Limited a lot Limited a little Not limited at all Moderate activities
Limited a lot Limited a little Not limited at all Vigorous activities
Pre-op 6 months 1 year
0.0%
Limited a lot Limited a little Not limited at all Carrying groceries
Limited a lot Limited a little Not limited at all Bending and stooping
Limited a lot Limited a little Not limited at all One flight of stairs
Limited a lot Limited a little Not limited at all Several flights of stairs
Limited a lot Limited a little Not limited at all Walking one hundred yards
Limited a lot Limited a little Not limited at all Walking several hundred yards
Pre-op 6 months 1 year
0.0%
Limited a lot Limited a little Not limited at all Walking more than 1 mile
Limited a lot Limited a little Not limited at all Bathing and dressing
Pre-op 6 months 1 year
A comparitive graphical rapresentation of limitations experied by endometriosis patients in the pre-opeartive period, six months post operatively and at one year post-operatively.
Within 6 months of surgery, there was an overall improvement in general health of patients with 61.9% of the study patients reporting good overall health levels 6 months post-surgery compared to 31.6%
preoperatively (P=0.031). Within a year, reports of the same patients reporting good levels of health fell to 35.3% which is similar to the pre-operative value of 31.6% (P=1). This is in keeping with the short term reported benefits of surgery with high relapse rates necessitating future surgery with increased patient morbidity. There was a small observed increase in the percentage of people reporting excellent levels of health at 1 year post surgery (11.7%) when compared to pre-operative levels of 5.3%. This however did not reach statistical significance (P=0.576). Interestingly within six months of surgery 0% of my study population classified their health as excellent and values were only seen to rise within the 6 month to 1 year post-operative recovery period.
In the pre-operative questionnaires, 5.3% of the study population described their health as fair to poor.
Within six months of surgery these reports increased to 14.3% (P=0.329) reaching 17.6% at one year (P=0.329). The reason for this rise is a question of debate. Whilst some might argue that post-operative scarring can contribute to worsening of pain and discomfort, others might attribute perceived increased levels of poor health as a result of the negative psychological impact on patients once a diagnosis of endometriosis has been made.
Interestingly, when patients were asked to compare their post-operative overall health levels, one year following their surgery, to the one year prior to their surgery, the responses was positive. Within 6 months of surgery, 23.8% felt their health had significantly improved when compared to 10.5% pre- operatively (P=0.186). This percentage increased to 41.2% at one year (P=0.096). There was a decrease in the patient groups reporting the worst levels of pre-operative general health, with a reduction from 26.3% to 0%
(P=0.021) within 6 months of surgery and a further increase to 11.8% at the one year follow up (P=0.267). From the 5.3% of patients who believed their health was progressively worsening pre-operatively, there was an observed reduction to 4.8% within six months of surgery (P=1) and this fell to 0% at one year post surgery (P=0.329).
The ability to perform moderate activities was reported as limited in a total of 21% of the study patients in the pre-operative period. This percent fell to 9.5% within 6 months and to 0% at their one year follow up (P=0.162). Within 6 months of surgery 71.4% of patients did not report any limitations in performing daily vigorous activities in comparison to the 57.9% in the pre-operative period (P=0.213). This percentage totalled out to 70.6% of the study population at one year post-operatively (P=0.747).
Restrictions in daily functions such as lifting or carrying objects, climbing flights of stairs, bending and kneeling, walking a mile and bathing or dressing showed improvements at the one year post-operative follow up in the patient groups reporting the worst pre-operative symptoms. Respective results were as follows: lifting or carrying objects (10.5% to 0% (P=0.162)), climbing flights of stairs (26.3% to 0%
(P=0.021)), bending and kneeling (10.5% to 0% (P=0.162)), walking a mile (15.8% to 0% (P=0.082)) and bathing or dressing (10.5% to 0% (P=0.082)).
FIGURE 3-2
0.0%
Not at all Slightly Moderately Quite a bit Extremely
Emotional problems interferring with
Not at all A little bit Moderately Quite a bit Extremely
Pain interfered with work
Pre-op 6 months 1 year
0.0%
Not at all A little bit Moderately Quite a lot Extremely
Pain interfering with work
0.0%
0.0%
0.0%
A comparative graphical representation of limitations due to the negative emotional impact experienced by endometriosis patients in the pre-operative period, six months post operatively and at one year post-operatively.
In the questionnaires I also assessed the activities which could be impacted by psychological rather than physical symptoms.
Patients were asked whether they had cut down on time from work (See section 1.13.2). In the pre-operative period, 58% of my patient group had never cut down on work due to symptoms of endometriosis. In the one year after their operation, this number rose to 77% (P= 0.54) potentially indicating a positive impact in patients pain or psyche after diagnosis and treatment (Figure 3-2).
Other studies confirm the deterioration in the work life productivity of patients with endometriosis, at an average of approximately 10 hours per week compared to 7 hours in non-affected women4. At one year post laparoscopy, 82% of patients reported that their health no longer restrained or limited their work achievements compared to 68% pre-operatively (P=0.77). The percentage of study patients who felt they required an increased level of effort to perform work tasks and who had difficulty performing their work tasks fell by 19% at one year operatively. 77% reported no work impediment in the one year post-operative time period compared to the 58% pre-post-operatively (P=0.576). (Figure 3-2)
Patients were also asked how they felt emotionally (Figure 3-2) and how this impacted their work. Of my pre-operative patient population 58%, reported no adverse impact on their work. This improved to 67%
(P=0.266) within six months of surgery and 88% after a one year (P=0.296). Reduction of accomplishments due to emotional barriers was also assessed. At 6 months 71% (P=0.004) and at one year 94% (P=0.04) of my post-operative patient population felt no reduction in their work of life accomplishments due to disease. This contrasts with the 42% of the study populat ion who had claimed they were not impacted by disease pre-operatively. This confirms an increase in patient accomplishment previously impeded due to the emotional impact of endometriosis on their lives.
Non-specific bodily pain levels interfering with work was assessed (Figure 3-2). Pre-operatively, 21% of my patient population had no issues with bodily pain affecting daily work. At six months post-operatively this increased to 38% (P=0.162) and further increased to 71% at the one year follow up (P=0.042).
In my study I also aimed to identify effects of endometriosis on the general emotional wellbeing of my patients. The reduction of emotional problems after treatment of disease is visible (Figure 3-2). In the one year post-operative follow up, 77% of women felt full of life and were not depressed, this contrasts with the 26% who reported not feeling depressed pre-operatively (P=0.028). Energy levels were elevated in 59% of my patients at the one year visit, this can be compared to the 11% reporting good energy levels pre-operatively (P=0.002).A feeling of nervousness fell from 74% pre-operatively to 53% (P=0.378) at the one year follow up and during the same time period, the percentage of patients reporting feelings of calmness increased from 21% pre-operatively to 47% within six months(P=0.05) and 59% at one year (P=0.03). Depression was seen in 37% of my pre-operative patient population, interestingly no patient (0%) reported feeling depressed at the one year follow up visit (P=0.004) (Figure 3-2).
An improvement in social activities was also seen after surgery (Figure 3-2). 65% reported no impact of pain or disease on their social interactions at the one year post-operative visit. Pre operatively, only 16%
had felt that their social life was not being adversely affected by endometriosis (P=0.016). Patient’s perception of being less healthy than other people they knew fell by 21%. Pre-operatively, only 26%
believed they were as healthy as their acquaintances, this was seen to rise to 47% at the one year follow up (P=0.329). Overall, 11% expected their health to deteriorate before their operation, this value rose
0
Respective graphical representation of patient subjective pain levels (y-axis pain levels 0-100%) for dysmenorrhoea, deep dyspareunia, dyschesia, ovulatory pain and pain on micturition pre-operatively, at 6 months and one year post operatively.
The perception of pain was also assessed (See section 1.12). I asked patients to rate their pain scores (0%
indicating no pain and 100% indicating the highest levels of pain) for dysmenorrhoea, deep dyspareunia, dyschesia, ovulatory pain, chronic pelvic pain and pain on micturition (Figure 3-3). All of these symptoms have been attributed to endometriosis although there is no direct link between severity of disease and pain scores11. The patient’s perception of pain varies according to the psychology of the individual304 and therefore pain scores will be subjective rather than objective values. Looking at the graphical results (Figure 3-3) there is a notable decrease in overall experienced pain levels for dysmenorrhoea from the pre-operative time period (Average dysmenorrhoea pain score 59%) when compared to the 6 months (Average dysmenorrhoea pain score 51%) and one year post-operative levels of pain (Average dysmenorrhoea pain score 26%). Overall pain levels for deep dyspareunia also showed an improvement. Deep dyspareunia is not usually experienced by all patients with endometriosis. It is believed to be a result of deeply infiltrating disease in the Pouch of Douglas. Though deep dyspareunia is mostly believed to be due to pathology268, psychosexual influences of each individual patient will also affect pain scores during intercourse. The average deep dyspareunia pain level pre-operatively stood at 30%, these fell to 17% at 6 months post operatively and 18% at one year post-operatively. Dyschesia is another symptom that is related to endometriosis. This is usually attributed to disease around the rectum
and Pouch of Douglas and changes in bowel habits are also known to be linked to presence of endometriosis268. Confounding factors such as irritable bowel syndrome or inflammatory bowel conditions might also deteriorate pre-menstrually so the values of pain are once again patient dependant and subjective. Pre-operatively, pain scores for dyschesia stood at 23%, these fell to 19% within six months of surgery and 10% at one year post-operatively. Pain on micturition was also assessed though this is a clinically rarer reported symptom of endometriosis. This is usually attributed to disease in the vicinity of the bladder on the anterior aspect of the Uterus or the uterovescal fold of peritoneum. Pre-operatively, pain scores were around 8%, they were seen to increase to 14% within 6 months of the operation and fell again to 3% at one year post-operatively (Figure 3-3). This interesting rise in the 6 month follow up could potentially be attributed to an early recovery period or increased pain awareness once a diagnosis of endometriosis has been imparted. Pain perceptions vary with patient psychology which is multifactorial304. This makes it difficult to attribute pain levels to the presence of physical disease.
Mid-cycle or ovulatory pain was also assessed in conjunction with chronic pelvic pain. Pain perception varies according to the patient in question and typically patients who complain of chronic pelvic pain will also report mid-cycle ovulatory discomfort302. Pain related with ovulation was reported at 38% pre-operatively, falling to 11% at six months and slightly rising to 15% at one year post-surgery. In a similar pattern, chronic pain was reported at 34% pre-operatively, fell to 8% within six months of surgery and there was an increase to 12% at one year (Figure 3-3).
Therapeutic laparoscopic surgery shows benefits in the symptoms and psyche of patients with endometriosis. Surgical risks must be balanced against the benefits which are obtained with symptom resolution. Due to the chronicity of the condition, long term follow up is required in endometriosis, with high recurrence rates reported274. A multidisciplinary team follow up will ensure both physical and psychological benefits are achieved in women being treated for this disease492.