Outcomes of hysterectomy

Thyroid cancer risk in women after hysterectomy: A nationwide cohort study

OBJECTIVES

Hysterectomy is commonly performed for benign uterine pathologies but there is some controversy over whether it is associated with an increased risk of thyroid cancer. This study examines the associations of hysterectomy with ovarian conservation or with bilateral salpingo-oophorectomy and thyroid cancer incidence in Taiwan.

METHODS

We analyzed data from a nationwide health insurance claims database and identified 29,577 women aged ≥30 years who underwent hysterectomy with ovarian conservation or hysterectomy with bilateral salpingo-oophorectomy between 2000 and 2016. Propensity score-matching analyses were performed at ratios of 1:1 for the hysterectomy and no-hysterectomy groups, to reduce selection bias. We monitored thyroid cancer occurrence in both groups until 2017. Cox regression was used to calculate hazard ratios with 95 % confidence intervals and determine thyroid cancer risk in women who underwent hysterectomy.

RESULTS

The study comprised 29,577 patients who underwent any hysterectomy and 29,577 participants who did not. The mean follow-up period was 10.03 ± 4.92 years. Patients who underwent hysterectomy had higher thyroid cancer incidence (4.72 per 10,000 person-years) than those who did not (3.06 per 10,000 person-years) and a greater risk of any thyroid cancer (adjusted hazard ratio = 1.40; 95 % confidence interval = 1.08-1.82). However, there was no association between hysterectomy with bilateral salpingo-oophorectomy and thyroid cancer incidence (p > 0.05).

CONCLUSIONS

Our findings suggest that women who undergo hysterectomy are at a higher risk of developing thyroid cancer than those who do not.

The Impact of Symptoms of Depression, Anxiety, and Low Stress-Coping Capacity on the Effects of Telephone Follow-Up on Recovery Measures After Hysterectomy

Background

To investigate if symptoms of depression, anxiety, and stress-coping capacity have an impact on the effect of telephone follow-up (TFU) on trajectories of six recovery measures after hysterectomy and influence the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) to health care providers.

Material and Methods

A post hoc nonrandomized analysis of participants enrolled in a randomized, four-armed, single-blinded, controlled multicenter intervention study comprising 487 women where the women were allocated 1:1:1:1 to one of four TFU models. The Swedish Postoperative Symptom Questionnaire (SPSQ) and two health-related quality of life questionnaires, the EuroQoL-5 dimension with three levels (EQ-5 D-3 L) and the Short-Form-Health Survey (SF-36) assessed the recovery measures. The six recovery measures consisted of the EQ-5D-3L health index, the SF-36 physical component summary (PCS) and mental component summary (MCS), and the maximum and average pain intensity, and symptom sum score obtained from the SPSQ. Psychological distress was evaluated by the psychometric forms, the Hospital Anxiety and Depression Scale and the Stress Coping Inventory. The occurrence of uTC and uV within the 6 weeks of follow-up was registered.

Results

Preoperative anxiety, depression, and stress-coping capacity did not modify the effects of the TFU models on the trajectories of the recovery measures, although anxiety and depression were strongly associated with all six recovery measures. uTCs, but not uVs occurred more often in the women with anxiety.

Conclusions

Preoperative anxiety, depression, and stress-coping capacity did not appear to influence the effects of TFU contacts on the recovery measures after hysterectomy. Preoperative anxiety seemed to increase the occurrence of uTC. Clinical Trials Registration: ClinicalTrials.gov (NCT01526668).

Association between hysterectomy and hypertension among Indian middle-aged and older women: a cross-sectional study

OBJECTIVE

To examine the association between hysterectomy and hypertension among middle-aged and older women in India, as well as to determine if the association differs across different age groups.

DESIGN

A cross-sectional exploratory study.

SETTING AND PARTICIPANTS

Nationally representative population-based data of the Longitudinal Ageing Study in India (2017-2018) were used in this study. The sample included 32 460 women aged 45 years and above.

OUTCOME MEASURES

Self-reported hypertension was the outcome variable. The variable was a binary variable, with 1 representing hypertensive and 0 representing not hypertensive.

METHODS

Entropy balance method, along with logistic regression analysis, was used to meet the objectives.

RESULTS

31.3% of the women with hysterectomy and 42.5% of the women without hysterectomy were hypertensive. A perfect covariate balance was achieved between the treatment and control groups using the entropy balance method. Women with hysterectomy had 36% (OR 1.36; 95% CI 1.26 to 1.48) higher odds of hypertension than women without hysterectomy. The OR was 1.23 (95% CI 1.03 to 1.47) for the age group 45-49, whereas, for the age group 80+, it was 1.87 (95% CI 1.18 to 2.97), showing that the magnitude of the association between hysterectomy and hypertension varied with age.

CONCLUSION

The findings of this study suggest that hysterectomy and hypertension have a significant association in middle-aged as well as older women in India.

Prevalence, socio-demographic determinants, and self-reported reasons for hysterectomy and choice of hospitalization in India

BACKGROUND

There is limited evidence of hysterectomy in India because of a lack of data in large-scale, nationally representative health surveys. In 2015-16, the fourth National Family Health Survey (NFHS-4)-a cross-sectional survey-collected for the first-time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. The current study evaluates the prevalence, determinants, and choice of hospitalization (Public vs. Private) for conducting hysterectomy in India among women aged 15-49 years in 29 states and seven union territories (UTs) based on the new large-scale population-based nationally representative dataset (NFHS 5).

METHODS

Cross-tabulations and percentage distributions were utilized to analyse the prevalence of hysterectomy and the choice of hospitalization (public vs. private) across different socioeconomic backgrounds and reasons for undergoing hysterectomy. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy.

RESULTS

In India as a whole, 3.3% of women aged 15-49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs. The southern region stands out for the considerably higher prevalence of hysterectomy; particularly in the states of Andhra Pradesh (8.7%) and Telangana (8.2%), the prevalence was very high followed by Bihar (6%) and Gujrat (4%). On the other hand, the North-eastern region had the lowest prevalence of hysterectomy (1.2%). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector (69.6%) in India. But the scenario was quite different in north-eastern region as in this region more hysterectomies were performed in public health facilities (73%) rather than private health facilities (26.7%). Age, place of residence, religion, caste, level of education, geographic region, wealth quintiles, parity, age at first cohabitation of women were found to be the socio-demographic determinants statistically associated with hysterectomy in India. The likelihood of hysterectomy was higher among women living in rural areas (AOR: 1.3, CI: 1.23-1.35), in the richest wealth quintile (AOR 2.6; CI 2.37-2.76) and in the southern region (AOR 1.6; CI 1.47-1.66). The reasons frequently reported for hysterectomy were excessive menstrual bleeding/pain, followed by fibroids/cysts.

CONCLUSION

This study has attempted to analyse hysterectomy prevalence and its socio-economic determinants using the latest fifth round of NFHS data of all the states and covering 21 states and union territories of India, which gives wider coverage of hysterectomy and more recent with accurate data. More research is needed therefore to unravel the complex dynamics of hysterectomy in India (and elsewhere) which could be used to help women make more informed choices and in turn advance their reproductive health and rights.

Trends and predictors of hysterectomy prevalence among women in the United States

BACKGROUND

Hysterectomy is the most common nonobstetrical medical procedure performed in US women. Evaluating hysterectomy prevalence trends and determinants is important for estimating gynecologic cancer rates and management of uterine conditions.

OBJECTIVE

This study aimed to assess hysterectomy prevalence trends and determinants using the Behavioral Risk Factor Surveillance System (2006-2016).

STUDY DESIGN

We estimated crude hysterectomy prevalences and multivariable-adjusted odds ratios and 95% confidence intervals for associations of race or ethnicity, age group (5-year), body mass index (categorical), smoking status, education, insurance, income, and US region with hysterectomy. Missing data were imputed. The number of women in each survey year ranged from 220,302 in 2006 to 275,631 in 2016.

RESULTS

Although overall hysterectomy prevalence changed little between 2006 and 2016 (21.4% and 21.1%, respectively), hysterectomy prevalence was lower in 2016 than in 2006 among women aged ≥40 years, particularly among non-Hispanic Black and Hispanic women. Current smoking (odds ratio, 1.38; 95% confidence interval, 1.35-1.41), increasing age (odds ratio, 1.40; 95% confidence interval, 1.39-1.40), living in the South compared with the Midwest (odds ratio, 1.36; 95% confidence interval, 1.34-1.39), higher body mass index (odds ratio, 1.26; 95% confidence interval, 1.25-1.27), Black race compared with White (odds ratio, 1.10; 95% confidence interval, 1.07-1.13), and having insurance compared with being uninsured (odds ratio, 1.26; 95% confidence interval, 1.22-1.30) were most strongly associated with increased prevalence. Hispanic ethnicity and living in the Northeast were most strongly associated with decreased prevalence (odds ratio, 0.73; 95% confidence interval, 0.70-0.76; odds ratio, 0.67; 95% confidence interval, 0.65-0.69).

CONCLUSION

Nationwide hysterectomy prevalence decreased among women aged ≥40 years from 2006 to 2016, particularly among non-Hispanic Black and Hispanic women. Age, non-Hispanic Black race, having insurance, current smoking, and living in the South were associated with increased odds of hysterectomy, even after accounting for possible explanatory factors. Further research is needed to better understand associations of race and ethnicity and region with hysterectomy prevalence.

Hysterectomy in India: Spatial and multilevel analysis

Objective:

Using the unit-level data of women aged 15–49 years from National Family Health Survey-IV (2015–2016), the article maps the prevalence of hysterectomy across districts in India and examines its determinants.

Methods:

Descriptive statistics, multivariate techniques, Moran’s Index and Local indicators of Spatial Association were used to understand the objectives. The data were analysed in STATA 14.2, Geo-Da and Arc-GIS.

Results:

In India, the prevalence of hysterectomy operation was 3.2%, the highest in Andhra Pradesh (8.9%) and the lowest in Assam (0.9%). Rural India had higher a prevalence than urban India. The majority of women underwent the operation in private hospitals. Hysterectomy prevalence ranged between 3% and 5% in 126 districts, 5% and 7% in 47 districts and more than 7% in 26 districts. Moran’s Index (0.58) indicated the positive autocorrelation for the prevalence of hysterectomy among districts; a total of 202 districts had significant neighbourhood association. Variation in the prevalence of hysterectomy was attributed to the factors at the primary sampling unit, district and state level. Age, parity, wealth and insurance were positively associated with the prevalence of hysterectomy, whereas education and sterilization was negatively associated.

Conclusion:

Hysterectomy operation in India presented the geographical, socio-economic, demographic and medical phenomenon. The high prevalence of hysterectomy in many parts of the country suggested conducting in-depth studies, considering the life cycle approach and providing counselling and education to women about their reproductive rights and informed choice. Surveillance and medical audits and promoting the judicial use of health insurance can be of great help.

Longitudinal Risk Management for Patients with Increased Risk for Breast Cancer

INTRODUCTION

This study aims to characterize longitudinal care management and evaluate the relationship between various patient factors and the likelihood of choosing risk-reducing behaviors in women with increased risk of developing breast cancer.

METHODS

A retrospective study was conducted to evaluate all adult female patients who had at least one clinic visit with a surgical provider for discussion of breast cancer risk assessment between January, 2017 to July, 2020 at an academic center. Patients with prior history of breast cancer were excluded. Patient details and strategies pursued at clinic visits were recorded. A time-to-event analysis was performed, and hazard ratios were determined to characterize associations between patient characteristics and time to pursuing risk-reducing care management.

RESULTS

There were 283 participants with at least one follow-up visit and 48 (17.0%) ultimately changed their initial strategy to either chemoprevention or prophylactic mastectomy. Patients with gene mutations were 6 times more likely to engage in risk-reducing management compared to those without (hazard ratio (HR) 5.99, P < 0.001). Those with histories of high-risk proliferative changes (HR 7.62, P < 0.001) and hysterectomy (HR 2.99, P = 0.019) were also more likely to engage in risk-reducing management. Age, race, and increased predicted risk of developing breast cancer (estimated by various calculators) were not associated with increased likelihood of engaging in risk-reducing strategies.

CONCLUSION

Known gene mutations, history of high-risk proliferative changes, and prior hysterectomy were factors associated with women who were more likely to engage in risk-reducing strategies. These findings, when paired with patient reported outcome measures, may help guide shared decision-making.

Female Sexual Function at Midlife and Beyond

Sexual function is an important component of quality of life for women. Midlife poses several challenges to optimal sexual function and intimacy for women. In addition to anatomic factors related to estrogen deficiency, such as genitourinary syndrome of menopause, vulvovaginal atrophy, and pelvic organ prolaps, psychosocial factors, including prior sexual trauma, play an important role in sexual function in women. Several treatments have emerged for female sexual dysfunction; long-term studies and head-to-head comparisons are lacking.

Predictors of hysterectomy among married women 15-49 years in India

BACKGROUND

In India, community based studies and media reports indicate a surge in the number of young women undergoing hysterectomy in the past few years. This has led to suspicion on the misuse of procedure, and intense debates on its potential ill health-effects on young women. However, there are no population-based studies that provide insights into hysterectomy prevalence and its determinants at the national level.

DATA AND METHODS

This study used data from India's District Level Household Survey that involved a sample of 3, 16,361 married women in the age group of 15-49 years spread across 21 States and Union Territories of India. Bivariate and multivariate regression analysis was performed to estimate hysterectomy prevalence and identify its predictors.

RESULTS

The study estimated hysterectomy prevalence of 17 per 1000 ever married women. The number of women undergoing hysterectomy ranged from 2 to 63/1000 across different states. A little more than one-third of women who had undergone hysterectomy were under the age of 40 years. The proportion of women below 40 years of age who had had hysterectomy was much higher in southern states of Andhra Pradesh (42%) and Telangana (47%). The likelihood of hysterectomy was higher among women belonging to households with health insurance (OR: 1.88, CI: 1.77-2.00) and women who were sterilized (OR 1.55; CI 1.45-1.67) than uninsured and unsterilized women, and lower among women with education level of matriculation and above (OR 0.47; CI 0.42-0.50) than those with no and/or low education.

CONCLUSIONS

A sizable proportion of young women undergoing hysterectomy in India may have severe ill-health effects on their physical, reproductive and socio-psycho health. As women with low or no education are also more prone to hysterectomy, providing more information and education to them on the possible after-effects of hysterectomy and alternative options will enable them to make more informed choices.

Association of Mid-Life Changes in Body Size, Body Composition and Obesity Status with the Menopausal Transition

The mid-life period is a critical window for increases in body weight and changes in body composition. In this review, we summarize the clinical experience of the menopausal transition by obesity status, and examine the evidence regarding the menopausal transition and reproductive hormones effects on body weight, body composition, or fat distribution. Mid-life obesity is associated with a different menopausal experience including associations with menstrual cycle length prior to the final menstrual period (FMP), age at the FMP, and higher prevalence of vasomotor symptoms. The menopausal transition is associated with weight gain and increased central body fat distribution; the majority of evidence suggests that changes in weight are due to chronological aging whereas changes in body composition and fat distribution are primarily due to ovarian aging. Continuous and regular physical activity during mid-life may be an efficacious strategy to counteract the age-related and menopause-related changes in resting energy expenditure and to prevent weight gain and abdominal adiposity deposition.

The MRI features of placental adhesion disorder-a pictorial review

Placental adhesion disorder (PAD) comprises placenta accreta, increta and percreta lesions; these are classified according to the depth of uterine invasion. Although PAD is considered a rare condition, its incidence has increased 10-fold in the last 50 years. Ultrasound is the primary imaging modality for the assessment of the placenta and in the majority of cases, it is sufficient for diagnosis; however, when ultrasound findings are suspicious or inconclusive, MRI is recommended as an adjunct imaging technique. Numerous MRI features of PAD have been described, including dark intraplacental bands, disorganized intraplacental vascularity and abnormal uterine bulging. This pictorial review describes and illustrates these characteristics and discusses their implications in planning delivery. In addition, we present a series of "pitfall" cases to aid the interpreting radiologist and discuss management of PAD. PAD is a clinical and diagnostic challenge that is encountered with increasing frequency, requiring a cohesive multidisciplinary approach to its management.

A biopsychosocial approach to women's sexual function and dysfunction at midlife: A narrative review

A satisfying sex life is an important component of overall well-being, but sexual dysfunction is common, especially in midlife women. The aim of this review is (a) to define sexual function and dysfunction, (b) to present theoretical models of female sexual response, (c) to examine longitudinal studies of how sexual function changes during midlife, and (d) to review treatment options. Four types of female sexual dysfunction are currently recognized: Female Orgasmic Disorder, Female Sexual Interest/Arousal Disorder, Genito-Pelvic Pain/Penetration Disorder, and Substance/Medication-Induced Sexual Dysfunction. However, optimal sexual function transcends the simple absence of dysfunction. A biopsychosocial approach that simultaneously considers physical, psychological, sociocultural, and interpersonal factors is necessary to guide research and clinical care regarding women's sexual function. Most longitudinal studies reveal an association between advancing menopause status and worsening sexual function. Psychosocial variables, such as availability of a partner, relationship quality, and psychological functioning, also play an integral role. Future directions for research should include deepening our understanding of how sexual function changes with aging and developing safe and effective approaches to optimizing women's sexual function with aging. Overall, holistic, biopsychosocial approaches to women's sexual function are necessary to fully understand and treat this key component of midlife women's well-being.

Assessment of selected perioperative parameters in patients undergoing laparoscopic and abdominal supracervical hysterectomy

Introduction

Subtotal hysterectomy is a method of treatment of patients with mild changes in the uterine body. Laparoscopic methods are increasingly used in surgical gynaecology. One of the limitations of laparoscopy is the proper level of operating surgeon's training, which may be assessed with the use of the learning curve. The aim of the study was to compare data regarding the perioperative period in patients who underwent subtotal hysterectomy with the two methods, and to establish a learning curve for laparoscopic subtotal hysterectomy.

Material and methods

One hundred and twenty-seven patients qualified for subtotal hysterectomy due to mild disturbances in the uterine body participated in the study. The study was conducted at the Clinical Department of Gynaecology and Obstetrics of Fryderyk Chopin Provincial Specialist Hospital in Rzeszów in 2012-2013.

Results

The time of laparoscopic subtotal hysterectomy is longer than that of the classical surgical procedure. Uterine myomas are the main indication for subtotal hysterectomy. Laparoscopic operation results in lower blood loss compared to the classical surgical method. The mean age of the patients operated due to mild changes in the uterine body is similar in both groups. Patients who are obese or have undergone Caesarean sections are more frequently qualified for the classical surgery. The study revealed a reduction in time of laparoscopic subtotal hysterectomy by ca. 31 minutes (33%).

Conclusions

Laparoscopic subtotal hysterectomy is a method chosen by operating surgeons for patients with a lower perioperative risk. The period of the study made it possible to determine a learning curve for laparoscopic subtotal hysterectomy.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure

OBJECTIVES

To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall.

METHODS

Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups.

RESULTS

Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044).

CONCLUSION

Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

Body mass index following natural menopause and hysterectomy with and without bilateral oophorectomy

OBJECTIVE

The directional and temporal nature of relationships between overweight and obesity and hysterectomy with or without oophorectomy is not well understood. Overweight and obesity may be both a risk factor for the indications for these surgeries and a possible consequence of the procedure. We used prospective data to examine whether body mass index (BMI) increased more following hysterectomy with and without bilateral oophorectomy compared with natural menopause among middle-aged women.

METHODS

BMI was assessed annually for up to 10 years in the Study of Women's Health Across the Nation (SWAN (n=1962)). Piecewise linear mixed growth models were used to examine changes in BMI before and after natural menopause, hysterectomy with ovarian conservation and hysterectomy with bilateral oophorectomy. Covariates included education, race/ethnicity, menopausal status, physical activity, self-rated health, hormone therapy use, antidepressant use, age and visit before the final menstrual period (FMP; for natural menopause) or surgery (for hysterectomy/oophorectomy).

RESULTS

By visit 10, 1780 (90.6%) women reached natural menopause, 106 (5.5%) reported hysterectomy with bilateral oophorectomy and 76 (3.9%) reported hysterectomy with ovarian conservation. In fully adjusted models, BMI increased for all women from baseline to FMP or surgery (annual rate of change=0.19 kg m(-2) per year), with no significant differences in BMI change between groups. BMI also increased for all women following FMP, but increased more rapidly in women following hysterectomy with bilateral oophorectomy (annual rate of change=0.21 kg m(-2) per year) as compared with following natural menopause (annual rate of change=0.08 kg m(-2) per year, P=0.03).

CONCLUSION

In this prospective examination, hysterectomy with bilateral oophorectomy was associated with greater increases in BMI in the years following surgery than following hysterectomy with ovarian conservation or natural menopause. This suggests that accelerated weight gain follows bilateral oophorectomy among women in midlife, which may increase risk for obesity-related chronic diseases.

Reported symptoms before and one year after hysterectomy in African American and white women

PURPOSE

Although African American women are more likely than white women to undergo hysterectomy, there are few data describing their symptoms before and after surgery. This report compares reported symptoms in white and African American women before and 1-year after having a hysterectomy with at least one ovary retained.

METHODS

Using data from a prospective cohort study, we compared self-reported symptoms at baseline and 1-year follow-up among 382 women undergoing hysterectomy without bilateral oophorectomy (197 African American and 185 white) and 448 controls (199 African American and 249 white). Symptoms were assessed using an 11-item scale with questions on somatic, psychologic, and urogenital symptoms.

RESULTS

Women undergoing hysterectomy had more severe symptom scores before surgery than controls, but no significant racial differences were found. At follow-up, total scores for women with hysterectomies were comparable to those of control women, but some differences were observed within individual domains. Urogenital scores were worse for women with hysterectomies for both African American and white women. African American women with hysterectomies had better scores in the psychologic domain than either controls or white women with hysterectomies.

CONCLUSIONS

African American women, despite having such characteristics as larger uterine weight and lower hemoglobin that might suggest they would have more severe symptoms, had scores that were no worse than white women both before and after hysterectomy.

Negative attitudes and affect do not predict elective hysterectomy: a prospective analysis from the Study of Women's Health Across the Nation

OBJECTIVE

Cross-sectional studies suggest an association between hysterectomy and negative affect. Using prospective data, we examined the associations of negative affect, attitudes toward aging and menopause, premenstrual symptoms, and vasomotor symptoms with elective hysterectomy in midlife.

METHODS

Data were from the Study of Women's Health Across the Nation, a multisite, community-based prospective cohort study of the menopausal transition (n = 2,818). Annually reported hysterectomy at visits 2 to 9 was verified with medical records when available (71%). Anxiety, perceived stress, depressive symptoms, attitudes toward aging and menopause, vasomotor symptoms, and premenstrual symptoms were assessed at baseline using standardized questions. Cox proportional hazards models were used to relate these variables to subsequent elective hysterectomy. Covariates included demographic variables, menstrual bleeding problems, body mass index, hormone levels, and self-rated health, also assessed at baseline.

RESULTS

Elective hysterectomy was reported by 6% (n = 168) of participants over an 8-year period. Women with hysterectomy were not higher in negative affect or negative attitudes toward aging and menopause compared with women without hysterectomy. Vasomotor symptoms (hazard ratio [HR], 1.44; 95% CI, 1.03-2.01; P = 0.03) and positive attitudes toward aging and menopause (HR, 1.74; 95% CI, 1.04-2.93) at baseline predicted hysterectomy over the 8-year period, controlling for menstrual bleeding problems, site, race/ethnicity, follicle-stimulating hormone, age, education, body mass index, and self-rated health. Menstrual bleeding problems at baseline were the strongest predictor of hysterectomy (HR, 4.30; 95% CI, 2.05-9.05).

CONCLUSIONS

In this prospective examination, negative affect and attitudes were not associated with subsequent hysterectomy. Menstrual bleeding problems were the major determinant of elective hysterectomy.

Sleep and fatigue symptoms in women before and 6 weeks after hysterectomy

OBJECTIVE

To compare sleep and fatigue experiences of women before hysterectomy and at 3 and 6 weeks after surgery, to compare symptoms by type of surgical procedure, and to examine the biopsychosocial contextual factors related to symptoms.

DESIGN

A descriptive repeated measures study assessed sleep and fatigue using questionnaires and objective wrist actigraphy monitoring for sleep.

SETTING

Data were collected in women's homes at least 2 days before surgery, and at 3 and 6 weeks postoperatively.

PARTICIPANTS

A convenience sample of 25 women scheduled for hysterectomy.

RESULTS

There was significantly higher self-reported sleep disturbance 3 weeks after surgery compared with baseline. Women who had vaginal hysterectomy continued to experience sleep disturbance and fatigue 6 weeks after surgery, while those who had abdominal hysterectomy reported better sleep and less fatigue at 6 weeks compared with baseline. The number of awakenings recorded with actigraphy increased postoperatively for both groups, and younger women experienced more wake time during the night than older women. Level of education was positively related to preoperative fatigue severity.

CONCLUSIONS

Findings suggested poor sleep and fatigue during the postoperative period should be evaluated in light of women's ages, level of education, and type of surgical procedure.

Pattern of mental ill health morbidities following hysterectomy for benign gynaecological disorders among Nigerian women

Objective

to compare the pre and post hysterectomy mental ill health (MIH) status and also, to determine whether there is any association with the surgical indication.

Methodology

An observational study, conducted among women scheduled for hysterectomy at the University College Hospital, Ibadan from January till June 2005. The MIH morbidities were assessed using a validated general health questionnaire (GHQ) before and after the surgery by trained research assistant. The score of 4 and above was used as the cut off. Cross tabulations were performed to detect any association and also to compare pre and post hysterectomy mental health status. The level of statistical significance was set at P < 0.05.

Results

Of the 50 women recruited, 45 participated in the study. The age range of the participants was 35 to 63 years with a mean of 48.6 (SD = 0.6) years. Anxiety related disorder was present in 20 (44.4%), and depression in 3 (6.7%) before hysterectomy. Post surgery, there was significant increase in those with anxiety by 6.8% and a reduction in the proportion of depressive illness by 2.3%. Uterine fibroid as a preoperative diagnosis, had significant association among those with anxiety related disorder (68.4%) and depression (10.5%).

Conclusion

This study suggests that mental ill health may complicates hysterectomy for benign uterine pathology among Nigerian women, and that anxiety related disorders increases after operation with the highest proportion in those with clinical diagnosis of Uterine Fibroid. We recommend adequate preoperative counseling using properly trained psychologists when affordable to minimize these morbidities.

The effect of hysterectomy on sexuality and psychological changes

Every year, many women all over the world will undergo a hysterectomy, the removal of their uterus. The majority of hysterectomies are performed to treat conditions such as fibroids, heavy bleeding, endometriosis, adenomyosis and prolapse. A hysterectomy is not often a procedure that needs to be performed urgently, except in the case of cancer. Therefore, a woman considering the procedure should take time to investigate all her options, including other possible treatments. Deciding whether to have a hysterectomy can be a difficult and emotional process. Signs of depression may include severe and prolonged feelings of sadness and hopelessness; diminished interest in activities; significant weight loss or gain; insomnia; fatigue; and thoughts of death or suicide. Every person reacts differently, and reactions are a combination of emotional and physical responses. We still have much to learn about the effects of hysterectomy on sexual function. We investigated many studies published in different journals relative to this subject and we compare their results. Women are more likely to report improved sexual functioning after the surgery when their symptoms have been alleviated. A new hysterectomy procedure that 'spares' abdominal ligaments and nerves is quicker and results in less blood loss and shorter hospital stays and seems to respect the tissues more, without affecting the sexuality of the women.

The role of supracervical hysterectomy in benign disease of the uterus

The aim of this study was to investigate the type of hysterectomy that gynaecological surgeons and female hospital staff would choose for benign disease of the uterus, and to investigate the most influential factors in that choice. We performed a prospective survey of 369 gynaecological surgeons and 370 female staff members of a large teaching hospital. Our survey found that 88% of UK gynaecological oncologists and 50% of US gynaecological oncologists responding would perform a supracervical hysterectomy (SCH) over a total abdominal hysterectomy (TAH) for benign disease of the uterus. A total of 72% of the female staff surveyed would choose a SCH for benign disease of the uterus. In conclusion, our study has given gynaecological and prospective patient approval to support the idea of replacing total hysterectomy with supracervical hysterectomy for benign disease of the uterus.

A prospective study of weight gain after premenopausal hysterectomy

PURPOSE

Many women who have had hysterectomies have the perception that they gained weight after surgery that cannot be attributed to changes in diet or physical activity. The purpose of this analysis was to assess weight gain in premenopausal women in the first year after hysterectomy compared with a control group of women with intact uteri and ovaries.

METHODS

As part of a prospective cohort study designed to assess the risk for ovarian failure after premenopausal hysterectomy, weight was measured at baseline and 1-year follow-up in 236 women undergoing hysterectomy and 392 control women. Changes in measured weight and reported weight were assessed. Unconditional logistic regression analyses were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for weight gains of >10 pounds.

RESULTS

Women with hysterectomies weighed more and had a higher mean body mass index (BMI) than control women at baseline. Mean weight gain was 1.36 kg ( approximately 3 pounds) for women with hysterectomies vs. 0.61 kg ( approximately 1.3 pounds) for control women (p = 0.07). Weight gain of >10 pounds occurred in 23% of women with hysterectomies compared with 15% of control women (multivariable OR = 1.61, 95% CI 1.04 = 2.48).

CONCLUSIONS

Women undergoing hysterectomies appear to be at higher risk for weight gain in the first year after surgery. Heavier women and women who have had weight fluctuations throughout adulthood may be at greater risk for postsurgical weight gain, suggesting that lifestyle interventions to maintain or lose weight may be particularly helpful for these women in the months following hysterectomy.

Hysterectomy and subsequent psychological health: findings from a British birth cohort study

BACKGROUND

The association between hysterectomy and subsequent, long-term psychological health is still not well characterised. We aimed to test the association between hysterectomy and subsequent psychological health and examine variation in this association by characteristics of hysterectomy.

METHODS

Using data on women in the MRC National Survey of Health and Development, followed up since birth in 1946 until age 53 years (N=1790) the associations between hysterectomy and General Health Questionnaire (GHQ)-28 scores were tested.

RESULTS

There was no clear association between hysterectomy status and GHQ-28 score at age 53 years when grouping all hysterectomies together. However, this masked significant variation in association by characteristics of hysterectomy. In unadjusted analyses women who had undergone hysterectomy for cancer had mean GHQ-28 scores at age 53 years which were 49.0% higher (95% CI: 3.4%, 94.7%) than women who had not undergone hysterectomy. In analyses adjusted for prior psychological state and vulnerability, lifetime socioeconomic position, weight at age 26 years, smoking status and hormone replacement therapy use, women who had undergone hysterectomy before age 40 years had GHQ-28 scores 29.5% higher (95% CI: 2.7%, 56.3%) than women who had not undergone hysterectomy.

CONCLUSIONS

Our findings suggest that women who undergo hysterectomy at a young age are a defined group who may require more support than other women to maintain good psychological health in middle-age.

Design and validation of a comprehensive fecal incontinence questionnaire

PURPOSE

Fecal incontinence can have a profound effect on quality of life. Its prevalence remains uncertain because of stigma, lack of consistent definition, and dearth of validated measures. This study was designed to develop a valid clinical and epidemiologic questionnaire, building on current literature and expertise.

METHODS

Patients and experts undertook face validity testing. Construct validity, criterion validity, and test-retest reliability was undertaken. Construct validity comprised factor analysis and internal consistency of the quality of life scale. The validity of known groups was tested against 77 control subjects by using regression models. Questionnaire results were compared with a stool diary for criterion validity. Test-retest reliability was calculated from repeated questionnaire completion.

RESULTS

The questionnaire achieved good face validity. It was completed by 104 patients. The quality of life scale had four underlying traits (factor analysis) and high internal consistency (overall Cronbach alpha = 0.97). Patients and control subjects answered the questionnaire significantly differently (P < 0.01) in known-groups validity testing. Criterion validity assessment found mean differences close to zero. Median reliability for the whole questionnaire was 0.79 (range, 0.35-1).

CONCLUSIONS

This questionnaire compares favorably with other available instruments, although the interpretation of stool consistency requires further research. Its sensitivity to treatment still needs to be investigated.

Loss of cyclin g1 expression in human uterine leiomyoma cells induces apoptosis

Observations from the authors' laboratory suggest a physiological role for increased cyclin G1 protein levels in human uterine leiomyoma. The hypothesis of the present study is that the strategic modulation of cyclin G1 by antisense technology will inhibit the survival of in vitro-grown uterine leiomyoma cells. Cultured uterine leiomyoma cells were transfected with cyclin G1 ribbon-type antisense oligonucleotide (cyclin G1 RiAS) to effectively reduce cyclin G1 expression. Cell viability, in situ terminal deoxyuridine nick end-labeling (TUNEL) assay, flow cytometry, DNA fragmentation, and expression of cell cycle regulatory-related proteins were evaluated by Western blot. Antisense oligonucleotides compromised uterine leiomyoma cell viability and inducted apoptosis in a caspase-independent mechanism. In situ TUNEL and DNA fragmentation revealed apoptosis induction, and fluorescent-activated cell sorting analysis showed increased sub-G1-phase cells. Furthermore, abrogation of cyclin G1 enhanced p53 accumulation, phosphorylation of p53 at Ser-15 residue, and increased expression of cyclin-dependent kinase inhibitors p21 and p27. These data imply that cyclin G1 expression is associated with growth promotion and the potential utility and novelty of using ribbon-type antisense oligonucleotides as a gene therapy strategy to treat human uterine leiomyoma.

Bilateral oophorectomy and depressive symptoms 12 months after hysterectomy

OBJECTIVE

This study was performed to examine whether bilateral oophorectomy is related to depressive symptoms.

STUDY DESIGN

A secondary analysis of data collected from a cohort study of 1047 premenopausal women undergoing hysterectomy with or without concomitant oophorectomy for benign indications was performed. Data on depressive symptoms, based on the Profile of Mood States survey, were collected presurgically and 12 months postoperatively.

RESULTS

The effect of bilateral oophorectomy on postoperative depressive symptoms varied, depending on the presence of baseline depressive symptoms. Bilateral oophorectomy was associated with a decrease in risk of depressive symptoms in women without baseline depressive symptoms (risk ratio [RR] 0.36 [95% confidence interval (CI), 0.17, 0.78]) and did not change significantly in those with baseline depressive symptoms (RR 1.21 [95% CI, 0.73, 2.00]).

CONCLUSIONS

Bilateral oophorectomy, in comparison with unilateral or no oophorectomy, is associated with less risk of postoperative depressive symptoms in women without baseline depressive symptoms undergoing hysterectomy.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study

PURPOSE

This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence.

METHODS

In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics.

RESULTS

The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up.

CONCLUSIONS

Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Urinary incontinence after hysterectomy—three-year observational study

OBJECTIVES

To perform a prospective evaluation of the long-term effects of hysterectomy on symptoms of urinary incontinence.

METHODS

A prospective observational cohort study was performed. Preoperatively, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on symptoms associated with urge and stress urinary incontinence. Of the 120 patients, 44 underwent vaginal and 76 abdominal hysterectomy. Follow-up questionnaires were administered at 1 and 3 years postoperatively.

RESULTS

Postoperatively, the questionnaire was answered by 115 (96%) of 120 patients after 1 year and by 107 (89%) after 3 years of follow-up. At surgery, the mean patient age was 49.5 years (range 32 to 78). In the abdominal hysterectomy cohort, a tendency was found for decreased episodes of urinary incontinence, although the difference was not significant. No significant changes were noted in micturition frequency. In the vaginal hysterectomy cohort, no significant changes were detectable in the symptoms associated with urge or stress incontinence, and no significant changes were noted in micturition frequency. For the entire hysterectomy group, a significant decrease occurred in stress urinary incontinence symptoms (P = 0.03). Subgroup analysis did not identify any particular risk factors for the development of urinary incontinence after hysterectomy.

CONCLUSIONS

In contrast to the results of several studies, the results of our 3-year prospective study showed that total hysterectomy, independent of route, was not associated with an increase in urge or stress urinary incontinence symptoms.

The Psychosocial Outcomes of Total and Subtotal Hysterectomy: A Randomized Controlled Trial

INTRODUCTION

Current controversies involve the adverse effects of hysterectomy on women's psychosocial functioning and whether subtotal as opposed to total hysterectomy mitigates these effects.

AIM

To investigate the psychosocial effects of hysterectomy by examining sexual, pain, and psychological outcomes of total vs. subtotal hysterectomy in a randomized controlled trial.

METHODS

Patients suffering from benign gynecological conditions were randomly assigned to one of two groups: (i) total hysterectomy, that is, laparoscopic assisted vaginal hysterectomy (TOT, N = 32); or (ii) subtotal hysterectomy, that is, supracervical laparoscopic hysterectomy (SUB, N = 31). Both groups were premenopausal and underwent hysterectomy without concurrent oophorectomy. Two premenopausal control groups: (i) minor gynecological surgery (SURG-CON, N = 30); and (ii) healthy nonsurgical controls (NORM-CON, N = 40), were also tested. All surgical groups were assessed 2-3 weeks before surgery and then 6-7 months afterward; the nonsurgical control group was assessed at the time of recruitment and 6-7 months later.

OUTCOME MEASURES

Assessments included semistructured interviews, standardized questionnaires, and standardized gynecological examinations.

RESULTS

For the TOT group, sexual drive, arousal, and sexual behavior significantly improved postoperatively. For the SUB group, sexual behavior and overall sexual functioning significantly improved. For both TOT and SUB groups, unprovoked pain in the abdomen and pain in the abdomen during gynecological examinations was significantly reduced. For both TOT and SUB groups, overall psychological functioning did not significantly change postoperatively. Although between 3% and 16% of women undergoing hysterectomy reported adverse changes in psychosocial well-being after surgery, similar percentages of women in the control groups reported such effects.

CONCLUSIONS

Hysterectomy resulted in a consistent reduction in abdominal pain, some improvement in sexual functioning, but no change in overall psychological functioning. There was no evidence supporting the idea that subtotal hysterectomy produced more favorable psychosocial outcomes than total hysterectomy nor was there any evidence that either type of hysterectomy resulted in adverse effects.

Women's sexual dysfunction: a review of the "surgical landscape"

OBJECTIVES

To assess the impact of urogynaecologic surgery for stress urinary incontinence, oncologic pelvic surgery, and hysterectomy on women's overall sexual health.

METHODS

We used Ovid and PubMed (updated January 2006) to conduct a literature electronic search on MEDLINE that included peer-reviewed English-language articles. We analysed all studies identified that provided any functional outcome data about urogynaecologic surgery for the treatment of stress urinary incontinence, radical cystectomy for bladder cancer, surgery for rectal cancer, and hysterectomy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data.

RESULTS

Most studies showed that either urogynaecologic or oncologic pelvic surgery may have a significant impact on women's sexual health. Epidemiology varied widely among the studies and reported either improvement or impairment of postoperative sexual functioning, due to different definitions, study designs, and small cohorts of patients. An increasing number of studies have prospectively examined this issue and have found often controversial findings about the role of pelvic and perineal surgery in women's sexual health.

CONCLUSIONS

Although numerous controversies exist, data demonstrate an overall positive impact of the surgical repair for stress urinary incontinence on resolution of coital incontinence, coupled with an improvement of overall sexual life. In contrast, genitourinary and rectal cancers are commonly associated with treatment-related sexual dysfunction, but few studies rigorously assessed women's postoperative sexual function after major oncologic pelvic surgery. Data about the functional outcome after hysterectomy are often contradictory. Adequately powered prospective clinical trials are needed.

Progress in Female Sexual Dysfunction

INTRODUCTION

Female sexual dysfunction (FSD) is a significant age-related, progressive and highly prevalent problem that affects a substantial number of women that causes personal distress and has negative effects on quality of life and interpersonal relationships.

DEFINITIONS

The female sexual response cycle consists of three phases: desire, arousal, and orgasm, and is initiated by non-adrenergic/non-cholinergic, e.g. vasoactive intestinal polypeptide and nitric oxide, neurotransmitters that maintain vascular and non-vascular smooth muscle relaxation resulting in increased pelvic blood flow, vaginal lubrication, and clitoral and labial engorgement. Furthermore, hormonal status may influence female sexual function. For the diagnosis of FSD, a detailed history should be taken initially, followed by a physical examination and laboratory studies.

CONCLUSION

Due to the fact that there has been little research and attention on FSD, our knowledge in this field is quite limited and there is still no approved therapy. Future advances in evaluation and treatment of female sexual problems are forthcoming.

Hysterectomy prevalence and cardiovascular disease risk factors in American Indian women

OBJECTIVES

We investigated hysterectomy prevalence and associated demographic and reproductive factors among American Indian women. The association between hysterectomy and cardiovascular disease (CVD) risk factors was also examined.

METHODS

Data were from 2689 American Indian women who participated in the first examination of the Strong Heart Study from 1989 to 1992. Odds ratios were estimated for factors related to hysterectomy adjusting for other covariates. The association between hysterectomy and CVD risk factors was examined among 1726 eligible women using analysis of covariance.

RESULTS

Hysterectomy prevalence ranged from 24% to 34% across differing age groups and the percent with oophorectomy among those with a hysterectomy ranged from 43% to 63%. Geographic area, more prior pregnancy losses, more education, and less speaking of the native language were associated with increased hysterectomy prevalence. After adjustment for age, the women who had a hysterectomy with intact ovaries had higher total cholesterol and low-density lipoprotein cholesterol levels than those with a natural menopause.

CONCLUSIONS

American Indian women have comparable hysterectomy prevalence as non-Hispanic white women. Education and native language speaking related to hysterectomy in this population. Hysterectomy alone may relate to unfavorable changes of lipid profile.

Ethnic differences in past hysterectomy for benign conditions

BACKGROUND

Hysterectomy for a benign condition is common, particularly in the underserved. The objective was to determine if ethnic differences could be explained by known risk factors.

METHODS

A phone survey was conducted at random on 15,160 women, ages 40-55, from seven US cities. Subjects were 49.9% Caucasian, 28.1% African American, 12.3% Hispanic, and 9.8% Asian American.

RESULTS

Ethnicity was associated with past hysterectomy (odds ratio [OR]: Caucasian = 1.0, African American = 1.66; confidence interval [CI] = 1.46-1.88, Hispanic = 1.64, CI = 1.29-2.07; Asian American = 0.44, CI = 0.34-0.56), after adjustment for age, education, fibroids, body mass index, marital status, smoking, geographic site, and country of education.

CONCLUSION

Because the highest rates occurred in the disadvantaged African American and Hispanic subgroups, and could not be explained by known risk factors, disparity in the form of overuse in these disadvantaged groups may exist.

Hysterectomy: effects on quality of life and psychological aspects

Most gynaecological disorders are not life-threatening. They may nevertheless severely affect women's quality of life. The majority of hysterectomies are performed to treat non-malignant conditions, to enhance the quality of life rather than save life. Recent research shows an enhancement in quality of life during the early years after hysterectomy. Furthermore, research shows that hysterectomy does not cause any adverse psychological outcome in otherwise psychologically healthy women, but presurgical psychopathology is predictive of postsurgical psychopathology. Research also shows that most gynaecological cancer survivors enjoy a relatively good quality of life.

ORIGINAL RESEARCH—PATHOPHYSIOLOGY: Clinical Biologic Pathophysiologies of Women's Sexual Dysfunction

INTRODUCTION

Data concerning the biologic pathophysiology of desire, arousal, and orgasm in women are limited.

AIM

To gain knowledge of biologic pathophysiology of female sexual function. METHODS. To provide state-of-the-art knowledge concerning female sexual dysfunction, representing the opinions of seven experts from five countries developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURE

An International Consultation in alliance with key urological and sexual medicine societies convened over 200 multidisciplinary specialists from 60 countries into 17 consultation committees. The aims, goals and intentions of each committee were defined. Expert opinion was based on grading of evidence-based medical literature, extensive internal committee dialogue, open presentation, and debate.

RESULTS

Three critical physiologic requirements, including intact sex steroids, autonomic/somatic nerves, and arterial inflow/perfusion pressure to women's genital organs play fundamental roles in maintaining women's sexual function. Despite this, there are nominal data supporting a direct pathophysiologic involvement of abnormal sex steroid values, and/or damage/injury to neurologic and/or blood flow integrity in women with problems in sexual desire, arousal, and/or orgasm. This summary details the available literature concerning hormonal, neurologic, and vascular organic pathophysiologies of women's sexual dysfunctions.

CONCLUSIONS

Additional research on clinical pathophysiologies in women's sexual dysfunction is needed. This chapter encompasses data presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

[Embolization of uterine arteries for uterine fibroids: state-of-the-art]

Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.

Current treatment of dysfunctional uterine bleeding

OBJECTIVES

We performed a review of the treatment modalities for dysfunctional uterine bleeding.

METHODS

Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies.

RESULTS

Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores.

CONCLUSION

Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

Selective P2Y2 receptor agonists stimulate vaginal moisture in ovariectomized rabbits

OBJECTIVE

To determine the expression of P2Y(2) receptors in vaginal and cervical tissues and the effects of P2Y(2) receptor agonists INS45973 and INS365 on vaginal moisture.

DESIGN

Pilot in vivo and histological study using animal subjects.

SETTING

Experimental laboratory research.

ANIMAL(S)

Female New Zealand White rabbits were used for in vivo studies and female cynomolgus monkey (Macaca fascicularis) was used for in situ hybridization.

INTERVENTION(S)

Rabbits were kept intact or ovariectomized. Two weeks after ovariectomy, animals received daily vaginal instillation of vehicle or drugs for 16 days.

MAIN OUTCOME MEASURE(S)

Vaginal moisture was assessed in rabbits on 4 separate days during the treatment period. The P2Y(2) receptor mRNA distribution was assessed by in situ hybridization of monkey vagina and cervix.

RESULT(S)

Compared to control, vaginal moisture was significantly diminished in ovariectomized animals treated with vehicle. INS365 (8.1%) and INS45973 (0.9%) increased vaginal moisture in ovariectomized animals to levels that were comparable to or significantly higher than control animals, respectively. In situ hybridization studies indicated that P2Y(2) receptor mRNA was localized to endocervical and cervical gland, epithelium, and stratified squamous epithelium of the vagina.

CONCLUSION(S)

INS45973 and INS365 may interact with P2Y(2) receptors in the cervix and vagina to stimulate vaginal moisture in the estrogen (E)-deprived state. The P2Y(2) receptor agonists provide a potential nonhormonal alternative for treating vaginal dryness in postmenopausal women.

Impact of pelvic floor disorders and prolapse on female sexual function and response

Pelvic floor disorders and FSD are prevalent and challenging problems. These disorders include prolapse of the uterus, cervix, vagina, bladder, and rectum and incontinence. These diseases likely affect women's sexual well-being through physical and emotional effects. Women with pelvic floor disorders often have co-existing urologic and sexual complaints. Patients who present with these urologic problems should be questioned about their sexual function. Surgical treatment in these patients may be curative of their sexual disorders (e.g., by repairing incontinence) but may also have undesired effects on sensation, blood flow, and the anatomy. These effects can affect sexual arousal and orgasm or cause dyspareunia. It is hoped that a better understanding of the anatomy of this area will guide us in a more targeted approach to management of these conditions.

The general health in women suffering from gynaecological disorders is improved by means of hysterectomy

Gynaecological disorders can have adverse effects on women's general health, and for a substantial number of these women hysterectomy is performed. This study aims to evaluate the long-term impact of hysterectomy on this outcome variable. The patient-group was tested pre-operatively and 6 and 12 months after hysterectomy. The control-group was tested once. This study shows that the general health in women suffering from gynaecological disorders is significantly lower compared with that of the control-group (p < 0.00). Both 6 and 12 months after the hysterectomy, however, the patient-group has reached the same level of their general health as the control-group. Twenty-eight per cent of their potentiality for improved health has been obtained. For those women with poorest health both pre- and postoperatively, other factors than the hysterectomy have had a negative impact on their general health and lives. The results from this study suggest that hysterectomy is associated with a positive long-term impact on women's general health.

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.