The effects of hysterectomy on patients' quality of life are important factors in the management of uterine-related conditions. Performing a hysterectomy is expected to treat abnormal bleeding, endometriosis, and chronic pelvic pain. Although it provides positive effects, problems such as reduced sexual functioning, pelvic pain, and depression encountered after hysterectomy negatively affect quality of life of the hysterectomized patients.
The purpose of this systematic review was to synthesize the available evidence related to quality of life after hysterectomy in areas of sexuality, pain, and depression. This review updated the systematic reviews published in 1997 and 2005.
Chapter One: Introduction
Hysterectomy is a surgical operation to remove all or part of the uterus.
(Abate & Jewell, 2001). The three approaches to hysterectomy for benign disease are abdominal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. Abdominal hysterectomy involves removal of the uterus through an incision on the lower abdomen. Vaginal hysterectomy involves removal of the uterus via the vagina, without abdominal incision. Laparoscopic hysterectomy involves removal of the uterus through small incisions on the abdomen. In laparoscopic hysterectomy, the uterus is removed with the aid of a surgical telescope, also called laparoscope, inserted through the umbilicus and the instruments are inserted through two or three further keyholes. A total hysterectomy refers to the removal of the entire uterus including the cervix. When the cervix is not removed, it is called subtotal or supracervical hysterectomy (Nieboer, 2009). Removal of the ovaries is sometimes performed at the time of the hysterectomy, and the procedure is termed an oophorectomy (Abate & Jewell, 2001).
Hysterectomy is the second most common major surgical procedure performed for women of reproductive age in the United States each year. Several primary indications for hysterectomy are leiomyomas, dysfunctional uterus bleeding, chronic pelvic pain, and endometriosis (Naughton & McBee, 1997). Cancerous conditions such as cervical intraepithelial neoplasia, cervical carcinoia, ovarian and fallopian tube neoplasm account for only 10% of all hysterectomies performed (Naughton & McBee, 1997).
Hysterectomy is a major event in a woman's life. It will result in instant menopause and the woman will experience all the physiological changes of menopause after undergoing hysterectomy. The symptoms associated with surgical menopause are similar to those in women who experience natural menopause. She will no longer menstruate and will not be able to bear children. Other physical discomforts associated with hysterectomy are fatigue, short-term memory deficits, hot flashes and sleep disturbances (Taylor, 2001). Many women also become irritable and suffer from mood swings as a result of the hormone withdrawal. Younger women sometimes find it difficult to cope with such changes and can go into depression. Depression is likely to increase when there is a change in hormone levels in women, possibly due to the effects of estrogen levels on serotonergic activity and its impact on other neurotransmitters. Surgically menopausal women may also experience a decline in sexual interest and activity (Taylor, 2001). Hysterectomy may be performed to improve chronic pelvic pain, especially when it is caused by uterine disorders such as adenomyosis or fibroids. However, some women still have pain even after a hysterectomy, particularly in younger women less than 30 years of age and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction (Hillis, 1995).
Purpose
The purpose of this systematic review was to synthesize the available evidence related to quality of life after hysterectomy in areas of sexuality, pain, and depression framed within Roy's nursing theory of adaptation. This review updated the systematic reviews published in 1997 and 2005.
Definitions of Terms
The following terms have been conceptually and operationally defined for the purpose of this literature review.
Impact: Impact refers to as the effect or influence of one person, thing, or action on another (Abate & Jewell, 2001).
Hysterectomy: Hysterectomy is a surgical operation to remove all or part of the uterus (Abate & Jewell, 2001).
Quality of life: quality of life is defined as satisfaction in areas of life deemed important to the individual (Peterson & Bredow, 2004).
Depression: depression refers to a condition of mental disturbance characterized by such feelings to a greater degree than seems warranted by the external circumstances, typically with lack of energy and difficulty in maintaining concentration or interest in life (Abate & Jewell, 2001).
Pain: pain is defined as physical suffering or discomfort caused by illness or injury (Abate & Jewell, 2001).
Sexual dysfunction: Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse.
Theoretical Framework
The Roy adaptation model (RAM) by Sister Callista Roy provides the theoretical framework for this systematic review because of its holistic perspectives on individuals and the process of adaptation. The individuals' responses to a constantly changing environment are dependent on their coping processes. This model categorized coping processes into two subsystems: the cognator and the regulator. The cognator manages processes that are related to brain functions such as perception, judgment, learning, and emotion. On the other hand, the regulator works primarily through the use of the autonomic nervous system in making physiologic adjustments (Roy, 1976). The regulator and cognator are coping subsystems that allow clients to adapt and make necessary changes when dealing with stress (Roy & Andrews, 1999). The regulator subsystem is related primarily to the physiological mode, whereas the cognator subsystem is related to all four adaptive modes. The four adaptive modes are physiological, self-concept, role function, and interdependence. Together, both the regulator and cognator subsystems work to responds to changing internal and external stimuli and maintain the integrity of the individual. A conceptualization of the Roy adaptation model, as it relates to this study, is shown in Figure 1 (p.5).
For the purpose of framing the current literature on the impact of hysterectomy on a woman's quality of life, each of the key concepts within Roy's adaption model will be explained and how the concept could potentially manifest within hysterectomized women.
Adaptation is the central concept of the RAM. According to this model, the person is viewed as an adaptive system composed of input, control processes, effectors, output, and feedback (Roy, 1984). Roy believes that the adaptation level of persons is constantly changing based upon the influences of internal and external stimuli. The persons' ability to adapt to stimuli is influenced by their coping abilities. The behavioral response also serves as feedback stimuli to the person (Roy & Andrews, 1999). Needs within persons that stimulate response to preserve integrity and the ability to adapt are interrelated because needs are viewed as focal stimuli. Therefore, stimuli immediately confront individuals (input). In response to internal and external environmental changes that affect satiety, need deficits or excesses occur that trigger off regulator and cognator coping mechanism (control processes). As a result of these mechanisms, responses occur that manifest themselves through the physiological, self-concept, interdependence, and role-function modes (effectors) (Roy, 1984). According to Roy (1984), the interrelatedness of input, control processes, and effectors determines whether or not a person exhibits adaptive or ineffective responses (output). These responses then feed back into the system (feedback). The goal of adaptation nursing is to enhance the individual's adaptive responses and diminish ineffective responses.
The five major concepts of nursing explicates in the RAM are person, goal, health, environment, and nursing activities (Roy, 1984). By addressing all five concepts in this manner, health becomes an outcome of adaptive processes that reflects patterns of being and becoming whole and integrated with self and with the environment (Frederickson, 2000). The first concept in the RAM model is persons. According to the Roy's model, the persons recognize the unique role of the innate and acquire coping mechanisms to help them in adapting to their surroundings. Pertinent to this study, the person is the hysterectomized woman. Roy has discovered four main areas that address the activities of the coping mechanisms. She refers to these areas as adaptive modes. The four adaptive modes are physiological, self-concept, role function, and interdependence. These adaptive modes are often referred to as effectors (Roy & Andrews, 1999).
Another concept described in the RAM is goal. The goal of nursing within this model is to promote adaptation in four adaptive modes. Together the coping mechanisms and the modes reflect the integration of the individual (Roy, 1984, p.38).
Theoretical Framework for Proposed Study
Figure 1Effects of Hysterectomy on Quality of Life
Conceptualized with Roy's Adaptation Model (1999)
RAMwotheme
To help people in achieving their health maximum potential, nurses can initiate their actions with the assessment process. First, they make a decision based on the presence or absence of maladaptation. Next, they begin their assessment on the stimuli influencing the family's maladaptive behaviors. They may possibly need to manipulate the environment or elements of the client system in order to promote health by promoting adaptation. It is the nurse's role to promote adaptation in situations of health and illness in order to enhance the interaction of the persons with their environment (Roy & Andrews, 1999).
Roy (1976) describes health as a state of successful positive adaptation to stimuli from the environment interfering with some basic need satisfaction and threatening to disrupt the equilibrium. Health reflects the adaptation process and is demonstrated by adaptation in each of four integrated adaptive modes: physiologic, self-concept, role function, and interdependence (Roy & Andrews, 1999). The integration of these four adaptive modes reflects wholeness. Health refers to a process that individuals are trying to achieve their maximum potential. This process is manifested in healthy people who exercise regularly, do not smoke, and pay special attention to the terminal stages of cancer in order to take control over symptoms, such as pain, and strive for integration within themselves and in relation to significant others (McQuiston & Webb, 1995).
Roy (1976) describes the environment as being both internal and external in relation to the person that act as stressors. Therefore, all stimuli, whether internal or external, are part of the person's environment. The main goal of the interaction between the person and the environment is to maintain balance and growth. Changes in the environments can affect the development and behavior of the person and threaten his integrity (Roy & Andrews, 1999). Applicable to this study, if a woman responded to the hysterectomy by withdrawing from society and prolonging feelings of sadness and hopelessness, she would be responding ineffectively to the changing environment.
The last key concept in the Roy adaptation model is nursing activities, which also have been described as the nursing process. According to the RAM, there are six steps in the nursing process: assessment of behavior, assessment of stimuli, nursing diagnosis, goal setting, intervention, and evaluation. The nurse goes through the client system by utilizing the nursing process and managing incoming stimuli to promote adaptation. By assessing behaviors and the stimuli, the nurse can formulate nursing diagnoses for the client. Goals are established based on the nursing diagnoses, and interventions are developed to alter stimuli and to enhance the coping mechanism of the client (Roy & Andrews, 1999). In this context, nursing interventions become a powerful force for managing the focal or contextual stimuli to produce a source of stability and growth called adaptation level (Frederickson, 2000).
Chapter Two: Review of Literature
Sexual Functioning
Changes in sexual function after hysterectomy have been a subject of concern to women because it has a significant impact on their quality of life. Currently, there is no strong evidence to suggest that hysterectomy contributes to sexual dysfunction. Some of the common sexual complaints following a hysterectomy include decreased frequency of sexual activity, loss of desire, dyspareunia (painful intercourse), diminished sexual responsiveness, difficulty achieving orgasm and decreased genital sensation (Vomvolaki, 2006). Several studies have been reported that sexual problems after hysterectomy like dyspareunia is possibly related to vagina shrinkage and decreased lubricant, low libido, and not experiencing orgasm (Flory, Bissonnette & Binik, 2005).
Early studies of hysterectomized patients indicated that between 10 to 46 percent of these patients experienced poorer sexual functioning after surgery. Furthermore, as much as one-third of women having hysterectomies reported decreased excitement and orgasm related to absence of cervical stimulation and reduced pelvic congestion. Subsequently, several mechanisms have been proposed in a response to these adverse effects on sexual arousal, changes in pelvic anatomy after surgery, decreasing orgasmic ability because of loss of the uterus, decreasing ovarian function, and the symbolic psychological meaning of loss of the uterus (Flory, Bissonnette & Binik, 2005).
Removal of the uterus fundamentally affects the anatomical structure of the pelvic basin, including the bowel, bladder, and nerves supply to the area. The autonomic nerves of the female internal genital organs are thought to come through the superior hypogastric plexus, which divides and eventually forms the interior hypogastric plexuses. The inferior hypogastric plexus extends into the left and right cardinal and uterosacral ligaments (Harmann, et al, 2004). Furthermore, many of the nerves to the pelvic area run through a structure called uterovaginal plexus, and sometimes excision of the cervix may result in damage to this plexus. As a result, a reduction in sexual arousal and orgasm may follow. The loss of the cervix also may reduce lubrication of the vagina from a decreasing of mucous through the cervix. The reduced quantity of sensitive tissue also results in lessened vasocongestion in to the area, which may lead to a decrease in arousal and a probability of multiple orgasms (Naughton & McBee, 1997).
Hormonal and psychological factors are proposed to be the two major reasons that lead to a reduction in sexual desire following a hysterectomy. Approximately half of patients who undergo the surgical removal of their ovaries (oophorectomy) result in instant surgical menopause. Even hysterectomy without oophorectomy hastens ovarian failure, thereby leading to earlier menopause (Naughton & McBee, 1997). Some women may also find they have loss of libido following a hysterectomy due to the drop in the hormone testosterone. This hormone, also known as the libidinal hormone, appears to be responsible for sex drive. When testosterone levels decline, sexual interest, sensation and frequency of orgasm also may be seen to decline among these women (Vomvolaki, 2006).
For some women, the loss of the uterus and cervix also appears to interfere with their sexual responsiveness. The uterus is a contractory organ. It elevates during sexual excitement and contracts with orgasm. Therefore, women who were aware of this uterine sexual sensation prior to having hysterectomy are likely to feel a change in sexual sensation afterward. Likewise, some women gain their sexual pleasure and orgasm from having the cervix touched repeatedly. Women who lose cervical stimulation through a hysterectomy may experience difficulty in reaching orgasm or find that orgasms are less intense (Vomvolaki, 2006). The loss of the uterus can also be perceived as a loss of femininity and vitality. These psychological issues are important factors to be considered because they are related to sexual outcomes following a hysterectomy (Flory, Bissonnette & Binik, 2005).
Another important factor that plays a role in the postoperative sexual behavior is the preoperative sexual adaptation. Women who have a satisfying sexual relationship preoperatively tend to resume it from where they left in the postoperative period (Bayram & Beji, 2009). If women have sexual problems preoperatively, they will be likely to have it after the operation. Studies evaluating preoperative sexual functions and comparing them with the postoperative functions are highly useful in determining the impact of hysterectomy on sexual functions. However, the existing state of the sexual functions before the operation is not sufficient alone to explain the impact of hysterectomy on sexual functions. Furthermore, sexuality is a highly complex concept shaped by many factors to consider such as previously taken medications, chronic diseases, level of hormones, satisfaction of the relationship between partners, and social norms. Feeling unwell can also interfere with women's interest in sex as well. It is a tremendous challenge to methodologically bring all of these external factors under control (Bayram & Beji, 2009).
Depression
Depression has been cited as the most common psychiatric risk after hysterectomy (Flory, Bissonnette & Binik, 2005). The incident of depression following a hysterectomy is dependent on a number of factors. One of the main factors that many women suffer depression after having hysterectomy is the losing of fertility function. Additionally, other factors like fear of losing sexual attractiveness, decrease in sexual interest, loss of sexual identity, and change of body image are responsible for this psychiatric disorder. Although it is difficult to foresee psychiatric problems following a hysterectomy in the early weeks, psychological problems can be seen later during the period of adaptation to new life (Bayram & Beji, 2009). Women are more likely to develop depression if they do not allow themselves enough time to consider various changes that a hysterectomy will bring. 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 suicidal ideation (Vomvolaki, 2006).
In the past decade, several prospective studies have suggested that hysterectomy for benign disorders does not cause depression and may actually decrease psychiatric symptoms in many women. These studies repeatedly have found that presurgical psychopathology was predictive of postsurgical psychopathology. A more recent prospective cohort study used a non-clinical population-based sample to assess the effects of hysterectomy on psychological functioning using the patients' psychological state before any indication of a need for hysterectomy as a baseline. The findings from this study are very similar to the previous studies, suggesting that women who undergo hysterectomy do not have a higher risk of having depression, stress, or other psychosomatic symptoms than premenopausal control women (Bayram & Beji, 2009). From a clinical standpoint, the implications of these findings suggest that women with pre-existing conditions or those who have a history of depression may be at higher risk for psychiatric morbidity after hysterectomy and therefore should be psychologically prepared for surgery and closely monitored afterward (Flory, Bissonnette & Binik, 2005).
Although there is little evidence to suggest that hysterectomy is a risk factor for
depression, others have suggested that depression may be a risk factor for hysterectomy. A study of trends in psychiatric morbidity in women undergoing hysterectomy for benign conditions over a period of time demonstrated a decline in preoperative psychiatric morbidity between 1975 and 1990. The decline was not related to socio-demographic factors, menstrual problems, or women's understanding and expectations of surgery. One possible explanation for this finding may be that, in the past, patients reporting emotional symptoms preferentially were referred for hysterectomy (Bayram & Beji, 2009). From a clinical perspective, women with pre-existing psychiatric disorders may be at higher risk for psychiatric morbidity after hysterectomy and should be psychologically prepared for surgery and closely followed afterward. The majority of women experiencing symptoms of depression and anxiety before hysterectomy for benign conditions can expect a significant improvement in psychological status in the year after hysterectomy.
Hysterectomy status may not be the only determining factor. Research findings suggest that women with clinical depression are likely to be at greater risk for surgery than those who are not depressed. In general, several research studies indicate that women with preoperative depression are at increased risk for depression after surgery, suggesting that
hysterectomy itself may not be the contributing factor in the development of depressive symptomatology (Naughton & McBee, 1997).
Pain Outcomes
Pelvic pain has been the center of attention of some research on quality of life following a hysterectomy. The majority of studies have focused more on pain resolution and symptom relief rather than addressing the global impact on quality of life. Currently, the etiology of chronic pelvic pain in women is not well understood. Although a specific diagnosis cannot be determined in the majority of cases, common diagnoses like endometriosis, irritable bowel syndrome, adhesions, and interstitial cystitis are responsible for some chronic pelvic pain (Ortiz, 2008). Estimates of the prevalence of pelvic pain in patients with uterine-related problem ranged from 40% to 75%, although only a fraction of these patients chose to discuss the subject of painful intercourse with care givers and receive a diagnosis. In theory, the removal of the affected uterus should alleviate pelvic pain. However, scarring in the pelvic region may be responsible for postoperative pain. Some of the risk factors for continued pain include the patients' age (less 30 years old), a history of pelvic inflammatory disease, no insurance or coverage by Medicaid, no identified pelvic pathology, and a history of two or more pregnancies (Hillis, 1995). Presently, it is not clearly understood of why some women experience positive pain outcomes following a hysterectomy while others do not. It still cannot be determined whether there are specific factors, such as surgical route, concomitant oophorectomy, or simply psychosocial factor, that can increase women's risk of having poor outcomes after hysterectomy (Kjerulff, 2000).
Systematic Reviews
Multiple systematic reviews have been done in the past on the subject of the effects of hysterectomy on quality of life. Three systematic reviews published with synthesis of literature through 2005 are chosen to discuss in this paper.
Naughton & McBee (1997) conducted a systematic review on the published studies in the past 10 years to examine the effects of hysterectomy on the daily lives of hysterectomized patients. According to Nauthton & McBee (1997), the findings from various studies demonstrated an improvement in symptoms and quality of life after surgery, particularly for those women who had more severe symptoms before surgery. The majority of women reported a reduction in physical symptoms, pain, health perceptions and overall health-related quality of life following a hysterectomy. After thoroughly reviewing the studies on depression following a hysterectomy, the authors concluded that hysterectomy did not seem to cause depression, but may brought relief in overall symptoms. For some women who may experience depression after hysterectomy, the authors suggested that the results of research in area did not indicate that hysterectomy was the causative factor. The findings regarding the quality of one's sexual life after hysterectomy is mixed. The majority of recent studies have suggested that hysterectomy without oophorectomy was not related to decreased sexual functioning after surgery, although between 10 to 20 percent of women might report some degree of sexual dysfunction after hysterectomy.
Flory et al. (2005) analyzed over 100 studies that were published in the past 30 years evaluating the psychosocial outcomes following a hysterectomy in areas of pain, sexuality and psychological functioning. The findings from this systematic review suggested that although hysterectomies appeared to minimize the pain, they did not have any effects on sexuality and psychological well-being. Nevertheless, there might be a subgroup of women of 10 to 20 percent who reported negative psychosocial outcomes such as reduced sexual interest, arousal, and orgasm, as well as elevated depressive symptoms and impaired body image.
Vomualoki et al. (2005) reviewed studies that were published in different journals between 1966 and 2002 on the effects of hysterectomy on sexuality and psychological changes. According to the authors, women were more likely to have depression if they rushed into the procedure without having enough time and opportunity to consider changes that a hysterectomy would bring. Vomualoki et al. (2005) found that women were more likely to report improved sexual functioning after the surgery when their symptoms had been alleviated. Furthermore, they suggested that a new hysterectomy procedure that spared abdominal ligaments and nerves was faster and resulted in shorter hospital stay and seemed to respect the tissues more, without affecting sexuality of the women.
Chapter Three: Methodology
This chapter describes the search strategies employed to indentify research related to the impact of hysterectomy on a woman's quality of life. The data collection process will be explained thoroughly and the chapter concludes with a step-by-step description of the data analysis.
Search Strategies
The University of North Florida (UNF) library database was searched using various combinations of the following key words: hysterectomy, surgical menopause, laparosc*, abdominal, quality of life, pelvic pain, depression, and sexual functioning. CINAHL, Medline, PubMed, Cochrane Library, and Proquest Medical Library search engines, as well as cross references were utilized to locate research articles. Most articles related to quality of life after hysterectomy published since the last review of the literature through 2009 were indentified using CINAHL. A total of 48 articles were retrieved from these different databases.
Criteria for inclusion in this analysis were studies published in English since 1994 to date that examine the effects of hysterectomy on women's quality of life. Limitations were inclusion criteria of the English language only and the exclusion of studies focusing on depression, pelvic pain and sexual interest. A total of 14 studies satisfied these criteria and were retained for analysis. Appendices A, B, and C present critical analysis tables with details of these studies.
Overview of Studies Examining Sexual Functioning After Hysterectomy
Lambden et al. (1997) conducted a study to describe women's perceived sense of well-being before and after hysterectomy for benign conditions. There were 178 women participated in the study, and they completed questionnaires before surgery and at four months and again at 11 months postoperatively. The findings suggested sexual functioning and overall health status were improved after the immediate recovery period. Frequency of intercourse and sexual desire increased at four months after operation.
Rhodes et al. (1999) conducted a two-year study (Maryland Women's Health Study) to examine changes in sexual functions after hysterectomy. This relatively large study (n = 1,101) measured sexual desire, frequency of coitus, orgasm, dyspareunia and vaginal dryness as outcome measure 6, 12, 18, and 24 months after hysterectomy. The findings suggested significant differences such as an increase in sexual activity (70.5 percent of women before hysterectomy to 76.7 percent two years after hysterectomy. Moreover, women experienced orgasm after surgery than before, and low libido rates decreased from 10.4 percent before surgery to 6.2 percent at the endpoint of the study.
Ayoubi et al. (2002) conducted a retrospective study to determine the relative effects of abdominal, vaginal, or laparoscopic approaches for hysterectomy on female sexuality. Pre and postoperative sexuality was assessed by questionnaire, and this questionnaire was mailed to each participant approximately one year after hysterectomy. According to the study, sexuality after hysterectomy remained unchanged in 60.4 percent of cases, and improved or deteriorated in 21.3 and 18.3 percent respectively. In addition, women who had vaginal hysterectomy resumed sexual activity sooner than those who had vaginal hysterectomy. The results suggested that the impact of vaginal and laparoscopic hysterectomy on women's sexuality may be milder than of abdominal hysterectomy.
Kupermann et al. (2004) conducted a study 63 premenopausal women, aged 30 to 50 years, who had abnormal uterine bleeding for a median four years despite a variety of medical treatments. The authors randomly assigned women who underwent hysterectomy (n=31) or expanded medical treatment (n=32). The authors also assessed overall mental health as the primary outcome by using the Mental Component Summary (MCS) of the 36-Item Short-Form Health Survey (SF-36). The participants were followed-up for two years. The purpose of this study was to compare the effect of hysterectomy versus expanded medical treatment on health-related quality of life. The findings from this study suggested that quality of life among women in the hysterectomy group was significantly improved compared to women in the medication group. Women in the hysterectomy group improved their overall mental health scores far more than women in medicine group at six months period. In addition, the hysterectomy group had better symptom resolution, better health outcomes, fewer pelvic problems that interfered with sex, more sexual desire, and greater satisfaction with overall health. Fifty three percent of women in the medicine group had requested and received a hysterectomy by the end of the study. The study reported improvement in quality of life outcomes among these women during the two years similar to those reported by women randomized to the hysterectomy group. Those who chose to continue with medical treatment also reported some improvement.
Learman et al. (2004) conducted a study to compare clinical outcomes after hysterectomy versus medical treatment in patients with chronic abnormal uterine bleeding refractor to medroxyprogesterone acetate. The findings suggested that clinical symptoms among women in the hysterectomy group were improved compared to women in the medicine group for cessation of vaginal bleeding (87 percent versus 11 percent). Furthermore, quality of life and sexual functioning were significantly improved among women in the two years follow-up, regardless of whether or not they had a hysterectomy. Learman et al. (2004) concluded that hysterectomy might be the most favorable choice for women who gave high priority to resolving difficult symptoms, but the authors noted that many women who were treated medically also experienced some improvement.
Overview of Study Examining Depression After Hysterectomy
Kinnick & Lener (1995) conducted a prospective study to examine the differences in a woman's quality of life following a hysterectomy, which include the incidence of depression and the effect of social support. Thirty women, who participated in the study, were mainly from agricultural setting. The questionnaire sent prior to surgery was self-administered that include the Beck Depression Inventory and the Ferrans and Powers Quality of Life Index. The researchers used the Beck Depression Inventory to measure depression. Three hypotheses included in the study were: 1. Women who do not have depression prior to their hysterectomy may will not develop depression post-operatively, 2. Women who have a high degree of social support throughout their hysterectomy experience will have less depression and have a more positive perception of quality of life post-operatively than women with a low degree of social support, 3. Women's perception of quality of life will be greater post-hysterectomy as compared to the perception of quality of life pre-operatively. The findings from the first hypothesis suggested that hysterectomy had no effect or actually decreased the degree of depression in the sample studied. The findings from the second hypothesis suggested that the degree of social support perceived by the sample studied did not change from pre-test to post-test. The finds from the last hypothesis suggested improvement of quality of life experienced by the sample studied.
Ryan et al. (1989) conducted a study with prospective and retrospective components to determine the effect of study design on the psychological aspects of hysterectomy. The Present State Examination and the POS were utilized two weeks prior and four months and again at 14 months after surgery in one group of women, and only at 14 months of follow-up in another group. The findings suggested a significant improvement in mood and a reduction in psychiatric morbidity among the patients studied prospectively (55 percent presurgery morbidity versus 32 percent at 14 months following a hysterectomy). No significant differences in depression at 14 months were seen between the prospective and retrospective groups.
Meson (2004) used an experimental-comparison design with a sample of 32 women who had a history of benign uterine fibroids and had undergone hysterectomy. The author wanted to examine the possibility that women who underwent hysterectomy also experienced an impaired vasocongestive response to erotic stimulation. To achieve this goal, two experimental sessions including self-reporting and physiological (vaginal pulse amplitude) sexual responses were recorded during an erotic film presentation. The findings from this study suggested potential impairment of physiological sexual arousal with hysterectomy surgery. The author of this study partially supported the hypothesis that physiological sexual arousal may be impaired with hysterectomy surgery.
Thakar et al. (2004) conducted a prospective, randomized and double-blind study to compare the impact of total versus subtotal abdominal hysterectomy on quality of life and psychological symptoms. There were 279 women who participated in the study, and their quality of life and psychological symptoms were similar in both groups at baseline. Quality of life was assessed by using the Short-Form-36 health survey and psychological outcomes were measured by using the General Health Questionnaire-28 before the operation and six and twelve months after. The findings from the study suggested that subtotal hysterectomy did not give more advantage over total hysterectomy. All women in both groups showed improvement in psychological symptoms following both operations.
Overview of Study Examining Pain Outcomes After Hysterectomy
Carlson et al. (1994) completed one of the leading investigations in the United States to evaluate the outcomes of hysterectomy for nonmalignant conditions. The Maine Women's Health Study was a prospective cohort study investigation of 418 women between the ages of 25 to 50 years who underwent hysterectomy between 1989 to 1991 period. Results from women undergoing hysterectomy suggested significant improvements in fatigue, pelvic pain, psychological symptoms, and sexual functioning. Relief from these symptoms resulted in improved quality of life, which was sustained at both six months and one year after surgery. Only a small number of women reported new symptoms after hysterectomy, such as hot flashes (13 percent), depression (eight percent), anxiety (six percent), and lack of sexual desire (seven percent).
Hillis (1995) evaluated the effectiveness of hysterectomy in treating chronic pelvic pain and to identify risk factors for persistent pelvic pain. A group of 308 women who had hysterectomy for chronic pelvic pain and were followed-up for at least six months participated in a large, prospective, multicenter cohort study. Results showed that 74 percent of hysterectomized patients were experienced compete resolution of pelvic pain. Hillis (1995) also suggested that pain was more likely to resolve in women with identifiable pelvic pathology or fewer than two pregnancies. Even in women with no identifiable pathology, 62 percent had complete resolution of their pain postoperatively.
Farquha et al. (2002) conducted a prospective study of the short-term outcomes of hysterectomy with and without oophorectomy to examine prospectively the physical and psychological effects of hysterectomy with and without conservation of the ovaries. The authors of this study focuses on the six-week and six-month follow-up of women undergoing hysterectomy with and without conservation of the ovaries. While majority of women are satisfied with the procedure after six-week and six-month, the findings suggest that there are still significant numbers of women in both groups who continue to experience pain. Pelvic pain was reported in more than half of the women at six weeks. Quality of sexual function in women did not improve. Furthermore, the results also suggested that new symptoms of pelvic pain or depression were present at six months in more than 16 percent to 37 percent of the women.
Hartmann (2004) conducted a cohort study of 1,240 women who had hysterectomy for benign conditions to examine differences in quality of life and sexual function after hysterectomy among women with preoperative pain and depression. Women who participated in this study were interviewed before surgery and at five intervals after regarding pelvic pain, depression, quality of life, and sexual function. The findings suggested that women with pain and depression had reduced prevalence of pelvic pain from 96.7 percent to 19.4 percent. Women with pain only improved in pelvic pain (95 percent to 9.3 percent). Furthermore, this study found that the majority of participants with pain, depression, or both, reported that their symptoms, quality of life, and sexual function improved substantially.
Brandsborg et al. (2008) conducted a prospective study of risk factors for pain persisting 4 months after hysterectomy to explore the role of surgery and other possible predictors for pain four months after hysterectomy. Ninety women referred for hysterectomy for benign conditions participated in the study. The women were interviewed and completed in questionnaires before surgery and after three weeks and four months. In addition, they also completed the short form-36 General Health Status Questionnaire and Coping Strategies Questionnaire before surgery. The findings from this study suggested that 16.7 percent of women have pain that affects daily living four months after hysterectomy, and in most cases the pain may be classified as likely to be continuing from surgery. The findings also suggested that both physiologic and psychosocial factors are involved in chronic pain after hysterectomy.
Appendix A: Critical Analysis Table (summary of the studies related to depression)
Researcher
Design
Sample
Data Collection
Ryan et al., 1989
Prospective and retrospective study
n:60 aged between 30 and 55 years, having hysterectomy for benign conditions
Two weeks of operation and after four months and 14 months
Kinnick & Lener, 1995
Prospective study
n:30
Pre-op questionnaire, the Beck Depression Inventory, the Norbeck Social Support Questionnaire, and the Ferrans and Powers Quality of Life Index
Kjerulff, 2000
Prospective study
n:1,162
pre-op 3, 6, 12, 18 months
Thakar et al., 2004
Randomized, prospective, comparative, double blind study
n:279 (n=146 had total hysterectomy, n=133 had subtotal hysterectomy)
Short-Form-36 health survey for quality of life assessment and General Health Questionnaire-28 for psychological outcome measurement
Meston, 2004
Experimental session
n:32
Physiological measurement
Appendix B: Critical Analysis Table (summary of the studies related to sexual function)
Researcher
Design
Sample
Data Collection
Rhodes et al., 1999
Prospective (Maryland Women's Health Study), comparative
n:1,101
Pre-op, post-op 6,12,18,24 months,
Ayoubi, 2003
Retrospective study
n:170 (n=68 underwent abdominal, n=68 vaginal, n=35 laparoscopic)
Pre-op, post-op 1 year
Kupperman et al., 2004
Randomized, prospective, comparative study
n: 63 premenopausal women with abnormal uterine bleeding
post-op 6th month and second year,
Lambden et al., 1997
Prospective, descriptive study
n:178 without nononcological symptoms
Pre-op questionnaire, Zung self-Rating Depression Scale pre-op and 4 months post-op, medical record
Learman et al., 2004
Ramdomized, prospective, comparative study
n:63 premenopausal women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate treatment
Post-op 6 and 12 months using an intention-to-treat approach
Appendix C: Critical Analysis Table (summary of the studies related to pelvic pain)
Researcher
Design
Sample
Data
Hillis, 1995
Prospective, multicenter cohort study
n:308 women had hysterectomy for pelvic pain
1 year after surgery follow-up
Farquha et al., 2005
Prospective study
n:323 women undergoing hysterectomy with and without oophorecomy
6 weeks and 6 months follow-up
Hartmann, 2004
Cohort study
n:1,249 women undergoing hysterectomy for benign conditions
Post-op 6 and 24 months questionnaire
Brandsborg, et al., 2008
Prospective study
n:90 women undergoing hysterectomy for benign conditions
Pain questionnaire pre-op and post-op 3 weeks and 4 months
