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Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Gynaecology
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery Sarah Walker, RN, MSc,1,2 Wilma M. Hopman, BAH, MA,3,4 Margaret B. Harrison, RN, PhD2,4 Dean Tripp, PhD,1,5,6 Elizabeth G. VanDenKerkhof, RN, DrPH1,2 1
Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston ON
2
School of Nursing, Queen’s University, Kingston ON
3
Clinical Research Centre, Kingston General Hospital, Kingston ON
4
Department of Community Health and Epidemiology, Kingston ON
5
Department of Psychology, Queen’s University, Kingston ON
6
Department of Urology, Queen’s University, Kingston ON
Abstract
Résumé
Objective: Pain is frequently a complaint prior to gynaecological surgery. Psychological factors are also known to influence the experience of pain. The primary objective of this study was to assess the prevalence of pain and the relationship between psychological factors and pain in women awaiting gynaecological surgery.
Objectif : La douleur figure fréquemment au nombre des plaintes avant la tenue d’une chirurgie gynécologique. On sait également que des facteurs psychologiques exercent une certaine influence sur l’expérience de la douleur. Cette étude avait pour objectif principal d’évaluer la prévalence de la douleur et la relation entre les facteurs psychologiques et la douleur chez les femmes en attente d’une chirurgie gynécologique.
Methods: Four hundred twenty-nine women in a tertiary care centre in southeastern Ontario were included in this cross-sectional analysis, which was embedded in a larger prospective study. Pain was assessed using the Brief Pain Inventory, anxiety using the State Trait Anxiety Inventory, depressive symptoms using the Center for Epidemiologic Studies Depression Scale, somatization using the Seven Symptom Screening Test, and catastrophizing with an abbreviated coping strategies questionnaire. Results: Eighteen percent of women reported high anxiety, 37% reported depressive symptoms, 47% had two or more symptoms of somatization, and 40% reported elevated pain catastrophizing. Approximately one third reported moderate to severe pain intensity and interference. Of those reporting pain, 81% believed their pain was due to their primary condition. Depressive symptoms, somatization, and catastrophizing were associated with elevated pain intensity and interference. Conclusion: The responses suggest a substantial burden of pain, anxiety, and depressive symptoms in women awaiting gynaecological surgery. Further research is needed to assess the management of these symptoms and their impact on health care resources and the well-being of women in this setting.
Key Words: Gynaecologic surgery, depression, anxiety, pain intensity, pain interference, preoperative Competing Interests: None declared. Received on November 15, 2011 Accepted on February 22, 2012
Méthodes : Quatre cent vingt-neuf femmes d’un centre de soins tertiaires du sud-est ontarien ont été incluses dans le cadre de cette analyse transversale, laquelle s’inscrivait dans une étude prospective de plus grande envergure. La douleur a été évaluée au moyen du Brief Pain Inventory; l’anxiété, au moyen du State Trait Anxiety Inventory; les symptômes de dépression, au moyen de la Center for Epidemiologic Studies Depression Scale; la somatisation, au moyen du Seven Symptom Screening Test; et la catastrophisation, au moyen d’un questionnaire abrégé sur les stratégies d’adaptation. Résultats : Dix-huit pour cent des femmes ont signalé une forte anxiété, 37 % ont signalé des symptômes de dépression, 47 % ont connu deux symptômes de somatisation ou plus et 40 % ont signalé une catastrophisation élevée de la douleur. Près du tiers des femmes ont signalé une interférence et une intensité de la douleur allant de modérées à graves. Chez les femmes signalant de la douleur, 81 % estimaient que leur douleur était attribuable à leur pathologie principale. Les symptômes de dépression, la somatisation et la catastrophisation étaient associés à une interférence et à une intensité de la douleur élevées. Conclusion : Les réponses semblent indiquer un fardeau de la douleur, une anxiété et des symptômes de dépression substantiels chez les femmes qui attendent de subir une chirurgie gynécologique. La tenue d’autres recherches s’avère requise pour évaluer la prise en charge de ces symptômes et leurs effets sur les ressources de santé et le bien-être des femmes dans ce milieu.
J Obstet Gynaecol Can 2012;34(6):543–551
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INTRODUCTION
T
he prevalence of chronic pain in the general population may be as high as 35%. Chronic pain results in a significant burden to the individual, the family, and society.1,2 It is estimated that pain costs the United States $635 billion annually in health care costs and lost productivity.3 Chronic pain adversely affects quality of life and function, and some populations are more vulnerable to pain than others. Vulnerable populations have been identified with respect to certain psychological characteristics (e.g., somatization and depression).4,5 The impact of psychological, social, and cultural factors on pain6–8 is also reflected in the International Association for the Study of Pain definition of pain.9 Pain is a common symptom in women experiencing gynaecological problems,10–16 and untreated gynaecologic pain, such as dysmenorrhea, premenstrual pelvic pain, ovulatory pain, and other cyclic pain, may develop into chronic pelvic pain if unmanaged.17 However, little is known about pain characteristics and psychological characteristics associated with pain in women waiting for gynaecologic surgery. Psychological factors, especially depression and anxiety, have been documented in women waiting for gynaecological surgery.11,18,19 There is also emerging evidence that women with preoperative psychological distress experience significant levels of pain. In a cross-sectional study of 472 women undergoing treatment for breast and gynaecological cancers in the United States, women with high levels of pain were also more likely to report depression.20 In a study of 1249 women awaiting hysterectomy in the United States, 13% reported depression and pain, 14% depression only, and 19% pain only.11 No studies of pain and psychological experience prior to gynaecological surgery have been reported for women in Canada. Evidence suggests that women waiting for gynaecologic surgery experience significant levels of pain and psychological symptoms, especially depression.11 Little is known about other psychological factors emerging as significant correlates of pain, i.e., somatization and catastrophizing. Physical symptoms may be influenced by or even stem from emotional problems.5 The experiences of such symptoms are real and manifest as anxiety.
ABBREVIATIONS CES-D Center for Epidemiologic Studies Depression Scale IQR
interquartile range
SSST
Seven Symptom Screening Test
544 l JUNE JOGC JUIN 2012
Somatization is characterized by the presence of physical symptoms with no identifiable medical cause.21,22 Catastrophizing is the tendency to engage in negative selfstatements, feelings, and ideation.23 Pain catastrophizing has been defined as a negative cognitive orientation towards pain or painful stimulation, and it is associated with increased reports of pain.24 Both somatization and catastrophizing have been associated with preoperative pain.25,26 The purpose of this study was to examine the relationship between pain and psychological symptoms in women awaiting gynaecological surgery. The objectives were: 1. to describe the prevalence of pain, pain-related interference, and psychological symptoms, and 2. to examine the association between psychological symptoms (i.e., anxiety, depressive symptoms, somatization, and catastrophizing) and pain. METHODS
For this cross-sectional study we recruited Englishspeaking women aged 18 years or older who were waiting to undergo gynaecological surgery. They formed a subset of women who had been recruited into a larger prospective study examining outcomes after surgery.27 The convenience sample was drawn from the waiting list of women at Kingston General Hospital, a tertiary care facility in southeastern Ontario that serves more than 500 000 people in the local and surrounding communities. Subjects were recruited and informed consent was obtained upon admission for surgery in the Same Day Admission Centre. Patients were excluded if they had Alzheimer disease or other cognitive impairment. The primary outcomes of interest were severity of preoperative pain and pain-related interference. These outcomes were measured using the Brief Pain Inventory Long Form, a multidimensional pain assessment instrument.28 Subscales for pain severity and pain-related interference (numerical responses to 4 and 7 questions respectively, averaged to provide scores ranging from 0 to 10) refer to pain experienced in the past week. For the purpose of this study, pain severity and pain interference summary scores were dichotomized into none/mild (≤ 3/10) and moderate/severe (> 3/10).29 The independent variables of interest were waiting time for surgery and the presence of anxiety, depressive symptoms, somatization, and catastrophizing. Demographic and gynaecological factors were considered potential
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 1. Baseline characteristics of women waiting for gynaecological surgery n = 429
%*
18 to 44
160
37.3
45 to 55
168
39.2
≥ 56
101
23.5
Single/divorced/widowed
123
28.7
Married
306
71.3
Caucasian
399
93.2
Non-Caucasian
29
6.8
Age, years
Marital status
Racial heritage†
Highest education grade achieved No diploma
50
11.7
High school diploma
87
20.3
Trade or professional school certificate/diploma
150
35.0
Some university/postgraduate degree(s)
142
33.1
Unemployed/retired/homemaker
111
25.9
Employed part time or full time
283
66.0
Other
35
8.2
≤ 24.9
126
29.4
25 to 29.9
126
29.4
≥ 30
177
41.3
Yes
90
21.0
No
339
79.0
Yes
295
68.8
No
130
30.3
<4
111
25.9
4 to 8
149
34.7
>8
169
39.4
Low (< 45)
350
82.0
High (≥ 45)
77
18.0
Low (< 16)
270
62.9
High (≥ 16)
159
37.1
0
78
18.2
1
147
34.3
2
115
26.8
3
55
12.8
4
20
4.7
≥5
10
2.3
Employment status
BMI (kg/m2)
Current smoker
Previous abdominal surgery
Adjusted wait time,‡ weeks
State Trait Anxiety Inventory score‡
CES-D depression score
SSST score§
Continued
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Table 1. continued n = 429
%*
No catastrophizing
128
29.8
Low catastrophizing
129
30.1
High catastrophizing
172
40.1
Catastrophizing score
Menstruation Unsure/irregular
31
7.2
Stopped naturally
128
29.8
Stopped surgically
45
10.5
Not stopped
225
52.4
Yes
23
6.8
No
316
93.2
Currently taking hormone replacement therapy
Have taken birth control pills in the past month║ Yes
40
9.5
No
382
90.5
Possibly malignant
99
23.1
Malignant
72
16.8
Not malignant
256
59.7
Continuous variables
Mean (SD)
Range (min/max)
Age in years
48.3 (11.0)
18 to 83
BMI
29.1 (7.4)
17 to 60
State Trait Anxiety Inventory score
34.2 (10.7)
20 to 72
Preoperative malignancy status
CES-D scores
13.8 (11.6)
0 to 58
Waiting time
63.8 (60.6)
0 to 680
*Values do not always equal 100% because of rounding †1 participant missing ‡2 participants missing §4 participants missing ║7 participants missing
confounders. Data collection consisted of five selfreporting questionnaires that gathered information on pain and psychological factors. Additional data such as age, smoking status, and BMI were gathered from the patient record. Waiting time for surgery was obtained from the hospital administrative database. Waiting time was defined as the time between the decision to treat and the date of surgery30 and was adjusted for time that the patients were not available for surgery. Trait anxiety was measured using the State Trait Anxiety Inventory, a validated and reliable self-reporting measurement tool of 20 questions about general feelings of anxiety (trait).31 Scores range from 20 to 80, with a higher score indicating a greater degree of anxiety. The scale was categorized into low (score < 45) versus high (≥ 45).18 Depressive symptoms were measured 546 l JUNE JOGC JUIN 2012
using the CES-D Scale.32 The CES-D is a 20-item selfreporting questionnaire assessing feelings of low mood and depressive thinking during the past week. Scores range from 0 to 60 points, with a higher score indicating a greater degree of depressive symptoms. Scores on the CES-D were categorized into low (< 16) or high (≥ 16) levels of depressive symptoms, with the latter suggesting a risk of depression that requires treatment.32,33 Somatization was measured with the SSST.34 According to the original developers of the SSST, the presence of three of the seven symptoms is suggestive of a somatization disorder; however, because of low prevalence of somatization characteristics, we elected to categorize SSST into low (< 2 symptoms) versus high (≥ 2 symptoms) using the median split for the total sample. Pain catastrophizing was measured using a two-
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 2. Pain intensity and pain interference scores obtained from the brief pain inventory for all participants and for women with pain Total number of women
Total number with pain > 0/10
n
median
IQR
n
median
IQR
Pain at its worst in the past week
429
2.0
0.0 to 7.0
226
6.0
4.0 to 8.0
Pain at its least in the past week
429
0.0
0.0 to 1.5
142
3.0
1.8 to 4.0
Pain on average
429
1.0
0.0 to 5.0
222
4.0
3.0 to 6.0
Pain you have right now
429
0.0
0.0 to 2.0
157
3.0
2.0 to 5.0
Pain Severity Score
429
1.0
0.0 to 4.0
226
4.8
4.0 to 6.0
General activity
429
0.0
0.0 to 5.0
198
5.0
3.0 to 7.0
Mood
429
0.0
0.0 to 5.0
187
5.0
3.0 to 7.0
Walking ability
429
0.0
0.0 to 3.0
153
5.0
3.0 to 7.0
Normal work (outside the home and housework)
429
0.0
0.0 to 5.0
188
5.0
3.0 to 8.0
Relations with other people
429
0.0
0.0 to 2.0
136
5.0
2.0 to 7.0
Sleep
429
0.0
0.0 to 5.0
177
6.0
3.0 to 8.0
Enjoyment of life
429
0.0
0.0 to 5.0
190
5.0
3.0 to 8.0
Pain interference score
429
0.0
0.0 to 4.0
226
6.0
4.0 to 7.0
Pain Intensity Scale (0 to 10)
Pain Interference Scale (0 to 10)
item pain-catastrophizing measure that asks individuals about thoughts of helplessness when they have pain.35 The overall score was calculated by taking the average of the 0 to 6 Likert scale scores for the two questions, resulting in an overall score ranging from 0 to 6. For the purpose of the analysis, we classified pain catastrophizing into low (< 2) and high (≥ 2) using the median split of the overall score. Gynaecologic variables captured through self-reporting included menstrual status, menopausal status, and the use of postmenopausal hormone therapy and oral contraceptives. The presence or absence of malignancy was captured from the hospital record. Demographic and clinical covariates including age, marital status, race, education, employment, and smoking status were collected using questionnaires. Previous abdominal surgery and BMI (calculated from height and weight) were captured from the hospital preadmission record. Descriptive statistics were calculated using frequency and percentages for categorical variables and means, standard deviation, range, median, and interquartile range for continuous variables. Bivariable analysis was conducted using the chi-square statistical test to assess possible associations between pain status and the independent variables and between waiting time and the independent variables. Variables were included in the multivariable analysis if we found P ≤ 0.1 in the bivariate analysis. The results are presented as odds ratio with 95% confidence
intervals for both bivariable and multivariable analyses. Given the descriptive nature of this study and the fact that it was embedded in a larger prospective cohort study, a sample size calculation was not conducted. Data analysis was carried out using SPSS software version 16.0 (IBM Corp., Armonk NY). Ethics approval was obtained from the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board. RESULTS
Of the 635 women approached and invited to join the study, 441 were recruited and six withdrew before completing the questionnaires, leaving 435 (69%) patients with complete data. Six participants who underwent urological surgery were excluded, leaving 429 participants for the final analysis. The predominant surgical procedure was hysterectomy (77%), followed by ovarian or tubal procedures (12%), exploratory/ peritoneal procedures (4%), pelvic floor repair (3%), and other gynaecological procedures (4%). Study participants ranged in age from 18 to 83 years (mean 48.3 yr, SD 11 years) and were predominantly Caucasian (93%) (Table 1). The majority (69%) had undergone previous abdominal surgery, 40% were no longer menstruating, and, of these, 11% had stopped menstruating because of surgery. Forty percent of participants had a preoperative diagnosis of possible or confirmed malignancy. JUNE JOGC JUIN 2012 l 547
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Figure 1. Number of pain descriptors used in women reporting pain (n = 230)
% of women with pain
16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
Number of pain quality descriptors used
Figure 2. Pain quality descriptors in women reporting pain (n = 230) 90% 80%
% of women
70% 60% 50% 40% 30% 20% 10% 0%
Fifty-three percent (226/429) of respondents reported some pain (> 0/10), with 31% (131/429) reporting moderate to severe pain and 32% (135/429) reporting moderate to severe pain-related interference. The median pain-related interference score in women with pain was 6.0 (IQR 4.0, 7.0) (Table 2). Of the women who had experienced pain in the last week, 81% believed that their pain was due to their primary gynaecological condition, and these women were more likely to be depressed (45% vs. 26%, P < 0.01) than women who did not believe that their pain was related to their gynaecological condition; however, anxiety, somatizing, and pain catastrophizing were not significantly different between these groups. Nearly one half of the participants used eight or more pain descriptors to characterize their pain (Figure 1). Aching (80%), tiring (74%), and nagging (71%) were most frequently reported (Figure 2). Eighteen percent reported high trait anxiety and 37% reported depressive symptoms. Somatization scores ranged between 0 and 6 out of 7, and almost half (47%) 548 l JUNE JOGC JUIN 2012
reported at least two somatic symptoms (Table 1). Pain catastrophizing scores ranged from 0 to 6 out of 6, and 40% of participants scored ≥ 2 out of 6. Depressive symptoms, somatization, and pain catastrophizing were independently associated with moderate to severe pain and pain interference, when controlling for potential confounders (Table 3). The median waiting time for surgery was 48 days (IQR 27, 85 days) and waiting time was not significantly associated with pain severity or interference. Somatization was the only psychological variable significantly associated with waiting time (P < 0.05). DISCUSSION
We found high levels of moderate to severe pain and adverse psychological symptoms in women awaiting gynaecological surgery. In addition, women reporting depressive symptoms, somatization, and pain catastrophizing were two to four times more likely to report moderate to severe pain and painrelated interference. There was a non-significant increase in
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 3. Bivariate and multivariate results for moderate to severe pain intensity and pain-related interference Bivariate analysis Variable
Total (n = 429)
Pain ≤ 3/10 n (%)†
Pain > 3/10 n (%)†
n = 298
n = 131
Odds Ratio
Multivariate analysis*
95% CI
Odds Ratio
95% CI
Pain Intensity Adjusted wait time, weeks <4
111
82 (73.9)
29 (26.1)
1.0
4 to 8
149
107 (71.8)
42 (28.2)
1.1
0.6 to 1.9
—
NA
>8
169
109 (64.5)
60 (35.5)
1.5
0.9 to 2.6
—
NA
Low (20 to 44)
350
258 (73.7)
92 (26.3)
1.0
High (≥ 45)
77
39 (50.6)
38 (49.4)
2.7
1.6 to 4.5
—
NS
Low (< 16)
270
217 (80.4)
53(19.6)
1.0
High (≥ 16)
159
81 (50.9)
78 (49.1)
3.9
2.6 to 6.1
2.0
1.2 to 3.3
Low (< 2)
225
186 (82.7)
39 (17.3)
1.0
High (≥ 2)
200
109 (54.5)
91 (45.5)
4.0
2.6 to 6.2
2.8
1.7 to 4.5
No/low (< 2/6)
257
217 (84.4)
40 (15.6)
1.0
High (≥ 2/6)
172
81 (47.1)
91 (52.9)
6.1
3.9 to 9.6
4.0
2.5 to 6.6
n = 135
n = 294
<4
111
82 (73.9)
29 (26.1)
1.0
4 to 8
149
100 (67.1)
49 (32.9)
1.4
0.8 to 2.4
—
NA
>8
169
112 (66.3)
57 (33.7)
1.4
0.8 to 2.4
—
NA
Low (20 to 44)
350
254 (72.6)
96 (27.4)
1.0
High (≥ 45)
77
39 (50.6)
38(49.4)
2.6
1.6 to 4.3
—
NS
Low (<16)
270
220 (81.5)
50 (18.5)
1.0
High (≥16)
159
74 (46.5)
85 (53.5)
5.1
3.3 to 7.8
3.0
1.8 to 4.8
Low (< 2)
225
180 (80.0)
45 (20.0)
1.0
High (≥ 2)
200
111 (55.5)
89 (44.5)
3.2
2.1 to 4.9
2.2
1.3 to 3.4
No/low (< 2/6)
257
209 (81.3)
48 (18.7)
1.0
High (≥ 2/6)
172
85 (49.4)
87 (50.6)
4.5
2.9 to 6.9
2.4
1.5 to 3.9
State Trait Anxiety Inventory score
CES-D Depression score
SSST‡
Pain catastrophizing score
Pain Interference Adjusted days waited, weeks
State Trait Anxiety Inventory score
CES-D Depression Score
SSST‡
Catastrophizing score
NS: not significant; NA: not applicable–not significant at bivariate analysis so not included in multivariate analysis *Variables entered in bivariate analysis were age, marital status, race, education, employment status, body mass index, smoking status, previous abdominal surgery, current menstruation status, current use of hormone replacement therapy or birth control pills, and malignancy status. Pain intensity analysis: age and race were significant in bivariate but not multivariate analysis and were therefore removed from the model. Pain interference analysis: menstrual status and age were significant in the bivariate analysis and age remained significant in the multivariate analysis, therefore age was controlled for in the final model. †Values do not always equal 100% because of rounding. ‡4 participants missing
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the likelihood of moderate to severe pain in women with longer waiting times for surgery (> 8 weeks vs. < 4 weeks, OR 1.5; 95% CI 0.9 to 2.6). Other studies have reported similar34 or higher36 prevalence estimates of pain and a relationship between pain and depression before surgery.20 However, this is the first study to examine the relationship between pain and other psychological symptoms while waiting for gynaecological surgery. It is also the first Canadian study to examine the prevalence and relationship between these psychological symptoms, waiting time, and pain in women awaiting gynaecological surgery. In addition, 80% of women with pain described the nature of their pain as aching. This is more than the 60% reported by a group of patients with cancer in the only previous study reporting pain quality prior to surgery.37 Thirty-seven percent of women reported depressive symptoms, similar to the findings in an Australian study in which 34% of women reported preoperative depression.38 Almost one half reported at least two somatic symptoms, and somatic symptoms were associated with pain. We found no other study reporting on somatization in this setting. However, in primary care somatization has been associated with anxiety and depression39 and greater use of health care.4 The association between pain catastrophizing and moderate to severe pain has not been studied in the primary care setting, but our findings are consistent with studies in healthy subjects and after spinal cord injury.24,40 Because of the cross-sectional nature of this study, the direction of the association between psychological characteristics and moderate to severe pain could not be identified; that is, it is not clear whether higher levels of pain or pain interference result from the individual psychological factors or whether the high levels of pain and pain interference cause the psychological factors to be greater. In addition, the psychological and pain characteristics are based on self-reports that were not corroborated by clinical examination. In the case of the measurement of pain, this is consistent with previous reports, as pain is a subjective characteristic.11,41,42 It is unknown to what extent women who declined to join the study experienced pain and psychological characteristics, and the direction of any potential bias this may have introduced into the study is also unknown. However, the prevalence estimates in our findings are similar to those reported in other studies.11,38,41 The strengths of our study include its having minimal missing data and a relatively large sample size, and the comprehensive nature of the data collected, which allowed several factors to be examined and subsequently controlled for within the analysis. The recall period for reporting of symptoms was relatively short (as short as one week), 550 l JUNE JOGC JUIN 2012
thereby reducing recall bias. Participants consisted of a relatively homogeneous sample of women waiting to undergo gynaecological surgery, thereby reducing variability. CONCLUSION
This study provides evidence for the presence of, and an association between, pain and psychological symptoms in women waiting for gynaecological surgery. Such information highlights the potential needs of patients prior to surgery, and the potential impacts on their well-being, surgical recovery, and health care resource use. This information reinforces the need for a biopsychosocial approach to symptom management, which should begin during the wait for surgery. Because of the heterogeneity of gynaecological surgical procedures, future research should include a sufficient sample size to allow stratification by type of and indication for surgery. Future research is also necessary to develop and test interventions to reduce psychological and pain symptoms in patients while they await surgery, and to examine the impact of symptoms on preoperative health care utilization and postoperative recovery. ACKNOWLEDGEMENTS
This study was funded in part through a CIHR Operating Grant (#79522). David Goldstein, Yuk-Miu Lam, Tanveer Towheed, Rosemary Wilson, and Patricia McGrath were investigators on the CIHR grant. Sarah Walker was supported by a Queen’s University Graduate Award, a Queen’s University International Tuition Award and a Registered Nurses Association of Ontario Education Initiative Award. REFERENCES 1. Reitsma ML, Tranmer JE, Buchanan DM, Vandenkerkhof EG. The prevalence of chronic pain and pain-related interference in the Canadian population from 1994 to 2008. Chronic Dis Inj Can 2011;31:157–64. 2. Smith BH, Elliott AM, Chambers WA, Smith WC, Hannaford PC, Penny K. The impact of chronic pain in the community. Fam Pract 2001;18:292–9. 3. Institute of Medicine of the National Academies. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. (Report Brief). 2011. 4. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003;163:2433–45. 5. McBeth J, Macfarlane GJ, Benjamin S, Silman AJ. Features of somatization predict the onset of chronic widespread pain: results of a large population-based study. Arthritis Rheum 2001;44:940–6. Comment 2001;44:751–3; 2001;46:1129–30; author reply 1130. 6. Andrasik F, Flor H, Turk DC. An expanded view of psychological aspects in head pain: the biopsychosocial model. Neurol Sci 2005;26(Suppl 2):s87–s91.
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
7. Gatchel RJ, Theodore BR. Evidence-based outcomes in pain research and clinical practice. Pain Pract 2008;8:452–60. 8. Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol 2002;70:678–90. 9. IASP Task Force on Taxonomy. Classification of chronic pain. 2nd ed. Seattle: IASP Press; 1994. 10. Grace VM, Zondervan KT. Chronic pelvic pain in New Zealand: prevalence, pain severity, diagnoses and use of the health services. Aust N Z J Public Health 2004;28:369–75.
26. Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res 2010;468:798–806. 27. VanDenKerkhof EG, Hopman WM, Goldstein DH, Wilson RA, Towheed TE, Lam M, et al. Impact of perioperative pain intensity, pain qualities and opioid use on chronic pain after surgery: a prospective cohort study. Reg Anesth Pain Med 2012;37:19–27. 28. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap 1994;23:129–38.
11. Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol 2004;104:701–9.
29. Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M. Identification of cut-points for mild, moderate and severe pain due to diabetic peripheral neuropathy. Pain 2005;115:29–36.
12. Kain ZN, Sevarino F, Alexander GM, Pincus S, Mayes LC. Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design. J Psychosom Res 2000;49:417–22.
30. Esmail N, Hazel M, Walker MA. Waiting your turn: hospital waiting lists in Canada 2008, 18th ed. Fraser Institute; 2008.
13. Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006;6:177. 14. Stovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990;75:676–9. 15. Weber AM, Walters MD, Schover LR, Church JM, Piedmonte MR. Functional outcomes and satisfaction after abdominal hysterectomy. Am J Obstet Gynecol 1999;181:530–5. 16. Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. The community prevalence of chronic pelvic pain in women and associated illness behaviour. Br J Gen Pract 2001;51:541–7. 17. Martin DC. Hysterectomy for treatment of pain associated with endometriosis. J Minim Invasive Gynecol 2006;13:566–72. 18. Carr E, Brockbank K, Allen S, Strike P. Patterns and frequency of anxiety in women undergoing gynaecological surgery. J Clin Nurs 2006;15:341–52. 19. Thornton EW, McQueen C, Rosser R, Kneale T, Dixon K. A prospective study of changes in negative mood states of women undergoing surgical hysterectomy: the relationship to cognitive predisposition and familial support. J Psychosom Obstet Gynaecol 1997;18:22–30. 20. Ell K, Sanchez K, Vourlekis B, Lee PJ, Dwight-Johnson M, Lagomasino I, et al. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol 2005;23:3052–60. 21. Morrison J. Chapter 7: Somatoform disorders. In: DSM-IV made easy: the clinician’s guide to diagnosis. New York: The Guildford Press; 1995: 287–310.
31. Spielberger CD. State-Trait Anxiety Inventory. Redwood City, CA: Mind Garden Publications; 1983. 32. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. 33. Beekman AT, Deeg DJ, Van Limbeek J, Braam AW, De Vries MZ, Van Tilburg W. Criterion validity of the Center for Epidemiologic Studies Depression scale (CES-D): results from a community-based sample of older subjects in The Netherlands. Psychol Med 1997;27:231–5. 34. Othmer E, DeSouza C. A screening test for somatization disorder (hysteria). Am J Psychiatry 1985;142:1146–9. 35. Jensen MP, Keefe FJ, Lefebvre JC, Romano JM, Turner JA. One- and twoitem measures of pain beliefs and coping strategies. Pain 2003;104:453–69. 36. Rannestad T, Eikeland OJ, Helland H, Qvarnstrom U. Are the physiologically and psychosocially based symptoms in women suffering from gynecological disorders alleviated by means of hysterectomy? J Womens Health Gend Based Med 2001;10:579–87. 37. Holtan A, Kongsgaard UE. The use of pain descriptors in cancer patients. J Pain Symptom Manage 2009;38:208–15. 38. Donoghue AP, Jackson HJ, Pagano R. Understanding pre- and posthysterectomy levels of negative affect: a stress moderation model approach. J Psychosom Obstet Gynaecol 2003;24:99–109. 39. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis 1991;179:647–55.
22. De Gucht V, Fischler B. Somatization: a critical review of conceptual and methodological issues. Psychosomatics 2002;43:1–9.
40. Turner JA, Jensen MP, Warms CA, Cardenas DD. Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury. Pain 2002;98:127–34.
23. Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain 1983;17:33–44.
41. Tripp DA, VanDenKerkhof EG, McAlister M. Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario. Pain Res Manag 2006;11:225–33.
24. Sullivan MJL, Tripp DA. Gender differences in pain and pain behavior: the role of catastrophizing. Cognit Ther Res 2000;24:121–34. 25. Riediger W, Doering S, Krismer M. Depression and somatisation influence the outcome of total hip replacement. Int Orthop 2010;34:13–8.
42. Reitsma ML, Tranmer JE, Buchanan DM, VanDenKerkhof EG. The epidemiology of chronic pain in Canadian men and women between 1994 and 2007: results from the longitudinal component of the National Population Health Survey. Pain Res Manage 2012;17:166–72.
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Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery Sarah Walker, RN, MSc,1,2 Wilma M. Hopman, BAH, MA,3,4 Margaret B. Harrison, RN, PhD2,4 Dean Tripp, PhD,1,5,6 Elizabeth G. VanDenKerkhof, RN, DrPH1,2 1
Department of Anesthesiology and Perioperative Medicine, Queen’s University, Kingston ON
2
School of Nursing, Queen’s University, Kingston ON
3
Clinical Research Centre, Kingston General Hospital, Kingston ON
4
Department of Community Health and Epidemiology, Kingston ON
5
Department of Psychology, Queen’s University, Kingston ON
6
Department of Urology, Queen’s University, Kingston ON
Abstract
Résumé
Objective: Pain is frequently a complaint prior to gynaecological surgery. Psychological factors are also known to influence the experience of pain. The primary objective of this study was to assess the prevalence of pain and the relationship between psychological factors and pain in women awaiting gynaecological surgery.
Objectif : La douleur figure fréquemment au nombre des plaintes avant la tenue d’une chirurgie gynécologique. On sait également que des facteurs psychologiques exercent une certaine influence sur l’expérience de la douleur. Cette étude avait pour objectif principal d’évaluer la prévalence de la douleur et la relation entre les facteurs psychologiques et la douleur chez les femmes en attente d’une chirurgie gynécologique.
Methods: Four hundred twenty-nine women in a tertiary care centre in southeastern Ontario were included in this cross-sectional analysis, which was embedded in a larger prospective study. Pain was assessed using the Brief Pain Inventory, anxiety using the State Trait Anxiety Inventory, depressive symptoms using the Center for Epidemiologic Studies Depression Scale, somatization using the Seven Symptom Screening Test, and catastrophizing with an abbreviated coping strategies questionnaire. Results: Eighteen percent of women reported high anxiety, 37% reported depressive symptoms, 47% had two or more symptoms of somatization, and 40% reported elevated pain catastrophizing. Approximately one third reported moderate to severe pain intensity and interference. Of those reporting pain, 81% believed their pain was due to their primary condition. Depressive symptoms, somatization, and catastrophizing were associated with elevated pain intensity and interference. Conclusion: The responses suggest a substantial burden of pain, anxiety, and depressive symptoms in women awaiting gynaecological surgery. Further research is needed to assess the management of these symptoms and their impact on health care resources and the well-being of women in this setting.
Key Words: Gynaecologic surgery, depression, anxiety, pain intensity, pain interference, preoperative Competing Interests: None declared. Received on November 15, 2011 Accepted on February 22, 2012
Méthodes : Quatre cent vingt-neuf femmes d’un centre de soins tertiaires du sud-est ontarien ont été incluses dans le cadre de cette analyse transversale, laquelle s’inscrivait dans une étude prospective de plus grande envergure. La douleur a été évaluée au moyen du Brief Pain Inventory; l’anxiété, au moyen du State Trait Anxiety Inventory; les symptômes de dépression, au moyen de la Center for Epidemiologic Studies Depression Scale; la somatisation, au moyen du Seven Symptom Screening Test; et la catastrophisation, au moyen d’un questionnaire abrégé sur les stratégies d’adaptation. Résultats : Dix-huit pour cent des femmes ont signalé une forte anxiété, 37 % ont signalé des symptômes de dépression, 47 % ont connu deux symptômes de somatisation ou plus et 40 % ont signalé une catastrophisation élevée de la douleur. Près du tiers des femmes ont signalé une interférence et une intensité de la douleur allant de modérées à graves. Chez les femmes signalant de la douleur, 81 % estimaient que leur douleur était attribuable à leur pathologie principale. Les symptômes de dépression, la somatisation et la catastrophisation étaient associés à une interférence et à une intensité de la douleur élevées. Conclusion : Les réponses semblent indiquer un fardeau de la douleur, une anxiété et des symptômes de dépression substantiels chez les femmes qui attendent de subir une chirurgie gynécologique. La tenue d’autres recherches s’avère requise pour évaluer la prise en charge de ces symptômes et leurs effets sur les ressources de santé et le bien-être des femmes dans ce milieu.
J Obstet Gynaecol Can 2012;34(6):543–551
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INTRODUCTION
T
he prevalence of chronic pain in the general population may be as high as 35%. Chronic pain results in a significant burden to the individual, the family, and society.1,2 It is estimated that pain costs the United States $635 billion annually in health care costs and lost productivity.3 Chronic pain adversely affects quality of life and function, and some populations are more vulnerable to pain than others. Vulnerable populations have been identified with respect to certain psychological characteristics (e.g., somatization and depression).4,5 The impact of psychological, social, and cultural factors on pain6–8 is also reflected in the International Association for the Study of Pain definition of pain.9 Pain is a common symptom in women experiencing gynaecological problems,10–16 and untreated gynaecologic pain, such as dysmenorrhea, premenstrual pelvic pain, ovulatory pain, and other cyclic pain, may develop into chronic pelvic pain if unmanaged.17 However, little is known about pain characteristics and psychological characteristics associated with pain in women waiting for gynaecologic surgery. Psychological factors, especially depression and anxiety, have been documented in women waiting for gynaecological surgery.11,18,19 There is also emerging evidence that women with preoperative psychological distress experience significant levels of pain. In a cross-sectional study of 472 women undergoing treatment for breast and gynaecological cancers in the United States, women with high levels of pain were also more likely to report depression.20 In a study of 1249 women awaiting hysterectomy in the United States, 13% reported depression and pain, 14% depression only, and 19% pain only.11 No studies of pain and psychological experience prior to gynaecological surgery have been reported for women in Canada. Evidence suggests that women waiting for gynaecologic surgery experience significant levels of pain and psychological symptoms, especially depression.11 Little is known about other psychological factors emerging as significant correlates of pain, i.e., somatization and catastrophizing. Physical symptoms may be influenced by or even stem from emotional problems.5 The experiences of such symptoms are real and manifest as anxiety.
ABBREVIATIONS CES-D Center for Epidemiologic Studies Depression Scale IQR
interquartile range
SSST
Seven Symptom Screening Test
544 l JUNE JOGC JUIN 2012
Somatization is characterized by the presence of physical symptoms with no identifiable medical cause.21,22 Catastrophizing is the tendency to engage in negative selfstatements, feelings, and ideation.23 Pain catastrophizing has been defined as a negative cognitive orientation towards pain or painful stimulation, and it is associated with increased reports of pain.24 Both somatization and catastrophizing have been associated with preoperative pain.25,26 The purpose of this study was to examine the relationship between pain and psychological symptoms in women awaiting gynaecological surgery. The objectives were: 1. to describe the prevalence of pain, pain-related interference, and psychological symptoms, and 2. to examine the association between psychological symptoms (i.e., anxiety, depressive symptoms, somatization, and catastrophizing) and pain. METHODS
For this cross-sectional study we recruited Englishspeaking women aged 18 years or older who were waiting to undergo gynaecological surgery. They formed a subset of women who had been recruited into a larger prospective study examining outcomes after surgery.27 The convenience sample was drawn from the waiting list of women at Kingston General Hospital, a tertiary care facility in southeastern Ontario that serves more than 500 000 people in the local and surrounding communities. Subjects were recruited and informed consent was obtained upon admission for surgery in the Same Day Admission Centre. Patients were excluded if they had Alzheimer disease or other cognitive impairment. The primary outcomes of interest were severity of preoperative pain and pain-related interference. These outcomes were measured using the Brief Pain Inventory Long Form, a multidimensional pain assessment instrument.28 Subscales for pain severity and pain-related interference (numerical responses to 4 and 7 questions respectively, averaged to provide scores ranging from 0 to 10) refer to pain experienced in the past week. For the purpose of this study, pain severity and pain interference summary scores were dichotomized into none/mild (≤ 3/10) and moderate/severe (> 3/10).29 The independent variables of interest were waiting time for surgery and the presence of anxiety, depressive symptoms, somatization, and catastrophizing. Demographic and gynaecological factors were considered potential
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 1. Baseline characteristics of women waiting for gynaecological surgery n = 429
%*
18 to 44
160
37.3
45 to 55
168
39.2
≥ 56
101
23.5
Single/divorced/widowed
123
28.7
Married
306
71.3
Caucasian
399
93.2
Non-Caucasian
29
6.8
Age, years
Marital status
Racial heritage†
Highest education grade achieved No diploma
50
11.7
High school diploma
87
20.3
Trade or professional school certificate/diploma
150
35.0
Some university/postgraduate degree(s)
142
33.1
Unemployed/retired/homemaker
111
25.9
Employed part time or full time
283
66.0
Other
35
8.2
≤ 24.9
126
29.4
25 to 29.9
126
29.4
≥ 30
177
41.3
Yes
90
21.0
No
339
79.0
Yes
295
68.8
No
130
30.3
<4
111
25.9
4 to 8
149
34.7
>8
169
39.4
Low (< 45)
350
82.0
High (≥ 45)
77
18.0
Low (< 16)
270
62.9
High (≥ 16)
159
37.1
0
78
18.2
1
147
34.3
2
115
26.8
3
55
12.8
4
20
4.7
≥5
10
2.3
Employment status
BMI (kg/m2)
Current smoker
Previous abdominal surgery
Adjusted wait time,‡ weeks
State Trait Anxiety Inventory score‡
CES-D depression score
SSST score§
Continued
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Table 1. continued n = 429
%*
No catastrophizing
128
29.8
Low catastrophizing
129
30.1
High catastrophizing
172
40.1
Catastrophizing score
Menstruation Unsure/irregular
31
7.2
Stopped naturally
128
29.8
Stopped surgically
45
10.5
Not stopped
225
52.4
Yes
23
6.8
No
316
93.2
Currently taking hormone replacement therapy
Have taken birth control pills in the past month║ Yes
40
9.5
No
382
90.5
Possibly malignant
99
23.1
Malignant
72
16.8
Not malignant
256
59.7
Continuous variables
Mean (SD)
Range (min/max)
Age in years
48.3 (11.0)
18 to 83
BMI
29.1 (7.4)
17 to 60
State Trait Anxiety Inventory score
34.2 (10.7)
20 to 72
Preoperative malignancy status
CES-D scores
13.8 (11.6)
0 to 58
Waiting time
63.8 (60.6)
0 to 680
*Values do not always equal 100% because of rounding †1 participant missing ‡2 participants missing §4 participants missing ║7 participants missing
confounders. Data collection consisted of five selfreporting questionnaires that gathered information on pain and psychological factors. Additional data such as age, smoking status, and BMI were gathered from the patient record. Waiting time for surgery was obtained from the hospital administrative database. Waiting time was defined as the time between the decision to treat and the date of surgery30 and was adjusted for time that the patients were not available for surgery. Trait anxiety was measured using the State Trait Anxiety Inventory, a validated and reliable self-reporting measurement tool of 20 questions about general feelings of anxiety (trait).31 Scores range from 20 to 80, with a higher score indicating a greater degree of anxiety. The scale was categorized into low (score < 45) versus high (≥ 45).18 Depressive symptoms were measured 546 l JUNE JOGC JUIN 2012
using the CES-D Scale.32 The CES-D is a 20-item selfreporting questionnaire assessing feelings of low mood and depressive thinking during the past week. Scores range from 0 to 60 points, with a higher score indicating a greater degree of depressive symptoms. Scores on the CES-D were categorized into low (< 16) or high (≥ 16) levels of depressive symptoms, with the latter suggesting a risk of depression that requires treatment.32,33 Somatization was measured with the SSST.34 According to the original developers of the SSST, the presence of three of the seven symptoms is suggestive of a somatization disorder; however, because of low prevalence of somatization characteristics, we elected to categorize SSST into low (< 2 symptoms) versus high (≥ 2 symptoms) using the median split for the total sample. Pain catastrophizing was measured using a two-
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 2. Pain intensity and pain interference scores obtained from the brief pain inventory for all participants and for women with pain Total number of women
Total number with pain > 0/10
n
median
IQR
n
median
IQR
Pain at its worst in the past week
429
2.0
0.0 to 7.0
226
6.0
4.0 to 8.0
Pain at its least in the past week
429
0.0
0.0 to 1.5
142
3.0
1.8 to 4.0
Pain on average
429
1.0
0.0 to 5.0
222
4.0
3.0 to 6.0
Pain you have right now
429
0.0
0.0 to 2.0
157
3.0
2.0 to 5.0
Pain Severity Score
429
1.0
0.0 to 4.0
226
4.8
4.0 to 6.0
General activity
429
0.0
0.0 to 5.0
198
5.0
3.0 to 7.0
Mood
429
0.0
0.0 to 5.0
187
5.0
3.0 to 7.0
Walking ability
429
0.0
0.0 to 3.0
153
5.0
3.0 to 7.0
Normal work (outside the home and housework)
429
0.0
0.0 to 5.0
188
5.0
3.0 to 8.0
Relations with other people
429
0.0
0.0 to 2.0
136
5.0
2.0 to 7.0
Sleep
429
0.0
0.0 to 5.0
177
6.0
3.0 to 8.0
Enjoyment of life
429
0.0
0.0 to 5.0
190
5.0
3.0 to 8.0
Pain interference score
429
0.0
0.0 to 4.0
226
6.0
4.0 to 7.0
Pain Intensity Scale (0 to 10)
Pain Interference Scale (0 to 10)
item pain-catastrophizing measure that asks individuals about thoughts of helplessness when they have pain.35 The overall score was calculated by taking the average of the 0 to 6 Likert scale scores for the two questions, resulting in an overall score ranging from 0 to 6. For the purpose of the analysis, we classified pain catastrophizing into low (< 2) and high (≥ 2) using the median split of the overall score. Gynaecologic variables captured through self-reporting included menstrual status, menopausal status, and the use of postmenopausal hormone therapy and oral contraceptives. The presence or absence of malignancy was captured from the hospital record. Demographic and clinical covariates including age, marital status, race, education, employment, and smoking status were collected using questionnaires. Previous abdominal surgery and BMI (calculated from height and weight) were captured from the hospital preadmission record. Descriptive statistics were calculated using frequency and percentages for categorical variables and means, standard deviation, range, median, and interquartile range for continuous variables. Bivariable analysis was conducted using the chi-square statistical test to assess possible associations between pain status and the independent variables and between waiting time and the independent variables. Variables were included in the multivariable analysis if we found P ≤ 0.1 in the bivariate analysis. The results are presented as odds ratio with 95% confidence
intervals for both bivariable and multivariable analyses. Given the descriptive nature of this study and the fact that it was embedded in a larger prospective cohort study, a sample size calculation was not conducted. Data analysis was carried out using SPSS software version 16.0 (IBM Corp., Armonk NY). Ethics approval was obtained from the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board. RESULTS
Of the 635 women approached and invited to join the study, 441 were recruited and six withdrew before completing the questionnaires, leaving 435 (69%) patients with complete data. Six participants who underwent urological surgery were excluded, leaving 429 participants for the final analysis. The predominant surgical procedure was hysterectomy (77%), followed by ovarian or tubal procedures (12%), exploratory/ peritoneal procedures (4%), pelvic floor repair (3%), and other gynaecological procedures (4%). Study participants ranged in age from 18 to 83 years (mean 48.3 yr, SD 11 years) and were predominantly Caucasian (93%) (Table 1). The majority (69%) had undergone previous abdominal surgery, 40% were no longer menstruating, and, of these, 11% had stopped menstruating because of surgery. Forty percent of participants had a preoperative diagnosis of possible or confirmed malignancy. JUNE JOGC JUIN 2012 l 547
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Figure 1. Number of pain descriptors used in women reporting pain (n = 230)
% of women with pain
16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0%
Number of pain quality descriptors used
Figure 2. Pain quality descriptors in women reporting pain (n = 230) 90% 80%
% of women
70% 60% 50% 40% 30% 20% 10% 0%
Fifty-three percent (226/429) of respondents reported some pain (> 0/10), with 31% (131/429) reporting moderate to severe pain and 32% (135/429) reporting moderate to severe pain-related interference. The median pain-related interference score in women with pain was 6.0 (IQR 4.0, 7.0) (Table 2). Of the women who had experienced pain in the last week, 81% believed that their pain was due to their primary gynaecological condition, and these women were more likely to be depressed (45% vs. 26%, P < 0.01) than women who did not believe that their pain was related to their gynaecological condition; however, anxiety, somatizing, and pain catastrophizing were not significantly different between these groups. Nearly one half of the participants used eight or more pain descriptors to characterize their pain (Figure 1). Aching (80%), tiring (74%), and nagging (71%) were most frequently reported (Figure 2). Eighteen percent reported high trait anxiety and 37% reported depressive symptoms. Somatization scores ranged between 0 and 6 out of 7, and almost half (47%) 548 l JUNE JOGC JUIN 2012
reported at least two somatic symptoms (Table 1). Pain catastrophizing scores ranged from 0 to 6 out of 6, and 40% of participants scored ≥ 2 out of 6. Depressive symptoms, somatization, and pain catastrophizing were independently associated with moderate to severe pain and pain interference, when controlling for potential confounders (Table 3). The median waiting time for surgery was 48 days (IQR 27, 85 days) and waiting time was not significantly associated with pain severity or interference. Somatization was the only psychological variable significantly associated with waiting time (P < 0.05). DISCUSSION
We found high levels of moderate to severe pain and adverse psychological symptoms in women awaiting gynaecological surgery. In addition, women reporting depressive symptoms, somatization, and pain catastrophizing were two to four times more likely to report moderate to severe pain and painrelated interference. There was a non-significant increase in
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
Table 3. Bivariate and multivariate results for moderate to severe pain intensity and pain-related interference Bivariate analysis Variable
Total (n = 429)
Pain ≤ 3/10 n (%)†
Pain > 3/10 n (%)†
n = 298
n = 131
Odds Ratio
Multivariate analysis*
95% CI
Odds Ratio
95% CI
Pain Intensity Adjusted wait time, weeks <4
111
82 (73.9)
29 (26.1)
1.0
4 to 8
149
107 (71.8)
42 (28.2)
1.1
0.6 to 1.9
—
NA
>8
169
109 (64.5)
60 (35.5)
1.5
0.9 to 2.6
—
NA
Low (20 to 44)
350
258 (73.7)
92 (26.3)
1.0
High (≥ 45)
77
39 (50.6)
38 (49.4)
2.7
1.6 to 4.5
—
NS
Low (< 16)
270
217 (80.4)
53(19.6)
1.0
High (≥ 16)
159
81 (50.9)
78 (49.1)
3.9
2.6 to 6.1
2.0
1.2 to 3.3
Low (< 2)
225
186 (82.7)
39 (17.3)
1.0
High (≥ 2)
200
109 (54.5)
91 (45.5)
4.0
2.6 to 6.2
2.8
1.7 to 4.5
No/low (< 2/6)
257
217 (84.4)
40 (15.6)
1.0
High (≥ 2/6)
172
81 (47.1)
91 (52.9)
6.1
3.9 to 9.6
4.0
2.5 to 6.6
n = 135
n = 294
<4
111
82 (73.9)
29 (26.1)
1.0
4 to 8
149
100 (67.1)
49 (32.9)
1.4
0.8 to 2.4
—
NA
>8
169
112 (66.3)
57 (33.7)
1.4
0.8 to 2.4
—
NA
Low (20 to 44)
350
254 (72.6)
96 (27.4)
1.0
High (≥ 45)
77
39 (50.6)
38(49.4)
2.6
1.6 to 4.3
—
NS
Low (<16)
270
220 (81.5)
50 (18.5)
1.0
High (≥16)
159
74 (46.5)
85 (53.5)
5.1
3.3 to 7.8
3.0
1.8 to 4.8
Low (< 2)
225
180 (80.0)
45 (20.0)
1.0
High (≥ 2)
200
111 (55.5)
89 (44.5)
3.2
2.1 to 4.9
2.2
1.3 to 3.4
No/low (< 2/6)
257
209 (81.3)
48 (18.7)
1.0
High (≥ 2/6)
172
85 (49.4)
87 (50.6)
4.5
2.9 to 6.9
2.4
1.5 to 3.9
State Trait Anxiety Inventory score
CES-D Depression score
SSST‡
Pain catastrophizing score
Pain Interference Adjusted days waited, weeks
State Trait Anxiety Inventory score
CES-D Depression Score
SSST‡
Catastrophizing score
NS: not significant; NA: not applicable–not significant at bivariate analysis so not included in multivariate analysis *Variables entered in bivariate analysis were age, marital status, race, education, employment status, body mass index, smoking status, previous abdominal surgery, current menstruation status, current use of hormone replacement therapy or birth control pills, and malignancy status. Pain intensity analysis: age and race were significant in bivariate but not multivariate analysis and were therefore removed from the model. Pain interference analysis: menstrual status and age were significant in the bivariate analysis and age remained significant in the multivariate analysis, therefore age was controlled for in the final model. †Values do not always equal 100% because of rounding. ‡4 participants missing
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the likelihood of moderate to severe pain in women with longer waiting times for surgery (> 8 weeks vs. < 4 weeks, OR 1.5; 95% CI 0.9 to 2.6). Other studies have reported similar34 or higher36 prevalence estimates of pain and a relationship between pain and depression before surgery.20 However, this is the first study to examine the relationship between pain and other psychological symptoms while waiting for gynaecological surgery. It is also the first Canadian study to examine the prevalence and relationship between these psychological symptoms, waiting time, and pain in women awaiting gynaecological surgery. In addition, 80% of women with pain described the nature of their pain as aching. This is more than the 60% reported by a group of patients with cancer in the only previous study reporting pain quality prior to surgery.37 Thirty-seven percent of women reported depressive symptoms, similar to the findings in an Australian study in which 34% of women reported preoperative depression.38 Almost one half reported at least two somatic symptoms, and somatic symptoms were associated with pain. We found no other study reporting on somatization in this setting. However, in primary care somatization has been associated with anxiety and depression39 and greater use of health care.4 The association between pain catastrophizing and moderate to severe pain has not been studied in the primary care setting, but our findings are consistent with studies in healthy subjects and after spinal cord injury.24,40 Because of the cross-sectional nature of this study, the direction of the association between psychological characteristics and moderate to severe pain could not be identified; that is, it is not clear whether higher levels of pain or pain interference result from the individual psychological factors or whether the high levels of pain and pain interference cause the psychological factors to be greater. In addition, the psychological and pain characteristics are based on self-reports that were not corroborated by clinical examination. In the case of the measurement of pain, this is consistent with previous reports, as pain is a subjective characteristic.11,41,42 It is unknown to what extent women who declined to join the study experienced pain and psychological characteristics, and the direction of any potential bias this may have introduced into the study is also unknown. However, the prevalence estimates in our findings are similar to those reported in other studies.11,38,41 The strengths of our study include its having minimal missing data and a relatively large sample size, and the comprehensive nature of the data collected, which allowed several factors to be examined and subsequently controlled for within the analysis. The recall period for reporting of symptoms was relatively short (as short as one week), 550 l JUNE JOGC JUIN 2012
thereby reducing recall bias. Participants consisted of a relatively homogeneous sample of women waiting to undergo gynaecological surgery, thereby reducing variability. CONCLUSION
This study provides evidence for the presence of, and an association between, pain and psychological symptoms in women waiting for gynaecological surgery. Such information highlights the potential needs of patients prior to surgery, and the potential impacts on their well-being, surgical recovery, and health care resource use. This information reinforces the need for a biopsychosocial approach to symptom management, which should begin during the wait for surgery. Because of the heterogeneity of gynaecological surgical procedures, future research should include a sufficient sample size to allow stratification by type of and indication for surgery. Future research is also necessary to develop and test interventions to reduce psychological and pain symptoms in patients while they await surgery, and to examine the impact of symptoms on preoperative health care utilization and postoperative recovery. ACKNOWLEDGEMENTS
This study was funded in part through a CIHR Operating Grant (#79522). David Goldstein, Yuk-Miu Lam, Tanveer Towheed, Rosemary Wilson, and Patricia McGrath were investigators on the CIHR grant. Sarah Walker was supported by a Queen’s University Graduate Award, a Queen’s University International Tuition Award and a Registered Nurses Association of Ontario Education Initiative Award. REFERENCES 1. Reitsma ML, Tranmer JE, Buchanan DM, Vandenkerkhof EG. The prevalence of chronic pain and pain-related interference in the Canadian population from 1994 to 2008. Chronic Dis Inj Can 2011;31:157–64. 2. Smith BH, Elliott AM, Chambers WA, Smith WC, Hannaford PC, Penny K. The impact of chronic pain in the community. Fam Pract 2001;18:292–9. 3. Institute of Medicine of the National Academies. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. (Report Brief). 2011. 4. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003;163:2433–45. 5. McBeth J, Macfarlane GJ, Benjamin S, Silman AJ. Features of somatization predict the onset of chronic widespread pain: results of a large population-based study. Arthritis Rheum 2001;44:940–6. Comment 2001;44:751–3; 2001;46:1129–30; author reply 1130. 6. Andrasik F, Flor H, Turk DC. An expanded view of psychological aspects in head pain: the biopsychosocial model. Neurol Sci 2005;26(Suppl 2):s87–s91.
Pain and Psychological Characteristics in Women Waiting for Gynaecological Surgery
7. Gatchel RJ, Theodore BR. Evidence-based outcomes in pain research and clinical practice. Pain Pract 2008;8:452–60. 8. Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol 2002;70:678–90. 9. IASP Task Force on Taxonomy. Classification of chronic pain. 2nd ed. Seattle: IASP Press; 1994. 10. Grace VM, Zondervan KT. Chronic pelvic pain in New Zealand: prevalence, pain severity, diagnoses and use of the health services. Aust N Z J Public Health 2004;28:369–75.
26. Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res 2010;468:798–806. 27. VanDenKerkhof EG, Hopman WM, Goldstein DH, Wilson RA, Towheed TE, Lam M, et al. Impact of perioperative pain intensity, pain qualities and opioid use on chronic pain after surgery: a prospective cohort study. Reg Anesth Pain Med 2012;37:19–27. 28. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap 1994;23:129–38.
11. Hartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstet Gynecol 2004;104:701–9.
29. Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M. Identification of cut-points for mild, moderate and severe pain due to diabetic peripheral neuropathy. Pain 2005;115:29–36.
12. Kain ZN, Sevarino F, Alexander GM, Pincus S, Mayes LC. Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design. J Psychosom Res 2000;49:417–22.
30. Esmail N, Hazel M, Walker MA. Waiting your turn: hospital waiting lists in Canada 2008, 18th ed. Fraser Institute; 2008.
13. Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006;6:177. 14. Stovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstet Gynecol 1990;75:676–9. 15. Weber AM, Walters MD, Schover LR, Church JM, Piedmonte MR. Functional outcomes and satisfaction after abdominal hysterectomy. Am J Obstet Gynecol 1999;181:530–5. 16. Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. The community prevalence of chronic pelvic pain in women and associated illness behaviour. Br J Gen Pract 2001;51:541–7. 17. Martin DC. Hysterectomy for treatment of pain associated with endometriosis. J Minim Invasive Gynecol 2006;13:566–72. 18. Carr E, Brockbank K, Allen S, Strike P. Patterns and frequency of anxiety in women undergoing gynaecological surgery. J Clin Nurs 2006;15:341–52. 19. Thornton EW, McQueen C, Rosser R, Kneale T, Dixon K. A prospective study of changes in negative mood states of women undergoing surgical hysterectomy: the relationship to cognitive predisposition and familial support. J Psychosom Obstet Gynaecol 1997;18:22–30. 20. Ell K, Sanchez K, Vourlekis B, Lee PJ, Dwight-Johnson M, Lagomasino I, et al. Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol 2005;23:3052–60. 21. Morrison J. Chapter 7: Somatoform disorders. In: DSM-IV made easy: the clinician’s guide to diagnosis. New York: The Guildford Press; 1995: 287–310.
31. Spielberger CD. State-Trait Anxiety Inventory. Redwood City, CA: Mind Garden Publications; 1983. 32. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. 33. Beekman AT, Deeg DJ, Van Limbeek J, Braam AW, De Vries MZ, Van Tilburg W. Criterion validity of the Center for Epidemiologic Studies Depression scale (CES-D): results from a community-based sample of older subjects in The Netherlands. Psychol Med 1997;27:231–5. 34. Othmer E, DeSouza C. A screening test for somatization disorder (hysteria). Am J Psychiatry 1985;142:1146–9. 35. Jensen MP, Keefe FJ, Lefebvre JC, Romano JM, Turner JA. One- and twoitem measures of pain beliefs and coping strategies. Pain 2003;104:453–69. 36. Rannestad T, Eikeland OJ, Helland H, Qvarnstrom U. Are the physiologically and psychosocially based symptoms in women suffering from gynecological disorders alleviated by means of hysterectomy? J Womens Health Gend Based Med 2001;10:579–87. 37. Holtan A, Kongsgaard UE. The use of pain descriptors in cancer patients. J Pain Symptom Manage 2009;38:208–15. 38. Donoghue AP, Jackson HJ, Pagano R. Understanding pre- and posthysterectomy levels of negative affect: a stress moderation model approach. J Psychosom Obstet Gynaecol 2003;24:99–109. 39. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis 1991;179:647–55.
22. De Gucht V, Fischler B. Somatization: a critical review of conceptual and methodological issues. Psychosomatics 2002;43:1–9.
40. Turner JA, Jensen MP, Warms CA, Cardenas DD. Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury. Pain 2002;98:127–34.
23. Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain 1983;17:33–44.
41. Tripp DA, VanDenKerkhof EG, McAlister M. Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario. Pain Res Manag 2006;11:225–33.
24. Sullivan MJL, Tripp DA. Gender differences in pain and pain behavior: the role of catastrophizing. Cognit Ther Res 2000;24:121–34. 25. Riediger W, Doering S, Krismer M. Depression and somatisation influence the outcome of total hip replacement. Int Orthop 2010;34:13–8.
42. Reitsma ML, Tranmer JE, Buchanan DM, VanDenKerkhof EG. The epidemiology of chronic pain in Canadian men and women between 1994 and 2007: results from the longitudinal component of the National Population Health Survey. Pain Res Manage 2012;17:166–72.
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