Improved quality of life after surgery for pelvic organ prolapse in Nepalese women

BACKGROUND

Pelvic organ prolapse (POP) is a common gynecological condition that can affect quality of life (QOL) in women. In Nepal, the prevalence of POP is high, but many affected women are still deprived of treatment. Vaginal hysterectomy with pelvic floor repair is one of the common treatment options for advanced POP. However, QOL outcomes after surgery have not been reported in low-income countries. Thus, we aimed to examine changes in QOL among Nepalese women with POP after such surgery.

METHODS

This longitudinal study was conducted in the selected central and peripheral hospitals in Nepal where vaginal hysterectomy was being performed free of cost for POP. A baseline study first measured the QOL domains (physical, psychological, social relationships and environment) among 252 women with advanced POP. Follow-up data was then collected at six weeks and three months after surgery. Among the 177 women that were available at six weeks post-surgery, 166 participated in the follow-up study at three months post-surgery. To evaluate QOL at baseline, 142 women with no history of POP were included as a comparison group.

RESULTS

The mean scores across QOL domains improved from baseline to 3 months after surgery. The baseline score for the physical domain increased from 11.2 to 12.8 at six weeks and 13.5 at three months post-surgery (p < 0.001); the psychological domain score increased from 11.6 to 13.1 at six weeks and 13.8 at three months post-surgery (p < 0.001); the social relationships domain score increased from 13.6 to 14.4 at six weeks and 15.0 at three months post-surgery (p < 0.001); and the environmental domain score increased from 12.9 to 13.9 at six weeks and 14.0 at three months post-surgery (p < 0.001).

CONCLUSION

QOL progressively improved among women undergoing surgery for POP. Such surgical services need to be scaled up for treatment of advanced POP in low-income countries.

Levonorgestrel-releasing intrauterine system versus laparoscopic supracervical hysterectomy for the treatment of heavy menstrual bleeding: a randomized study

BACKGROUND

The optimal treatment of heavy menstrual bleeding (HMB) remains a challenge for the physician. There is a need for further trials to compare the effectiveness and compliance between a levonorgestrel-releasing intrauterine system (LNG-IUS) and minimally invasive types of hysterectomy, for example, laparoscopic supracervical hysterectomy (LSH), in women with HMB. This article is the first to report a randomized trial aimed at comparing postoperative outcomes and effects on quality of life after LNG-IUS or LSH in women with HMB.

METHODS

The trial was performed at Tor Vergata University Hospital, Rome. Seventy-two women requiring treatment for HMB were randomly allocated into two treatment arms: LNG-IUS (n=36) or LSH (n=36). The primary outcome was the comparison of the effects on menstrual bleeding (pictorial blood loss assessment chart [PBAC]) at 12 months after the two procedures. The secondary outcome measures were the quality of life, improvement in bleeding patterns, intensity of postoperative pain, and early postoperative complications. A p<0.05 was considered statistically significant.

RESULTS

The PBAC score was significantly reduced in both treatment groups. The Medical Outcomes Survey Short Form 36 (SF-36) score improved in both groups. A more significant improvement in the parameters Role and Mental health was observed after LNG-IUS.

CONCLUSIONS

LNG-IUS can be considered as first option for the treatment of HMB unresponsive to drug therapy, and it is particularly suitable for women who want to preserve an acceptable menstrual flow. LSH may be considered the best surgical option in women with HMB unresponsive to any medical treatment.

Health-related quality of life after laparoscopically assisted vaginal hysterectomy: Is uterine weight a major factor?

OBJECTIVE

To assess uterine size, symptom severity, and hemoglobin level as determinants of health-related quality of life (HRQOL) in women subsequently undergoing laparoscopically assisted vaginal hysterectomy (LAVH).

METHODS

Sixty-one consecutive women with uterine leiomyoma or adenomyosis undergoing LAVH were studied using a prospective cohort design. The Chinese version of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire was assessed preoperatively. The Taiwan brief version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire and a self-assessment of the perceived health status were assessed preoperatively and 1 day, 1 week, 12 weeks, and 18 months postoperatively.

RESULTS

Women with a greater uterine weight did not report a greater severity of symptoms than those with lower uterine weight. Women with more severe symptoms had lower preoperative hemoglobin levels and were usually younger. Their perceived health status and their scores in physical domain of WHOQOL-BREF were also significantly lower, indicating a poorer HRQOL. The mixed-effects model found that a normal (higher) baseline hemoglobin level and a greater symptom severity were associated with a significant improvement of HRQOL in the physical domain of WHOQOL-BREF following LAVH.

CONCLUSIONS

Preoperative symptom severity, but not uterine weight, was associated with long-term improvement in HRQOL after LAVH. Women with severe symptoms could be considered for LAVH before development of anemia.

Psychometric properties of the Body Image Scale in women with benign gynaecological conditions

OBJECTIVES

To evaluate the psychometric properties of the Body Image Scale (originally designed for use in cancer) in women with benign gynaecological conditions.

STUDY DESIGN

Prospective completion of the Body Image Scale by women participating in the EVALUATE Hysterectomy Trial. The scale was completed pre-operatively, then 6 weeks, 4 and 12 months post-operatively. The psychometric properties were evaluated by assessing the reliability, response prevalence, discriminant validity and sensitivity to change. Factor analysis was also conducted to determine the scale structure.

RESULTS

The Body Image Scale showed good reliability and clinical validity. Differences between sub-groups of women were detected, demonstrating good discriminant validity. The Body Image Scale was shown to be responsive to changes in body image.

CONCLUSIONS

The Body Image Scale was shown to be a reliable and valid tool for assessing body image in women with benign gynaecological conditions and for use in clinical trials involving such women.

Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy

OBJECTIVES

To compare the effects of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy on sexual wellbeing.

DESIGN

Prospective observational study over six months.

SETTING

13 teaching and non-teaching hospitals in the Netherlands.

PARTICIPANTS

413 women who underwent hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.

MAIN OUTCOME MEASURES

Reported sexual pleasure, sexual activity, and bothersome sexual problems.

RESULTS

Sexual pleasure significantly improved in all patients, independent of the type of hysterectomy. The prevalence of one or more bothersome sexual problems six months after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy was 43% (38/89), 41% (31/76), and 39% (57/145), respectively (chi2 test, P = 0.88).

CONCLUSION

Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. The persistence and development of bothersome problems during sexual activity were similar for all three techniques.

[Feeling of illness after hysterectomy. Women's own assessment]

INTRODUCTION

The aim of the study was to investigate the time interval from the operation to no feeling of illness at all in a population of women, who had undergone a total abdominal or vaginal hysterectomy.

MATERIAL AND METHODS

Data on 361 women who had had a total abdominal or vaginal hysterectomy during the period, 1.1.1998 to 31.3.1999 were collected from a regional database. Those born before 1.1.1940, presented with a genital malignancy, had a diagnosis of genital prolapse, or received surgery in addition to the hysterectomy were excluded. Four months after the hysterectomy, all the women were sent a questionnaire asking about the time of returning to work and the complete absence of any feeling of illness. This information was related to selected perioperative data. Women who had had a total abdominal hysterectomy were not statistically comparable with those who had had a vaginal hysterectomy.

RESULTS

A total of 313 women participated (87%). After a total abdominal hysterectomy, 92%, 80%, and 35% had a subjective feeling of illness at four, six, and ten weeks, respectively. The median duration of feeling ill was nine weeks. The figures after a vaginal hysterectomy were 85%, 71%, and 18%, with a median duration of feeling ill of seven weeks. Only peroperative blood loss and the presence of postoperative complications related statistically to the duration of feeling ill.

CONCLUSION

The interval between the operation and no feeling of illness at all after a total abdominal or vaginal hysterectomy is longer than was formerly believed. Further investigation is recommended.

[Psychiatric and sexual sequelae of hysterectomy--a comparison of different surgical methods]

Comparison of Different Surgical Methods: The cardinal question of this prospective longitudinal study was whether different surgical methods of hysterectomy correlate with differences in adaptation and in respect of psychological as well as sexual consequences. A total of 83 patients were investigated immediately prior to surgery as well as 6 weeks later. 61 resp. 58 patients participated in follow-up investigations 6 months and 1 year following surgery. Total hysterectomy was performed vaginally in 16 females, abdominally in 22 patients. 23 patients underwent subtotal C.I.S.H. hysterectomy. 23 females indicated for myoma enucleation formed another group of this study. Besides several psychological variables of potential influence such as personality characteristics, coping, sexual attitudes and partner satisfaction, the study covered psychological as well as physical complaints, life satisfaction and differential characteristics of sexual experiences and behaviour longitudinally. The results indicate that single subgroups differ from each other in several respects. There were no indications of different psychological as well as sexual consequences depending on the surgical method. These findings support the view that consequences of hysterectomies are more likely to be predicted on the basis of psychological traits that existed before the operation, rather than from a medico-technical point of view.

Early discharge following vaginal hysterectomy

OBJECTIVE

To assess the feasibility of discharging selected patients home within 72 h of vaginal hysterectomy.

DESIGN

Women for whom vaginal hysterectomy was planned and who were invited to take part. Those who accepted were visited at home by a staff nurse experienced in gynaecology to assess home conditions and family support. If these were suitable, the general practitioner was informed and invited to comment. If the operation was uneventful women were discharged on the third post operative day and visited at home by the nurse until the seventh day.

SETTING

Leeds Western Health Authority.

MAIN OUTCOME MEASURES

The number of minor complications requiring treatment by the general practitioner, the readmission rate and the acceptability to the woman and her family.

RESULTS

For 11 out of 61, home conditions proved unsuitable for early discharge. In six of the remaining 50, abdominal hysterectomy proved preferable to vaginal. Thirty women were discharged home on the third day after vaginal hysterectomy, five on the fourth and seven on the fifth. Two developed urinary tract infections, treated by their general practitioners. Two required readmission to hospital. Twenty-eight of 30 discharged on the third post operative day and nine of 12 discharged on the fourth or fifth post operative day were enthusiastic about the scheme.

CONCLUSIONS

Early discharge following uncomplicated vaginal hysterectomy in selected patients appears to be a safe procedure, appreciated by the majority of women. Its adoption as a routine procedure would enable the surgical throughput in a unit to be maintained on a smaller bed complement.

Psychodynamics of four women with delayed cancer diagnosis

Four young women from 28 to 35 years old were referred for psychiatric evaluation because of anxiety, depression, and rage following diagnosis and treatment (radical hysterectomy in all plus radiation therapy in two) of carcinoma of the cervix. Negligence and dishonesty on the part of the laboratory that reported their Pap smears as normal when actually they had been either carelessly examined or not read at all intensified their emotional reactions of shock, panic, and fury. Feelings of injustice and victimization and fantasies about the laboratory technicians, who were women in their age group, complicated the clinical picture. The depressions that ensued in all of the women were prolonged and the working-through processes were impaired despite the fact that three have apparently been cured of their malignant disease.

Supravaginal uterine amputation vs. hysterectomy. Effects on libido and orgasm

Postoperative symptoms of hysterectomy have received relatively little attention. In the present study, the first author has personally interviewed and examined 105 abdominal hysterectomy patients and 107 patients with supravaginal uterine amputation preoperatively and 6 weeks, 6 months and 12 months postoperatively. Participation in the follow-up study was 99.5% (211/212) at one year. This paper deals with the effects of the two operations on libido and the frequency of orgasms. In the statistical analysis, McNemar's test of symmetry and the Fisher exact test were used. Weak or absent libido was reported preoperatively by 28.0% of hysterectomy patients and by 26.4% of amputation patients. One year postoperatively the corresponding figures were 35.4% and 31.4%. No statistical changes were observed between the two groups or within either group. In the frequency of orgasms a highly significant (p less than 0.001) reduction from the situation before operation to one year postoperatively was detected after hysterectomy. In the supravaginal amputation group no statistically significant decrease was detected. Preoperatively the two groups were alike; one year postoperatively the difference was almost significant (p less than 0.05). The reductions in orgasms after hysterectomy as compared with supravaginal amputation appears to result from the greater radicality of the former; at hysterectomy, the autonomous innervation of the proximal vagina and cervix is damaged more than in supravaginal amputation, the anatomy of the vagina is altered and scar tissue forms in the vagina. It is probable that these changes and subconscious psychological reactions due to total removal of the uterus explain why supravaginal uterine amputation gives better results than hysterectomy.

Supravaginal uterine amputation vs. hysterectomy. Effects on coital frequency and dyspareunia

The author has personally interviewed and examined 105 abdominal hysterectomy patients and 107 supravaginal amputation patients, first preoperatively and then 6 weeks, 6 months and one year postoperatively. At 12 months the follow-up percentage was 99.5 (211/212). This report concentrates on coital frequency and dyspareunia. In the statistical analysis, McNewar's test of symmetry and the Fisher exact test were used. With respect to coital frequency, no statistically significant changes occurred between or within the two groups. Dyspareunia was relieved by either operation, but more so by supravaginal amputation. When dyspareunia was experienced deep within the pelvis, removal of the uterus by either method almost always resulted in disappearance of the symptom.