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Risk Factors for Major Depressive Disorder and the Psychological Impact of Hysterectomy: A Prospective Investigation
Risk Factors for Major Depressive Disorder and the Psychological Impact of Hysterectomy: A Prospective Investigation JU-YU YEN, M.D., YUNG-HUNG CHEN, M.D. CHENG-YU LONG, M.D., YU CHANG, M.D. CHENG-FANG YEN, M.D., PH.D., CHENG-CHUNG CHEN, M.D., PH.D. CHIH-HUNG KO, M.D.
The authors prospectively evaluated the risk of major depressive disorder and the psychological impact of recent hysterectomy in 68 women who underwent hysterectomy for non-malignant conditions. Depression, anxiety, body image, sexual functioning, family support, life stress, and subjective gynecological symptoms were assessed 2 weeks before surgery and at 1 month and 4 months after surgery. Depression, anxiety, body image, and subjective gynecological symptoms improved after surgery; however, sexual functioning worsened after surgery. Previous emotional problems and poorer body image, sexual functioning, and higher stress 1 month after surgery are risk factors for post-hysterectomy major depressive disorder. (Psychosomatics 2008; 49:137–142)
H
ysterectomy is the second most common operation performed on North American women.1 Although the number of hysterectomies has declined over the past 30 years, 6.1%–10% of Taiwanese women have undergone a hysterectomy.2 Thus, its consequences concern a large proportion of women. Since around 90% of all hysterectomies are the result of benign conditions, improving the quality rather than the duration of life is a reasonable goal of this procedure.3 Thus, aside from mostly positive outcomes for gynecological symptoms,4 the psychological outcome and sexual functioning of patients should be another focus for informed decision-making regarding hysterectomy. Depression is one of the most commonly mentioned psychiatric risks after hysterectomy. Depression had been suggested earlier as a negative consequence;5 however, on the basis of recent prospective studies, there is no evidence to conclude that hysterectomy causes depression.6,7 However, major depressive disorder (MDD) has not been assessed by systematic diagnostic interview by psychiatrists in most prospective studies. Furthermore, there is a small proportion of women who do demonstrate negative psyPsychosomatics 49:2, March-April 2008
chological consequences.8 It would be beneficial to determine the risk factors for such outcomes because a preventive strategy should be implemented for risk groups so as to minimize or eliminate possible negative consequences. Sexual functioning after hysterectomy had been repeatedly reported to be a major concern of women; yet doctors, nurses, and other healthcare professionals are reluctant to discuss sexual issues with patients.8 In light of the results of recent prospective studies, however, hysterectomy has been shown to improve general sexual functioning.9,10 Because there are cultural differences in attitudes to sexual behavior between Eastern and Western societies,11 the impact of hysterectomy on women in an Eastern society might be different from those in a Western Received April 20, 2006; revised August 15, 2006; accepted August 30, 2006. From the Dept. of Psychiatry, Kaohsiung Medical University Hospital, Taiwan. Send correspondence and reprint requests to Chih-Hung Ko, M.D., Dept. of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd., Kaohsiung City, Taiwan 807. e-mail: cyberko@ seed.net.tw 䉷 2008 The Academy of Psychosomatic Medicine
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Major Depressive Disorder and Hysterectomy culture. Thus, research focusing on sexual dysfunction in women after hysterectomy in Eastern society was important. The loss of the uterus and scarring after surgery may result in impairment of body image, which includes the perception of a loss of femininity and vitality.12,13 Impairment of body image has been found in oophorectomized women;14 however oophorectomy is no longer a routine procedure in hysterectomy. Roussis et al., in a retrospective study,15 had reported no impairment in body image after hysterectomy, yet, in this study, recall bias could not be excluded. Since the evidence regarding change in body image is controversial, a prospective study utilizing a questionnaire directly relating to change in body image after surgery would provide clearer data. In order to demonstrate the need for clearer information to be provided to patients so as to enable them to make fully-informed decisions regarding hysterectomy, we evaluated 1) change in depressive and anxiety symptoms, family functioning, body image, and sexual functioning after hysterectomy; and 2) the risk factors for incidence of MDD after hysterectomy. METHOD All participants were recruited from the gynecological outpatient department of Kaohsiung Municipal Hsiao-Kang Hospital, having been scheduled for a hysterectomy to take place between February 2004 and August 2004. A total of 75 women were invited according to the surgical list provided by the gynecological staff; 68 agreed to participate in this research and gave informed consent. This research was approved by the Human Experiment and Ethics Committee of Kaohsiung Municipal Hsiao-Kang Hospital. The diagnosis of MDD was assessed by systematic diagnostic interview with one psychiatrist according to the Structured Clinical Interview for DSM–IV-TR (SCID).16 The 17-item Hamilton Rating Scale for Depression (Ham– D)17 and the Hamilton Rating Scale for Anxiety (Ham– A),18 administered by a psychiatrist, were utilized to objectively assess depression and anxiety, respectively. To address patients’ sexual functioning, we used the Short Form of the Personal Experience Questionnaire (SPEQ), previously validated by Dennerstein et al.19 The other self-report questionnaires included the APGAR family index (APGAR),20 the Life Distress Inventory (LDI),21 and the Body Image Scale (BIS);22 these were utilized to assess family functioning, life stress, and body image, respectively. Higher scores on the four scales indicated better 138
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sexual functioning, family functioning, higher life distress, and poorer body image, respectively. Clinical questionnaires for demographic data, previous emotional problems, and subjective gynecological symptoms were also included in the investigation. We queried whether they had been troubled by emotional difficulty, depression, or anxiety, for a period of time as a measure of previous emotional problems. The gynecological symptoms queried included dysmenorrhea, irregular menstrual cycle, vaginal bleeding, dyspareunia, low abdominal pain, low back pain, and constipation. The total number of symptoms was compounded to represent the subjective severity of gynecological symptoms. In addition to the above instruments, the indication for hysterectomy and the surgical technique applied were also collected from the surgical record. All participants were evaluated first (Investigation 1 [I-1]) within a 2-week period before the hysterectomy. The first assessment included a psychiatric interview, the Ham– D, Ham–A, SPEQ, APGAR, LDI, BIS, and the questionnaire for demographic data and previous emotional problems. Except for the last questionnaire, all measures were reassessed in the second (Investigation 2 [I-2]) and third investigation (Investigation 3 [I-3]), 1 month and 4 months after hysterectomy, respectively. The differences in psychological assessments between the three investigations were analyzed with repeated-measures ANOVA. The difference between each investigation was then analyzed with Bonferroni post-hoc analysis. The incidence of MDD was calculated, with the number of new cases divided by the number of non-MDD patients at I-1. Then the non-MDD participants at the beginning were placed into MDD and non-MDD groups according to the diagnosis made at I-3. The differences in continuous variables and categorical variables between the MDD and nonMDD groups were assessed by Fisher’s exact test and the Wilcoxon rank-sum test. All data were collected and analyzed with SPSS for Windows, Version 10.0. A p value less than 0.05 was considered significant for all tests. RESULTS A total of 68 women completed the three investigations. The demographic data and gynecological variables are shown in Table 1. Their mean age was 46.63 (standard deviation [SD]: 9.17; range: 32–78 years); 51.5% of the participants had had previous emotional problems. Most participants elected hysterectomy as indicated by uterine myoma (63.2%) and elected laparoscopic-assisted vaginal Psychosomatics 49:2, March-April 2008
Yen et al. hysterectomy (LAVH; 76.5%); however, only five women (7.4%) accepted oophorectomy. The diagnostic interview revealed that three women had suffered from MDD before the hysterectomy. Table 2 lists the results of the repeated-measures ANOVA. The results revealed significant differences on scores TABLE 1.
of the Ham–D (F⳱5.33; p⳱0.009), Ham–A (F⳱9.42; p⬍0.001), SPEQ (F⳱45.22; p⬍0.001), and BIS (F⳱8.08; p⳱0.002) and the number of subjective symptoms (F⳱35.07; p⬍0.001) among the three investigations. There were no significant differences for scores on the APGAR (F⳱2.52; p⳱0.09) and LDI (F⳱2.03; p⳱0.15).
Participants’ Demographic Data, Psychiatric History, Surgical Indication, and Surgical Technique Performed
Variable
N (%)
Age Education level Senior high school or higher Junior high school or lower Employment Yes No Marital status Married Not married or separated Previous emotional problems Yes No Surgical indication Uterine myoma Adenomyosis Cervical carcinoma in-situ Endometriosis Others Surgical technique Laparoscopic-assisted vaginal hysterectomy Total abdominal hysterectomy Vaginal hysterectomy Oophorectomy Yes No Major depressive disorder (MDD) at I-1 Yes No
Mean (SD) 46.63 (9.17)
31 (45.6%) 37 (54.4%) 31 (45.6%) 37 (54.4%) 53 (77.9%) 15 (22.1%) 35 (51.5%) 33 (48.5%) 43 11 6 4 4
(63.2%) (16.2%) (8.8%) (5.9%) (5.9%)
52 (76.5%) 14 (20.6%) 2 (2.9%) 5 (7.4%) 63 (92.6%) 3 (4.4%) 65 (95.6%)
SD: standard deviation.
TABLE 2.
Change in Ham-D, Ham-A, SPEQ, APGAR, LDI, BIS, and Number of Subjective Gynecological Symptoms in the Three Investigations, Repeated-Measures ANOVA
Ham-D Ham-A SPEQ APGAR LDI BIS Subjective symptoms
I-1
I-2
I-3
F
p
Post-Hoc Analysis
6.85 (4.22) 7.31 (4.29) 4.70 (1.92) 12.59 (2.97) 30.79 (16.95) 13.04 (3.68) 2.19 (1.64)
5.63 (4.63) 5.63 (3.95) 2.89 (1.45) 12.49 (3.47) 28.63 (13.95) 11.91 (2.78) 1.03 (0.98)
5.57 (4.76) 5.87 (4.05) 3.98 (1.66) 11.90 (4.09) 28.69 (12.49) 12.00 (3.40) 0.72 (0.84)
5.33 9.42 45.22 2.52 2.03 8.08 35.07
0.009 ⬍0.001 ⬍0.001 NS NS 0.002 ⬍0.001
I-1⬎I-2; I-1⬎I-3 I-1⬎I-2; I-1⬎I-3 I-1⬎I-3⬎I-2
I-1⬎I-2; I-1⬎I-3 I-1⬎I-2; I-1⬎I-3
Values are mean (standard deviation), unless otherwise indicated. Post-hoc significance analyses were Bonferroni-corrected. I-1: Investigation before hysterectomy; I-2: Investigation 1 month after hysterectomy; I-3: Investigation 4 months after hysterectomy. Ham-D: Hamilton Rating Scale for Depression; Ham-A: Hamilton Rating Scale for Anxiety; SPEQ: Personal Experience Questionnaire, Short Form; APGAR: APGAR Family Index; LDI: Life Distress Inventory; BIS: Body Image Scale.
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Major Depressive Disorder and Hysterectomy For the Ham–D, Ham–A, BIS, and number of subjective symptoms, Bonferroni post-hoc analysis revealed that scores on I-1 were significant higher than those for I-2 and I-3. For the SPEQ, scores at I-1 were higher than at I-3, and scores at I-3 were higher than at I-2. These results indicated that depressive symptoms, anxiety symptoms, body image, and subjective gynecological symptoms were all improved after hysterectomy; however, sexual functioning worsened after hysterectomy. The prospective follow-up revealed that 5 of 65 nonMDD participants at I-1 had been classified as having MDD at I-3. The 4-month incidence of MDD was 7.69% after hysterectomy. The associations between variables and MDD are shown in Table 3. The Fisher’s exact test indicated that the MDD group had a significantly higher proportion of self-reported previous emotional problems TABLE 3.
(p⳱0.024). Also, the results of Wilcoxon rank-sum tests showed that the MDD group had significantly lower scores on the SPEQ (Z ⳱ ⳮ2.07; p⳱0.039) and the LDI (Z ⳱ ⳮ2.43; p⳱0.015) and a higher score on the BIS (Z ⳱ ⳮ2.58; p⳱0.010) at I-2. However, there was no significant difference for other variables between the MDD and nonMDD groups. The results indicated that the MDD group had poorer sexual functioning, poorer body image, and higher stress levels 1 month after surgery. DISCUSSION The presenting prospective study revealed that depressive symptoms, anxiety symptoms, body image, and subjective gynecological symptoms were improved at 1 month and 4 months after hysterectomy. The result corresponded to pre-
Association Among Variables and Emergence of Depression, Analyzed by Fisher’s Exact Test or Wilcoxon Rank-Sum Test Depression (Nⴔ5) N (%)
Education level Senior high school or higher Junior high school or lower Employment Yes No Marital status Married Not married or separated Previous emotional problems Yes No Surgical technique Laparoscopic-assisted vaginal hysterectomy Others Oophorectomy Yes No First investigation SPEQ APGAR LDI BIS Subjective symptoms Secondary investigation (I-2) SPEQ APGAR LDI BIS Subjective symptoms
Mean (SD)
No Depression (Nⴔ60) N (%)
Mean (SD)
pa or Zb
2 (6.7%) 3 (8.6%)
28 (93.3%) 32 (91.4%)
1.000
0 (0.0%) 5 (14.3%)
30 (100.0%) 30 (85.7%)
0.057
4 (7.7%) 1 (7.7%)
48 (92.3%) 12 (92.3%)
1.000
5 (15.6%) 0 (0.0%)
27 (84.4%) 33 (100.0%)
0.024
3 (6.1%) 2 (12.5%)
46 (93.9%) 14 (87.5%)
0.590
1 (20.0%) 4 (6.7%)
4 (80.0%) 56 (93.3%)
0.339
4.27 9.60 30.20 12.80 1.40
(1.06) (5.77) (13.08) (3.63) (1.14)
4.86 12.92 29.22 12.97 2.20
(1.93) (2.51) (14.87) (3.42) (1.67)
ⳮ0.82 ⳮ1.47 ⳮ0.55 ⳮ0.06 ⳮ1.01
1.93 10.20 38.8 14.40 1.20
(0.60) (6.14) (12.81) (2.70) (1.10)
3.01 12.90 25.95 11.62 1.02
(1.48) (3.07) (9.97) (2.55) (1.00)
ⳮ2.07* ⳮ0.97 ⳮ2.43* ⳮ2.58* ⳮ0.40
SD: standard deviation; SPEQ: Personal Experience Questionnaire, Short Form; APGAR: APGAR Family Index; LDI: Life Distress Inventory; BIS: Body Image Scale. a p value of Fisher’s exact test. b Z value of Wilcoxon rank-sum test. *p⬍0.05; **p⬍0.01; ***p⬍0.001.
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Yen et al. vious positive reports on the psychological aspect of hysterectomy.23–25 In our sample, 76.5% of patients accepted laparoscopic-assisted vaginal hysterectomy, and only 7.4% accepted oophorectomy. The utilization of advanced techniques and sparing of ovaries may partially account for the improvement. On the other hand, although subjective gynecological symptoms and body image were improved, the prospective results demonstrated that sexual functioning had deteriorated at 1 month and 4 months after hysterectomy. Numerous gynecological, hormonal, and psychosocial mechanisms have been proposed to explain sexual dysfunction after hysterectomy. Hysterectomy can interrupt the nerve supply to the upper vagina, which is thought to interfere with lubrication and orgasm.26 Cervix removal may damage the uterovaginal plexus, which is responsible for internal orgasm sensation.27 Other gynecological factors associated with sexual dysfunction include a reduction in cervical mucus and vaginal shortening after hysterectomy.28 Also, vaginal dryness may result from bilateral oophorectomy or accelerated ovarian failure caused by hysterectomy without bilateral oophorectomy.29 Moreover, for women who feel uterine contractions as a pleasurable part of orgasm, hysterectomy may negatively affect the experience of orgasm.30 However, most recent research has reported positive results of hysterectomy on sexual functioning.9,10 Aside from physiological factors, cultural factors may also partly contribute to the negative results on sexual functioning seen in this study. In the traditional culture of Taiwan, a woman’s sense of identity comes from her childbearing role. Since the uterus functions in reproduction, women may see themselves as defeminized after hysterectomy.25 It has been reported that people in Taiwan tend to be embarrassed to discuss sexuality,31 and only 21% of patients with sexual dysfunction seek medical help.32 Consequently, post-surgical sexual dysfunction usually remained unresolved, without professional intervention. Thus, the results might suggest that more attention and available professional intervention for sexual dysfunction should be provided to the post-hysterectomy patient in Eastern societies. The 4-month incidence of MDD after hysterectomy, as evaluated by prospective systematic diagnostic inter-
view, was 7.69%. The risk factors described in the study included previous emotional problems, poor sexual functioning, higher life distress, and poor body image 1 month after surgery. Although we cannot conclude that self-reported previous emotional problems fulfilled specific psychiatric diagnoses, the result suggests that emotional difficulty should be evaluated and effective intervention provided before hysterectomy. Provision of psychiatric services and psychological support to manage sexual dysfunction, impaired body image, and life stresses post-hysterectomy are also necessary to prevent depression. Since antidepressants can alleviate depression effectively and rapidly,33 the early detection and treatment of depression could also prevent further negative impact on the psychological well-being of women after hysterectomy. Our study had several limitations. First, lacking a comparison result with a control group, the effect of other, background variables might have confounded the result of our study. Second, the size of our participant study is relatively small for detecting slight differences. Third, an observation period of more than 4 months (after total recovery from surgery) might reveal further effects. Fourth, diagnoses in this study were made according to the information provided by the subjects at interview. Contextual data, such as family observations, were not obtained. Diagnosis of depression might be underestimated without family reports. CONCLUSION This study demonstrated that depression, body image, life distress, and subjective gynecological symptoms improved after hysterectomy, whereas sexual functioning deteriorated. The 4-month incidence of major depressive disorder after hysterectomy is 7.69%. Also, previous emotional problems, poor sexual functioning, poor body image, and higher life stress after hysterectomy were risk factors for the emergence of major depressive disorder. Available psychiatric services, psychological support, and counseling to improve sexual functioning and body image and decrease life stressors should be provided to women with these problems after hysterectomy. This study was supported by a grant from the Department of Health, Taiwan (DOH94-TD-M-113-027).
References
1. Torpy JM, Lynm C, Glass RM: JAMA Patient Page: Hysterectomy. JAMA 2004; 291:1526
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2. Chang C, Mao CL, Hu YH: Prevalence of hysterectomy of Chinese women in Taiwan. Int J Gynaecol Obstet 1996; 52:73–74
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Major Depressive Disorder and Hysterectomy 3. Farquhar CM, Steiner CA: Hysterectomy rates in the United States, 1990–1997. Obstet Gynecol 2002; 99:229–234 4. Kjerulff KH, Langenberg PW, Rhodes JC, et al: Effectiveness of hysterectomy. Obstet Gynecol 2000; 95:319–326 5. Chakravarti S, Collins WP, Newton JR, et al: Endocrine changes and symptomatology after oophorectomy in premenopausal women. Br J Obstet Gynaecol 1977; 84:769–775 6. Baldaro B, Gentile G, Codispoti M, et al: Psychological distress of conservative and nonconservative uterine surgery: a prospective study. J Psychosom Res 2003; 54:357–360 7. Lambden MP, Bellamy G, Ogburn-Russell L, et al: Women’s sense of well-being before and after hysterectomy. J Obstet Gynecol Neonatal Nurs 1997; 26:540–548 8. Flory N, Bissonnette F, Binik YM: Psychosocial effects of hysterectomy: literature review. J Psychosom Res 2005; 59:117–129 9. Rhodes JC, Kjerulff KH, Langenberg PW, et al: Hysterectomy and sexual functioning. JAMA 1999; 282:1934–1941 10. Roovers JPWR, van der Bom JG, van der Vaart CH, et al: Hysterectomy and sexual well-being: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ 2003; 327:774–778 11. Higgins LT, Zheng M, Liu Y, et al: Attitudes to marriage and sexual behaviors: a survey of gender and culture differences in China and the United Kingdom. Sex Roles 2002; 46:75–89 12. Bachmann GA: Psychosexual aspects of hysterectomy. Women’s Health Issues 1990; 1:41–49 13. Sloan D: The emotional and psychosexual aspects of hysterectomy. Am J Obstet Gynecol 1978; 131:598–605 14. Bellerose SB, Binik YM: Body image and sexuality in oophorectomized women. Arch Sex Behav 1993; 22:435–459 15. Roussis NP, Waltrous L, Kerr A, et al: Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure. Am J Obstet Gynecol 2004; 190:1427– 1428 16. First MD, Spitzer RL, Gibbon M, et al (eds): Structured Clinical Interview for DSM–IV Axis I Disorders–Patient Edition (SCID-I/ P), Version 2.0. New York, New York State Psychiatric Institute, Biometrics Research, 1994 17. Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56–62 18. Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 1959; 32:50–55
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19. Dennerstein L, Dudley EC, Hopper JL, et al: Sexuality, hormones, and the menopausal transition. Maturitas 1997; 26:83–93 20. Smilkstein G, Ashworth C, Montano D: Validity and reliability of the family APGAR as a test of family function. J Fam Pract 1982; 15:303–311 21. Yoshioka MR, Shibusawa T: The Life Distress Inventory: A Psychometric Evaluation. Res Soc Work Pract 2002; 12:752–767 22. Hopwood P, Fletcher I, Lee A, et al: A body image scale for use with cancer patients. Eur J Cancer 2001; 37:189–197 23. Alexander DA, Naji AA, Pinion SB, et al: Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects. BMJ 1996; 312:280–284 24. Rannestad T, Eikeland OJ, Helland H, et al: The quality of life in women suffering from gynecological disorders is improved by means of hysterectomy: absolute and relative differences between pre- and postoperative measures. Acta Obstet Gynecol Scand 2001; 80:46–51 25. Rannestad T: Hysterectomy: effects on quality of life and psychological aspects. Best Pract Res Clin Obstet Gynaecol 2005; 19:419–430 26. Thakar R, Manyonda I, Stanton SL, et al: Bladder, bowel, and sexual function after hysterectomy for benign conditions. Br J Obstet Gynaecol 1997; 104:983–987 27. Hasson HM: Cervical removal at hysterectomy for benign disease: risks and benefits. J Reprod Med 1993; 38:781–790 28. Jewett JF: Intra-abdominal hemorrhage after hysterectomy. N Engl J Med 1957; 256:475–476 29. Oldenhave A, Jaszmann LJ, Everaerd WT, et al: Hysterectomized women with ovarian conservation report more severe climacteric complaints than do normal climacteric women of similar age. Am J Obstet Gynecol 1993; 168:765–771 30. Katz A: Sexuality after hysterectomy. J Obstet Gynecol Neonatal Nurs 2002; 31:256–262 31. Tsai YF, Hsiung PC: Aboriginal nurses’ perception of facilitators and barriers for taking a sexual history in Taiwan. Public Health Nurs 2003; 20:281–286 32. Nicolosi A, Glasser DB, Kim SC, et al: Sexual behaviour and dysfunction and help-seeking patterns in adults aged 40–80 years in the urban population of Asian countries. BJU Int 2005; 95:609– 614 33. Mitchell AJ: Two-week delay in onset of action of antidepressants: new evidence. Br J Psychiatry 2006; 188:105–106
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The authors prospectively evaluated the risk of major depressive disorder and the psychological impact of recent hysterectomy in 68 women who underwent hysterectomy for non-malignant conditions. Depression, anxiety, body image, sexual functioning, family support, life stress, and subjective gynecological symptoms were assessed 2 weeks before surgery and at 1 month and 4 months after surgery. Depression, anxiety, body image, and subjective gynecological symptoms improved after surgery; however, sexual functioning worsened after surgery. Previous emotional problems and poorer body image, sexual functioning, and higher stress 1 month after surgery are risk factors for post-hysterectomy major depressive disorder. (Psychosomatics 2008; 49:137–142)
H
ysterectomy is the second most common operation performed on North American women.1 Although the number of hysterectomies has declined over the past 30 years, 6.1%–10% of Taiwanese women have undergone a hysterectomy.2 Thus, its consequences concern a large proportion of women. Since around 90% of all hysterectomies are the result of benign conditions, improving the quality rather than the duration of life is a reasonable goal of this procedure.3 Thus, aside from mostly positive outcomes for gynecological symptoms,4 the psychological outcome and sexual functioning of patients should be another focus for informed decision-making regarding hysterectomy. Depression is one of the most commonly mentioned psychiatric risks after hysterectomy. Depression had been suggested earlier as a negative consequence;5 however, on the basis of recent prospective studies, there is no evidence to conclude that hysterectomy causes depression.6,7 However, major depressive disorder (MDD) has not been assessed by systematic diagnostic interview by psychiatrists in most prospective studies. Furthermore, there is a small proportion of women who do demonstrate negative psyPsychosomatics 49:2, March-April 2008
chological consequences.8 It would be beneficial to determine the risk factors for such outcomes because a preventive strategy should be implemented for risk groups so as to minimize or eliminate possible negative consequences. Sexual functioning after hysterectomy had been repeatedly reported to be a major concern of women; yet doctors, nurses, and other healthcare professionals are reluctant to discuss sexual issues with patients.8 In light of the results of recent prospective studies, however, hysterectomy has been shown to improve general sexual functioning.9,10 Because there are cultural differences in attitudes to sexual behavior between Eastern and Western societies,11 the impact of hysterectomy on women in an Eastern society might be different from those in a Western Received April 20, 2006; revised August 15, 2006; accepted August 30, 2006. From the Dept. of Psychiatry, Kaohsiung Medical University Hospital, Taiwan. Send correspondence and reprint requests to Chih-Hung Ko, M.D., Dept. of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd., Kaohsiung City, Taiwan 807. e-mail: cyberko@ seed.net.tw 䉷 2008 The Academy of Psychosomatic Medicine
http://psy.psychiatryonline.org
137
Major Depressive Disorder and Hysterectomy culture. Thus, research focusing on sexual dysfunction in women after hysterectomy in Eastern society was important. The loss of the uterus and scarring after surgery may result in impairment of body image, which includes the perception of a loss of femininity and vitality.12,13 Impairment of body image has been found in oophorectomized women;14 however oophorectomy is no longer a routine procedure in hysterectomy. Roussis et al., in a retrospective study,15 had reported no impairment in body image after hysterectomy, yet, in this study, recall bias could not be excluded. Since the evidence regarding change in body image is controversial, a prospective study utilizing a questionnaire directly relating to change in body image after surgery would provide clearer data. In order to demonstrate the need for clearer information to be provided to patients so as to enable them to make fully-informed decisions regarding hysterectomy, we evaluated 1) change in depressive and anxiety symptoms, family functioning, body image, and sexual functioning after hysterectomy; and 2) the risk factors for incidence of MDD after hysterectomy. METHOD All participants were recruited from the gynecological outpatient department of Kaohsiung Municipal Hsiao-Kang Hospital, having been scheduled for a hysterectomy to take place between February 2004 and August 2004. A total of 75 women were invited according to the surgical list provided by the gynecological staff; 68 agreed to participate in this research and gave informed consent. This research was approved by the Human Experiment and Ethics Committee of Kaohsiung Municipal Hsiao-Kang Hospital. The diagnosis of MDD was assessed by systematic diagnostic interview with one psychiatrist according to the Structured Clinical Interview for DSM–IV-TR (SCID).16 The 17-item Hamilton Rating Scale for Depression (Ham– D)17 and the Hamilton Rating Scale for Anxiety (Ham– A),18 administered by a psychiatrist, were utilized to objectively assess depression and anxiety, respectively. To address patients’ sexual functioning, we used the Short Form of the Personal Experience Questionnaire (SPEQ), previously validated by Dennerstein et al.19 The other self-report questionnaires included the APGAR family index (APGAR),20 the Life Distress Inventory (LDI),21 and the Body Image Scale (BIS);22 these were utilized to assess family functioning, life stress, and body image, respectively. Higher scores on the four scales indicated better 138
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sexual functioning, family functioning, higher life distress, and poorer body image, respectively. Clinical questionnaires for demographic data, previous emotional problems, and subjective gynecological symptoms were also included in the investigation. We queried whether they had been troubled by emotional difficulty, depression, or anxiety, for a period of time as a measure of previous emotional problems. The gynecological symptoms queried included dysmenorrhea, irregular menstrual cycle, vaginal bleeding, dyspareunia, low abdominal pain, low back pain, and constipation. The total number of symptoms was compounded to represent the subjective severity of gynecological symptoms. In addition to the above instruments, the indication for hysterectomy and the surgical technique applied were also collected from the surgical record. All participants were evaluated first (Investigation 1 [I-1]) within a 2-week period before the hysterectomy. The first assessment included a psychiatric interview, the Ham– D, Ham–A, SPEQ, APGAR, LDI, BIS, and the questionnaire for demographic data and previous emotional problems. Except for the last questionnaire, all measures were reassessed in the second (Investigation 2 [I-2]) and third investigation (Investigation 3 [I-3]), 1 month and 4 months after hysterectomy, respectively. The differences in psychological assessments between the three investigations were analyzed with repeated-measures ANOVA. The difference between each investigation was then analyzed with Bonferroni post-hoc analysis. The incidence of MDD was calculated, with the number of new cases divided by the number of non-MDD patients at I-1. Then the non-MDD participants at the beginning were placed into MDD and non-MDD groups according to the diagnosis made at I-3. The differences in continuous variables and categorical variables between the MDD and nonMDD groups were assessed by Fisher’s exact test and the Wilcoxon rank-sum test. All data were collected and analyzed with SPSS for Windows, Version 10.0. A p value less than 0.05 was considered significant for all tests. RESULTS A total of 68 women completed the three investigations. The demographic data and gynecological variables are shown in Table 1. Their mean age was 46.63 (standard deviation [SD]: 9.17; range: 32–78 years); 51.5% of the participants had had previous emotional problems. Most participants elected hysterectomy as indicated by uterine myoma (63.2%) and elected laparoscopic-assisted vaginal Psychosomatics 49:2, March-April 2008
Yen et al. hysterectomy (LAVH; 76.5%); however, only five women (7.4%) accepted oophorectomy. The diagnostic interview revealed that three women had suffered from MDD before the hysterectomy. Table 2 lists the results of the repeated-measures ANOVA. The results revealed significant differences on scores TABLE 1.
of the Ham–D (F⳱5.33; p⳱0.009), Ham–A (F⳱9.42; p⬍0.001), SPEQ (F⳱45.22; p⬍0.001), and BIS (F⳱8.08; p⳱0.002) and the number of subjective symptoms (F⳱35.07; p⬍0.001) among the three investigations. There were no significant differences for scores on the APGAR (F⳱2.52; p⳱0.09) and LDI (F⳱2.03; p⳱0.15).
Participants’ Demographic Data, Psychiatric History, Surgical Indication, and Surgical Technique Performed
Variable
N (%)
Age Education level Senior high school or higher Junior high school or lower Employment Yes No Marital status Married Not married or separated Previous emotional problems Yes No Surgical indication Uterine myoma Adenomyosis Cervical carcinoma in-situ Endometriosis Others Surgical technique Laparoscopic-assisted vaginal hysterectomy Total abdominal hysterectomy Vaginal hysterectomy Oophorectomy Yes No Major depressive disorder (MDD) at I-1 Yes No
Mean (SD) 46.63 (9.17)
31 (45.6%) 37 (54.4%) 31 (45.6%) 37 (54.4%) 53 (77.9%) 15 (22.1%) 35 (51.5%) 33 (48.5%) 43 11 6 4 4
(63.2%) (16.2%) (8.8%) (5.9%) (5.9%)
52 (76.5%) 14 (20.6%) 2 (2.9%) 5 (7.4%) 63 (92.6%) 3 (4.4%) 65 (95.6%)
SD: standard deviation.
TABLE 2.
Change in Ham-D, Ham-A, SPEQ, APGAR, LDI, BIS, and Number of Subjective Gynecological Symptoms in the Three Investigations, Repeated-Measures ANOVA
Ham-D Ham-A SPEQ APGAR LDI BIS Subjective symptoms
I-1
I-2
I-3
F
p
Post-Hoc Analysis
6.85 (4.22) 7.31 (4.29) 4.70 (1.92) 12.59 (2.97) 30.79 (16.95) 13.04 (3.68) 2.19 (1.64)
5.63 (4.63) 5.63 (3.95) 2.89 (1.45) 12.49 (3.47) 28.63 (13.95) 11.91 (2.78) 1.03 (0.98)
5.57 (4.76) 5.87 (4.05) 3.98 (1.66) 11.90 (4.09) 28.69 (12.49) 12.00 (3.40) 0.72 (0.84)
5.33 9.42 45.22 2.52 2.03 8.08 35.07
0.009 ⬍0.001 ⬍0.001 NS NS 0.002 ⬍0.001
I-1⬎I-2; I-1⬎I-3 I-1⬎I-2; I-1⬎I-3 I-1⬎I-3⬎I-2
I-1⬎I-2; I-1⬎I-3 I-1⬎I-2; I-1⬎I-3
Values are mean (standard deviation), unless otherwise indicated. Post-hoc significance analyses were Bonferroni-corrected. I-1: Investigation before hysterectomy; I-2: Investigation 1 month after hysterectomy; I-3: Investigation 4 months after hysterectomy. Ham-D: Hamilton Rating Scale for Depression; Ham-A: Hamilton Rating Scale for Anxiety; SPEQ: Personal Experience Questionnaire, Short Form; APGAR: APGAR Family Index; LDI: Life Distress Inventory; BIS: Body Image Scale.
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Major Depressive Disorder and Hysterectomy For the Ham–D, Ham–A, BIS, and number of subjective symptoms, Bonferroni post-hoc analysis revealed that scores on I-1 were significant higher than those for I-2 and I-3. For the SPEQ, scores at I-1 were higher than at I-3, and scores at I-3 were higher than at I-2. These results indicated that depressive symptoms, anxiety symptoms, body image, and subjective gynecological symptoms were all improved after hysterectomy; however, sexual functioning worsened after hysterectomy. The prospective follow-up revealed that 5 of 65 nonMDD participants at I-1 had been classified as having MDD at I-3. The 4-month incidence of MDD was 7.69% after hysterectomy. The associations between variables and MDD are shown in Table 3. The Fisher’s exact test indicated that the MDD group had a significantly higher proportion of self-reported previous emotional problems TABLE 3.
(p⳱0.024). Also, the results of Wilcoxon rank-sum tests showed that the MDD group had significantly lower scores on the SPEQ (Z ⳱ ⳮ2.07; p⳱0.039) and the LDI (Z ⳱ ⳮ2.43; p⳱0.015) and a higher score on the BIS (Z ⳱ ⳮ2.58; p⳱0.010) at I-2. However, there was no significant difference for other variables between the MDD and nonMDD groups. The results indicated that the MDD group had poorer sexual functioning, poorer body image, and higher stress levels 1 month after surgery. DISCUSSION The presenting prospective study revealed that depressive symptoms, anxiety symptoms, body image, and subjective gynecological symptoms were improved at 1 month and 4 months after hysterectomy. The result corresponded to pre-
Association Among Variables and Emergence of Depression, Analyzed by Fisher’s Exact Test or Wilcoxon Rank-Sum Test Depression (Nⴔ5) N (%)
Education level Senior high school or higher Junior high school or lower Employment Yes No Marital status Married Not married or separated Previous emotional problems Yes No Surgical technique Laparoscopic-assisted vaginal hysterectomy Others Oophorectomy Yes No First investigation SPEQ APGAR LDI BIS Subjective symptoms Secondary investigation (I-2) SPEQ APGAR LDI BIS Subjective symptoms
Mean (SD)
No Depression (Nⴔ60) N (%)
Mean (SD)
pa or Zb
2 (6.7%) 3 (8.6%)
28 (93.3%) 32 (91.4%)
1.000
0 (0.0%) 5 (14.3%)
30 (100.0%) 30 (85.7%)
0.057
4 (7.7%) 1 (7.7%)
48 (92.3%) 12 (92.3%)
1.000
5 (15.6%) 0 (0.0%)
27 (84.4%) 33 (100.0%)
0.024
3 (6.1%) 2 (12.5%)
46 (93.9%) 14 (87.5%)
0.590
1 (20.0%) 4 (6.7%)
4 (80.0%) 56 (93.3%)
0.339
4.27 9.60 30.20 12.80 1.40
(1.06) (5.77) (13.08) (3.63) (1.14)
4.86 12.92 29.22 12.97 2.20
(1.93) (2.51) (14.87) (3.42) (1.67)
ⳮ0.82 ⳮ1.47 ⳮ0.55 ⳮ0.06 ⳮ1.01
1.93 10.20 38.8 14.40 1.20
(0.60) (6.14) (12.81) (2.70) (1.10)
3.01 12.90 25.95 11.62 1.02
(1.48) (3.07) (9.97) (2.55) (1.00)
ⳮ2.07* ⳮ0.97 ⳮ2.43* ⳮ2.58* ⳮ0.40
SD: standard deviation; SPEQ: Personal Experience Questionnaire, Short Form; APGAR: APGAR Family Index; LDI: Life Distress Inventory; BIS: Body Image Scale. a p value of Fisher’s exact test. b Z value of Wilcoxon rank-sum test. *p⬍0.05; **p⬍0.01; ***p⬍0.001.
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Yen et al. vious positive reports on the psychological aspect of hysterectomy.23–25 In our sample, 76.5% of patients accepted laparoscopic-assisted vaginal hysterectomy, and only 7.4% accepted oophorectomy. The utilization of advanced techniques and sparing of ovaries may partially account for the improvement. On the other hand, although subjective gynecological symptoms and body image were improved, the prospective results demonstrated that sexual functioning had deteriorated at 1 month and 4 months after hysterectomy. Numerous gynecological, hormonal, and psychosocial mechanisms have been proposed to explain sexual dysfunction after hysterectomy. Hysterectomy can interrupt the nerve supply to the upper vagina, which is thought to interfere with lubrication and orgasm.26 Cervix removal may damage the uterovaginal plexus, which is responsible for internal orgasm sensation.27 Other gynecological factors associated with sexual dysfunction include a reduction in cervical mucus and vaginal shortening after hysterectomy.28 Also, vaginal dryness may result from bilateral oophorectomy or accelerated ovarian failure caused by hysterectomy without bilateral oophorectomy.29 Moreover, for women who feel uterine contractions as a pleasurable part of orgasm, hysterectomy may negatively affect the experience of orgasm.30 However, most recent research has reported positive results of hysterectomy on sexual functioning.9,10 Aside from physiological factors, cultural factors may also partly contribute to the negative results on sexual functioning seen in this study. In the traditional culture of Taiwan, a woman’s sense of identity comes from her childbearing role. Since the uterus functions in reproduction, women may see themselves as defeminized after hysterectomy.25 It has been reported that people in Taiwan tend to be embarrassed to discuss sexuality,31 and only 21% of patients with sexual dysfunction seek medical help.32 Consequently, post-surgical sexual dysfunction usually remained unresolved, without professional intervention. Thus, the results might suggest that more attention and available professional intervention for sexual dysfunction should be provided to the post-hysterectomy patient in Eastern societies. The 4-month incidence of MDD after hysterectomy, as evaluated by prospective systematic diagnostic inter-
view, was 7.69%. The risk factors described in the study included previous emotional problems, poor sexual functioning, higher life distress, and poor body image 1 month after surgery. Although we cannot conclude that self-reported previous emotional problems fulfilled specific psychiatric diagnoses, the result suggests that emotional difficulty should be evaluated and effective intervention provided before hysterectomy. Provision of psychiatric services and psychological support to manage sexual dysfunction, impaired body image, and life stresses post-hysterectomy are also necessary to prevent depression. Since antidepressants can alleviate depression effectively and rapidly,33 the early detection and treatment of depression could also prevent further negative impact on the psychological well-being of women after hysterectomy. Our study had several limitations. First, lacking a comparison result with a control group, the effect of other, background variables might have confounded the result of our study. Second, the size of our participant study is relatively small for detecting slight differences. Third, an observation period of more than 4 months (after total recovery from surgery) might reveal further effects. Fourth, diagnoses in this study were made according to the information provided by the subjects at interview. Contextual data, such as family observations, were not obtained. Diagnosis of depression might be underestimated without family reports. CONCLUSION This study demonstrated that depression, body image, life distress, and subjective gynecological symptoms improved after hysterectomy, whereas sexual functioning deteriorated. The 4-month incidence of major depressive disorder after hysterectomy is 7.69%. Also, previous emotional problems, poor sexual functioning, poor body image, and higher life stress after hysterectomy were risk factors for the emergence of major depressive disorder. Available psychiatric services, psychological support, and counseling to improve sexual functioning and body image and decrease life stressors should be provided to women with these problems after hysterectomy. This study was supported by a grant from the Department of Health, Taiwan (DOH94-TD-M-113-027).
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