Depression and hysterectomy: a prospective study

Sexuality and The Midlife Woman

Both physical and psychological factors affect the sexual interest and behavior of women at midlife. Hot flashes and genitourinary atrophy are the major menopausal complaints and may affect the ease and comfort of sexual exchange, although hormone replacement therapy can be helpful in reducing these symptoms. Changes in the sexual response cycle occur as well and may be attributable to the psychological and/or physical effects of aging, the partner's physical or psychological difficulties and/or the hormonal changes associated with the climacteric. Many women note a decline in sexual desire during the climacteric years, although orgasmic response is usually unimpaired. Hysterectomy, the second most commonly performed major surgical operation, can either enhance or diminish sexual comfort, depending on the women's preoperative distress and expectations. Often, sexual difficulties can be avoided at midlife by alterations in the sexual script.

Is the Uterus a Sexual Organ? Sexual Function Following Hysterectomy

INTRODUCTION

Hysterectomy has been a mainstay of gynecologic therapy for 100 years. It can be postulated that hysterectomy could affect female sexual function due to psychological factors, and also due to disruption of the local nerve and blood supply and the intimate anatomical relationships of the pelvic organs.

AIM

To evaluate the effects of hysterectomy performed for benign conditions on female sexual function.

METHODS

Peer-reviewed publications were identified through a PubMed search using the search terms "hysterectomy," "benign," "sexual function," "dyspareunia," "orgasm," "libido," and "dysfunction." The search was completed through to February 2015 and was limited to articles published in English.

MAIN OUTCOME MEASURE

The main outcome measure was sexual function after hysterectomy for benign conditions. As hysterectomy is performed via various routes, abdominal (open and laparoscopic) and vaginal, sexual function in each group was evaluated.

RESULTS

Studies were of varying methodology. Majority of women demonstrated either unchanged or improved sexual function after hysterectomy performed by any route in the short term. A significant minority of women reported sexual dysfunction following hysterectomy. Deterioration in sexual function was found on long-term follow-up, which is probably an effect of aging and bilateral salpingo-oophorectomy. There were no proven benefits supracervical compared with total hysterectomy either in the short term (up to 2 years postsurgery) or long term (up to 15 years after hysterectomy).

CONCLUSIONS

Women can be positively reassured that hysterectomy does not negatively affect sexuality. Health professions should be aware that a minority of women may develop adverse effects after the operation. Preoperative education about the potential negative sexual outcomes after surgery may enhance satisfaction with hysterectomy, independent of whether negative sexual outcomes are experienced. Thakar R. Is the uterus a sexual organ? Sexual function following hysterectomy.

La fonction érotique après hystérectomie

OBJECTIVE

This paper examines the evidence about the impact of hysterectomy on one aspect of quality of life, sexuality.

PATIENTS AND METHODS

A systematic review of the French and English language literature was conducted using the search terms "sexuality", "hysterectomy", "libido", and "orgasm".

RESULTS

Twenty-one studies were found, ten prospective and 11 retrospective. Outcome measures were mostly postoperative libido and orgasm. Most studies did not consider important confounding factors. The majority of authors found either no change or an enhancement of sexuality in women who had an hysterectomy.

DISCUSSION AND CONCLUSION

The majority of research evaluating the effect of hysterectomy on sexuality was poorly designed. The available evidence shows that hysterectomy did not adversely affect sexuality. A number of confounding factors should be taken into account in future studies. The role of the gynecologist in the preparation to this kind of operations is very important.

Understanding pre- and post-hysterectomy levels of negative affect: a stress moderation model approach

Before and after hysterectomy, 60 women completed self-report questionnaires. Measures of personality (NEO-Five Factor Inventory, NEO-FFI), coping (Coping Inventory for Stressful Situations, CISS), and procedure appraisal were completed pre-operatively. Measures of depression and anxiety were completed pre- and post-operatively. Pre-op, 34% of women reported depression at clinical levels, and 29% reported clinical anxiety. The prevalence of depression fell to 8% 3-months post-op although clinical levels of anxiety persisted post-op in 22% of women. Regression analyses revealed that the principal risk factors for post-op negative affect were pre-op levels of depression and concerns about hysterectomy outcome. In assessing proposed models of post-hysterectomy outcome, structural equational modelling revealed the key position of neuroticism and extraversion, which were both directly and indirectly related to pre- and post-operative depression and anxiety. The mediating variables in this model included coping dispositions and procedure appraisal. It is concluded that the variables contained within stress moderation models provide a useful framework for understanding the processes that may lead to elevated levels of negative affect both before and after hysterectomy. Such an approach may prove beneficial for other surgical-outcome studies.

Psychological distress of conservative and nonconservative uterine surgery: a prospective study

OBJECTIVE

The aim of the present study is to evaluate the psychological reaction to conization before and after the operation compared to hysterectomy. To study the incidence of psychological stress related to conization, 60 women undergoing conization were compared to 40 women who had undergone hysterectomy.

METHOD

Psychological disease was rated in the pre- and postoperative periods using the Symptom Questionnaire (SQ). Each patient was evaluated 2 weeks before the operation, and 3, 6 and 12 months after it.

RESULTS

Both the conization and hysterectomy groups showed a significant reduction in anxiety and depression at the 3-, 6- and 12-month follow-ups compared to the preoperative period. Two weeks before surgery, 8 conization patients (19.5%) showed an anxious status, while 10 (24.3%) presented high levels of anxiety and depression. Within hysterectomy patients, the occurrence was respectively of 4 (12.9%) and 10 women (32.2%). Twelve months after surgery, of the women with preoperative depression, only four (9.7%) conization and four (12.9%) hysterectomy patients presented a negative mood status. A similar trend was present for somatic symptoms but only in the conization group, because the hysterectomy patients did not show a reduction in these symptoms from the preoperative to the postoperative period. This result could be related to the surgical menopause due to the bilateral oophoriectomy executed in more than half of the hysterectomy group.

CONCLUSION

In general, the results of the present study show that the conservative and nonconservative uterine surgery determines a good psychological prognosis in the short- and long-term postoperative periods.

V. Uterine fibroid embolization: management of complications

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

Symptom experience in women after hysterectomy

OBJECTIVE

To review the literature addressing the symptom experience of women after hysterectomy.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as texts and references cited in articles. Key concepts in the searches included hysterectomy, sleep disturbance and pain, hysterectomy and fatigue, hysterectomy, depression, and depressed mood.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1970, with an emphasis on new findings from 1990 to 2000. Sixty-four citations were identified as useful to this review.

DATA EXTRACTION

Data were organized under the following headings: women and hysterectomy, biopsychosocial perspectives, common symptoms after hysterectomy (pain, disturbed sleep, fatigue, depressed mood, anxiety), and significance of review (implications).

DATA SYNTHESIS

Literature suggests that after a hysterectomy, women experience complications during the postoperative recovery period that may vary with the type of surgical procedure. During this period, the quantity and quality of sleep as well as other symptoms (pain, fatigue, anxiety, and depression) are influenced by various physiologic, psychologic, and social factors. Despite limited evidence that sleep problems may occur frequently during the recovery period, only a few researchers have systematically examined sleep patterns in women after hysterectomy. None of these studies, however, used objective sleep measures or examined multiple dimensions of these women's lives.

CONCLUSIONS

This review conceptualized the women's symptom experience as the experience of specific symptoms (pain, sleep disturbance, fatigue, depressed mood, and anxiety) that were influenced by biopsychosocial factors.

The psychological outcome of hysterectomy

The objective of this study is to review the published literature on psychological outcome of hysterectomy and oophorectomy for non-malignant indications. The relevant publications over the past 30 years until the end of 1997 were identified by a MEDLINE computer search. This was followed by hand searches of the relevant references in the literature identified by the electronic search. The published studies on the psychological outcome of hysterectomy have been selected to identify the incidence, possible causes and risk factors of psychological morbidity, and the measures that can be adopted to improve the outcome. The study showed that the majority of retrospective studies reported an adverse psychological outcome after hysterectomy. However, all prospective studies showed that the incidence of depressed mood is higher even before hysterectomy, owing to pre-existing psychiatric illness and personality and psychosocial problems, as a result of the emotional response to gynecological symptoms or as a manifestation of associated ovarian failure. Hence, the therapeutic effects of hysterectomy include improvement of mood in some but not all patients, unless proper case selection, psychiatric evaluation and preoperative counselling are arranged. An early detection of ovarian failure after hysterectomy, the initiation of hormone replacement therapy (HRT) immediately after surgery in perimenopausal women and in those undergoing oophorectomy, as well as regular follow-ups to ensure long-term compliance with HRT, would also improve the psychological outcome. In conclusion hysterectomy itself is not the cause of any adverse psychological outcome. Psychological symptoms actually improve in the majority of women, with the relief of distressing gynecological symptoms and the correction of ovarian hormone deficiency, but hysterectomy may not be of any benefit in women with prior psychiatric illness and those with personality and psychosocial problems.

Hysterectomy: what do women need and want to know?

OBJECTIVE

The purpose of this article is to describe women's experiences of hysterectomy and to identify their fears, concerns, and met as well as unmet health care needs.

DESIGN

Narrative data of women's hysterectomy experiences were collected via a written survey.

SETTING

Data were collected from women living in southeastern Wisconsin.

PARTICIPANTS

Participants were 102 women who had undergone hysterectomy within the previous 2 years. The mean age of the women was 43 and mean time since hysterectomy was 13 months. Eighty percent of the women had undergone both hysterectomy and oophorectomy, and 78% were taking hormone replacement therapy.

MAIN OUTCOME MEASURES

A questionnaire of women's hysterectomy needs and a demographic questionnaire were used to collect data via mail. The data from three open-ended questions were content analyzed.

RESULTS

Seven themes about women's experiences of hysterectomy were identified: (a) positive aspects, (b) hormone replacement therapy, (c) insufficient information, (d) changes in sexual feelings and functioning, (e) emotional support, (f) psychologic sequelae, and (g) feelings of loss.

CONCLUSIONS

Women wanted treatment choices, a part in decision-making, accurate and useful information at an appropriate time, provider support, and access to professional and lay support systems. The essentials for hysterectomy care are outlined and include the characteristics of care that women desire, the informational content that women want, health care systems that support patient satisfaction, and the outcomes women want.

Complications of hysterectomy

Hysterectomy is a popular operation that has a number of complications associated with it. The most common are hemorrhage, infection, and injuries to adjacent organs. Unintended major surgical procedures and second operations occur in approximately 4% of patients undergoing hysterectomy. Laparoscopic hysterectomy is a controversial new procedure that has both advocates and detractors. In skilled hands, the complication rate of laparoscopic hysterectomy does not exceed that of traditional hysterectomy methods. At the present time, there is a growing consensus that removal of the uterus only does not lead to an increase in psychosexual morbidity. It also appears that hysterectomy procedures have little, if any, effect on lower urinary tract function.

A prospective study of changes in negative mood states of women undergoing surgical hysterectomy: the relationship to cognitive predisposition and familial support

Levels of anxiety and depression were documented by questionnaire response from a sample of 89 women who were to undergo surgical hysterectomy 3 weeks later. Fifty-four per cent (n = 48) of the sample reported anxiety and 26% (n = 23) reported depression at clinical levels during the preoperative period, with an additional number (n = 16 anxiety; n = 19 depression) at borderline status. Despite an overall significant postoperative reduction of negative mood states, clinical levels of anxiety were found in a substantial minority of women both 2 (24%) and 6 months (31%) after surgery. Levels of depression at these times were respectively 13% and 11% of the sample which provided postoperative information. These data confirm previous reports of high levels of negative mood states in patients referred for surgical hysterectomy. However, analyses of individual profiles of change confirm that there was a beneficial outcome for the large majority of the women, with 83% of those with clinical levels of anxiety showing improved status. Regression analyses indicated that postoperative outcomes with respect to negative affect could be predicted from preoperative status, and the data provide some support for the hypothesis that for a minority of women, negative mood states co-presented with gynecological symptoms may not be attenuated by surgery. Both dispositional resilience and familial cohesiveness were entered as significant variables in regression models examining postoperative status, although they provided only a limited increase to the postoperative variance prediction from measure of preoperative levels of affect. Preoperative mood status was found to be inversely related to an intrapersonal dimension of 'dispositional resilience' and to 'family cohesiveness'. It is suggested that measurement of preoperative mood status to family cohesiveness and dispositional resilience may provide useful adjunctive measures in attempts to identify women at risk of reporting an unsatisfactory surgical outcome.

Consequences of hysterectomy in the lives of women

A longitudinal study of 63 adult, premenopausal women of low socioeconomic status who underwent hysterectomies is reported. Face-to-face in-depth interviews with the women were conducted on the day before hysterectomy and 4 weeks and 3 months after hysterectomy. After the interview, each woman completed the Derogatis Sexual Functioning Inventory (Derogatis & Melisaratos, 1979). The Responses to Hysterectomy tool was mailed to the women about 2 years after hysterectomy. Before their hysterectomies, most of the women had both positive and negative feelings about the hysterectomy. By 3 months posthysterectomy, most women had fairly positive general and sexual outcomes. However, by 2 years posthysterectomy, there were less positive outcomes. Most women reported at least sometimes having negative symptoms that they associated with their hysterectomy. More research must be conducted to fully understand the experience of hysterectomy in women's lives.

Sexual adjustment after hysterectomy

The impact of hysterectomy or oophorectomy is not limited to problems of altered body image and depression. Uterus removal, compounded by the possible loss of estrogen and androgens, alters sensations and reactions that had been part of a woman's sexual response. Sexual and marital adjustment after hysterectomy depends on anticipatory guidance regarding decreased libido, physical changes, loss and grief reactions, and the possible complications of cancer therapy. Nurses can affect outcomes through straightforward counseling and education.

A comprehensive education and support program for women experiencing hysterectomies

Women undergoing hysterectomies require special education and emotional support. A new comprehensive program of nursing interventions helps assist women in coping with hysterectomies. Nurses, combining their skills in gynecologic and mental-health nursing, conduct presurgery classes, provide information and support during hospitalization, and offer a postdischarge support group to hysterectomy patients. This article includes descriptions of the program's development process, class content, and ways in which continuity of care is provided.

Sexual issues at menopause

Although the desire for sexual encounters and the frequency of coitus decrease with menopause, sex in the elderly is no longer considered taboo and continues to be an important and acceptable activity for most older persons. Couples in their 50s or older expect continued sexual involvement, but most consider intercourse the only legitimate form of sexual exchange and reject other forms of sexual activity. Sexual dysfunctions which impair coital ability, especially ejaculatory difficulties in the male and genital atrophy and loss of vaginal lubrication in the female, are frequent. Menopausal couples are often not knowledgeable about physiologic aging changes that affect sexual performance and are reluctant to communicate sexual difficulties to their partner. Without professional counseling and/or pharmacologic intervention, these conditions may lead to sexual frustration and abstinence. The identification and treatment of problems, as well as patient education, are imperative in caring for the menopausal patient.

A quasi-experimental design based on regional variations: discussion of a method for evaluating outcomes of medical practice

A large proportion of common medical practices are subject to substantial regional variation resulting in numerous natural experiments. Opportunities are thereby provided for outcome evaluation through quasi-experimental design. If patients treated in different regions were comparable a natural experiment involving alternative treatments could be regarded as 'pseudo randomised', but empirical investigations are needed to verify this prerequisite. This paper discusses the role of quasi-experimental designs in assessment of medical care with evaluation of outcomes after hysterectomy in Denmark as an example. The design is developed and the comparability of selected groups of patients is elucidated from administrative data, while the outcome results are not presented in this context. One indication for hysterectomy is carcinoma in situ of the cervix uteri which may be treated with either hysterectomy, or conisation. A study group of patients was selected from departments where hysterectomy was the treatment of choice for this indication while the reference group was drawn from departments in which conisation was generally preferred. The comparability of the populations, effects and information for the two groups are elicited from administrative data. We conclude that it is possible to establish a quasi-experimental design based on regional variations and that the comparability of the groups included may be assessed through registry data. The importance of technology diffusion for the prospects of performing quasi randomised studies is emphasised. In this attempt to evaluate hysterectomy, it was not possible to identify groups of patients, which were sufficiently comparable to justify a study of soft outcomes.