer later on, dear,' he explained.

My immediate concern was not that I would feel less of a woman, or would have to spend a week in hospital and take a month or more off work, but that the operation would affect my sexual pleasure.

What specifically worried me was that the quality of my orgasms would be affected. Much of the pleasure I get during orgasm is from deep contractions that feel as if they are occurring in the womb and cervix. Common sense told me that if the womb and cervix were removed, orgasm would, at the very least, feel different and perhaps much less intense.

Trying to discuss this with the consultant and find out the facts proved a challenge. He looked at me as though I were from another planet and proceded to lecture me about the female orgasm being clitoris-based. He virtually told me I was talking rubbish. Surely, I thought, I'm not the only woman to have asked this question.

Reading up on female orgasm only confirmed my fears. Orgasm is defined by most sex researchers as a series of intensely pleasurable muscular contractions lasting 10 to 20 seconds. Although normally associated with the muscles of the vaginal walls, in some women the cervix, womb and pubic muscles can also contract rhythmically, causing involuntary pelvic spasms. According to some experts in human sexuality, some women even experience contractions of the anal sphincter.

Although direct or indirect stimulation of the clitoris is usually necessary for a woman to reach orgasm, my consultant's comment about orgasms being clitoris-based was incorrect.

The cervix has been identified by many researchers as a source of sexual pleasure. In the Fifties, the Kinsey Report found the cervix 'has been identified by some of our subjects . . . as an area which must be stimulated by the penetrating male organ before they can achieve full and complete satisfaction in orgasm'. And Vicky Hufnagel, an American doctor, says that an 'internally induced orgasm occurs when the penis presses hard and repetitively against the cervix, causing movements of the uterus and its broad supporting ligaments . . . which has great and pleasurable sensitivity'.

For many women, the uterus is also important to sexual response. In 1981, Dr Leon Zussman, writing in the American Journal of Obstetrics and Gynecology, said that while women who achieve orgasm mainly through clitoral stimulation will find that hysterectomy has little effect, for some women, 'the quality of the orgasm is related to the movement of the cervix and uterus. . . . The intensity of the orgasm is thus diminished when these structures are removed.' There is evidence that women experience one or both types of orgasm, sometimes blended together, he said.

Dr Hufnagel adds that many women are not satisified with clitoral stimulation and achieve an orgasmic response with stimulation of the vaginal walls. 'In these cases, the lack of a uterus and/or the shortening of the vaginal vault after hysterectomy would result in . . . sexual dysfunction.'

I was amazed to discover there are no British studies on this subject. One carried out in Finland in 1981 compared sex lives of women who had had total hysterectomy with women who had had a partial hysterectomy (where the cervix is left intact). It found that one year after the operation, women in the first group experienced significantly fewer orgasms.

In 1982, a Japanese study of a group of hysterectomy patients found that 27 per cent experienced diminished uterine sensation during sex and as many as 70 per cent had problems reaching orgasm at all.

Mr Ray Garry, consultant gynaecologist at South Cleveland Hospital, Middlesbrough, agrees that removal of the cervix may cause a woman to miss out on sexual pleasure. He hopes to set up the first research in Britain to look into the subject. 'We were all taught to do a total hysterectomy, which involves removing the cervix, as well as the womb,' he says. 'Before cervical screening was available, this was good practice because it prevented cancer forming later on. But now we need to think again. Is it really necessary to remove perfectly healthy organs?'

Was he surprised that more women did not ask the questions I had put to my own consultant? 'The problem is that it's not the sort of thing most consultants would deal with in a busy clinic,' Mr Garry says.

Mr Adam Magos, consultant gynaecologist at the Royal Free Hospital in Hampstead, north London, agrees: 'The problem is that we are so busy operating that we see only patients once post-operatively, three months afterwards - and that's probably too soon for women to have made a judgement about orgasm anyway.'

Mr Magos is conducting a trial that will compare the experience of women who have had a hysterectomy with those who have had a relatively new and less drastic operation - transcervical resection of the endometrium (TCRE). One question will concern loss of sexual pleasure. The survey will take about 18 months to complete.

Many surgeons routinely tell women that their sex lives will improve after hysterectomy. What they fail to add is that this is usually because the operation eradicates symptoms such as heavy bleeding, which often put a woman off sex anyway. Once the bleeding stops, many women do feel sexier.

But because my fibroids were not causing me problems, I felt my fears were valid. I did not want to risk ruining my sexual pleasure for no good reason.

In the end, I shopped around for a more sympathetic consultant and avoided a hysterectomy by opting for less drastic surgery. I had a TCRE for the smaller fibroids and a laparoscopic myomectomy to remove the larger ones: this involved inserting a laparoscope, a special viewing instrument, into my abdomen and removing the fibroids by laser. Instead of a drastic vertical cut across my abdomen, I was left with three tiny scars and was back home within three days. I felt fine within a week; the operations proved successful and they have not affected the quality of my orgasms. Although I had these operations on the NHS, they are still not widely available.

But I cannot help wondering why, given that 70,000 women have hysterectomies every year, this subject is not more widely discussed. Presumably some of these women were orgasmic beforehand. Are they enjoying sex as much as they used to?

Perhaps they don't care. One experienced gynaecologist, who recently started asking her patients about this, says that most of them look at her as if she is mad. 'The fact is, a lot of the women I come across are not really bothered about sex,' she says.

If a hysterectomy is performed to save a life - if a woman has cancer, for example - then, understandably, sex is likely to be a secondary consideration. But is everyone else willing to relinquish their sexual pleasure without so much as a murmur?

Shouldn't we be demanding to know why most surgeons still routinely remove the cervix during hysterectomy? Likewise, is it still necessary to insist on a hysterectomy where a less invasive operation might be more appropriate?

A LAYWOMAN'S GUIDE TO DIFFERENT TYPES OF SURGERY

Sub-total: removal of the womb only. This is now rarely performed in Britain.

Total: removal of both the womb and cervix, or neck of the womb.

Total with bilateral or unilateral oophorectomy: removal of womb, cervix, one or both ovaries and fallopian tubes.

Wertheim's: removal of womb, cervix, fallopian tubes, ovaries, upper part of vagina, ligaments and lymph glands. Rarely done.

Alternatives to hysterectomy have been developed but are not yet widely available. Nor are they suitable for everyone. They include trans-cervical resection of the endometrium (TCRE): suitable for women who have abnormal bleeding or small fibroids. An instrument called a resectoscope is inserted vaginally and cuts away the endometrium, the lining of the womb. Can be done under local anaesthetic.

Laparoscopic myomectomy: removal of fibroids in the womb using a laparoscope, a type of viewing instrument. Sometimes performed with lasers, laparascopic scissors, or high-frequency electric currents.

Endometrial laser ablation: this procedure is suitable for small fibroids. A small telescope is inserted through the cervix into the womb and a laser is used to remove the womb lining.

If you have any views on the subject of orgasm after hysterectomy, please write to Barbara Baker, PO Box 22, Totnes, Devon TQ9 5XF.

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