Psychiatric morbidity following hysterectomy in Egypt

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CLINICAL ARTICLE

Psychiatric morbidity following hysterectomy in Egypt

Yasser A. Helmy

^a

, Ibrahim M.A. Hassanin

^a

, Taher Abd Elraheem

^b

, Ahmed A. Bedaiwy

^c

, Rachele S. Peterson

^d

, Mohamed A. Bedaiwy

^d,

⁎

aDepartment of Obstetrics and Gynecology, Faculty of Medicine, Sohag University, Sohag, Egypt

bDepartment of Neuropsychiatry, Faculty of Medicine, Sohag University, Sohag, Egypt

cDepartment of Psychology, Faculty of Education, Helwan University, Cairo, Egypt

dDepartment of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA

Received 5 November 2007; received in revised form 20 January 2008; accepted 7 February 2008

Abstract

Objective: To evaluate psychiatric morbidity in Egyptian women before and after hysterectomy for benign indications.Method: A 2-year prospective observational study at Sohag University Hospital, Egypt, in which 96 women scheduled for hysterectomy were assessed for psychiatric comorbidity before and after the operation using the General Health Questionnaire (GHQ-28), Beck Depression Inventory, and Hamilton Anxiety Scale.Results: Of these, 35 (36.5%) had scores of 4 or higher, signifying psychiatric comorbidity (group 1), and 61 (63.5%) had scores less than 4, suggesting no psychiatric comorbidity (group 2). Postoperatively, severe anxiety and depressive symptoms were common in group 1. In group 2, 48 (78.7%) of the 61 women had scores of 4 or higher. In that subgroup, depressive and anxiety symptoms were more common among nulliparas whereas women with a high parity experienced the least psychiatric comorbidity.Conclusions: As women undergoing hysterectomy risk psychiatric morbidity, gynecologists should consider less invasive interventions to treat benign conditions.

KEYWORDS Anxiety;

Depression;

Egypt;

Hysterectomy;

Psychiatric morbidity

1. Introduction

Hysterectomy is one of the most common major operations for women in industrialized countries [1]. This trend is spreading to low-income countries, especially since the

⁎ Corresponding author. Cleveland Clinic, Department of Obste- trics and Gynecology, 9500 Euclid Ave. Desk A81, Cleveland, OH 44195, USA. Tel.: +1 216 445 1758; fax: +1 216 445 6325.

E-mail address:[email protected](M.A. Bedaiwy).

morbidity and mortality associated with the procedure have been greatly reduced. This in turn has encouraged an ex- pansion of indications for hysterectomy to include more benign diseases and symptoms related to the genital system.

About 1 in 3 women in the United States will undergo hysterectomy before the age of 60 years[2], and rates for the procedure were estimated as 5.6 per 1000 women in 1997 [3].

Psychiatric morbidity prior to and following hysterectomy has received increasing attention and analysis. A decline in sexual activity after hysterectomy may lead to increased

doi:10.1016/j.ijgo.2008.02.007

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depression and anxiety, and menopausal symptoms can occur even when the ovaries are conserved, which may also increase depression and anxiety. Repeated controlled studies indicate that hysterectomy can result in psychiatric conditions such as depression and anxiety[4]. Hysterectomy can complicate a woman's psychological state, and some women develop immediate postoperative symptoms of severe anxiety that significantly impact on their quality of life [5,6]. However, the procedure may improve psychiatric and psychosexual well-being in some women, especially those who underwent hysterectomy for indications that, although benign, caused great discomfort[7–9].

Hysterectomy as a treatment for benign indications should be critically and comprehensively re-evaluated to assess its potentially negative short- and long-term psychological consequences as well as its effects on psychosexual function [9,10].

The objective of the present study was to evaluate psychiatric morbidity (anxiety and depression) in Egyptian women who underwent abdominal or vaginal hysterectomy for benign indications.

2. Materials and methods

This 2-year prospective observational study was conducted at Sohag University Hospital, Egypt, from May 2005 to March 2007.

The 102 women recruited to the study were aged between 35 and 60 years, had no personal or family history of psychiatric illness, and were scheduled to undergo hysterectomy for a benign indication such as uterine prolapse, perimenopausal dysfunctional uterine bleeding not responding to treatment, or uterine or cervical myomas. Women were excluded from the study if hysterectomy was performed as an emergency procedure or to manage premalignant or malignant conditions. The study received approval from the ethical committee of the faculty.

All women underwent clinical and ultrasound examinations and colposcopic evaluations. Their medical history was taken and health status assessed prior to the operation. Moreover, a complete psychiatric history was taken using a semi-structured psychiatric interviewing approach; and when detected, psychiatric comorbidity was assessed. We chose D. Goldberg's 28-item General Health Questionnaire (GHQ-28) as a screening tool.

Developed to identify short-term changes in mental health (depression, anxiety, social dysfunction, and somatic symptoms), this extensively studied and widely accepted questionnaire is best used with a cut-off score of 4 for an optimal predictive value[11,12].

The women who scored 4 or higher on the GHQ-28 were classified as having a psychiatric comorbidity (group 1), whereas those who scored less than 4 were classified as having no psychiatric comorbidity (group 2). All women in group 1 were further evaluated prior to undergoing hysterectomy using the Beck Depression Inventory (BDI) and Hamilton Anxiety Scale (HAMA). The Beck Depression Inventory is a measure for as- sessing depression severity in diagnosed patients and for detecting possible depression in healthy populations. Its re- liability and validity are well documented[13,14]. The Hamilton Anxiety Scale (HAMA) was developed in the late 1950s to assess anxiety symptoms [15]. The scale is designed to be adminis- tered by a clinician. HAMA has been used extensively to monitor treatment response in studies of generalized anxiety disorder

and may also be useful for this purpose in clinical settings. A score of 14 has been suggested as a threshold for clinically significant anxiety, and scores of 5 or less are typical for indi- viduals living in the community.

The operative intervention was a hysterectomy (either abdominal or vaginal) and specimens were examined histo- pathologically for each woman to rule out malignancy. The operative and postoperative courses were uncomplicated. All patients were discharged within 1 week, had a follow-up visit at an outpatient clinic after 2 weeks, and were given a psychiatric re-evaluation 1 month later. In group 2, the impact of the procedure on the women’s psychiatric well-being was evaluated using the GHQ-28. Those who scored 4 or higher were reclassified as group 2A and those who scored less than 4 were classified as group 2B. The women in group 2A were further evaluated with the BDI and HAMA to assess the impact of hysterectomy on their symptoms of depression and anxiety.

Statistical analysis was performed using SPSS version 11.0 (SPSS, Chicago, IL, USA). Data are presented as mean, standard deviation, and range or as number and percentage. Comparisons between groups were done using thet test or theχ²test, as appropriate.P≤0.05 was considered statistically significant.

3. Results

A total of 102 women scheduled for abdominal or vaginal hysterectomy were eligible for inclusion and 96 (94.1%) completed the study. Their demographic characteristics are

Table 1 Characteristics of women with (group 1) and without (group 2) psychiatric comorbidity before hysterectomy

Characteristic Group 1

(n= 35)

Group2 (n= 61)

Pvalue Age, y

Mean ± SD (range) 45.6 ± 3.8 (39–58)

47.3 ± 4.9 (37–59)

NS Duration of marriage, y

Mean ± SD (range) 20.6 ± 4.1 (15–31)

22.1 ± 4.4 (17–31)

NS Level of education

Illiterate 15 (42.9) 29 (47.5) NS

Primary school 10 (28.6) 16 (26.3) NS Secondary school 6 (17.1) 10 (16.4) NS

University 4 (11.3) 6 (9.8) NS

Indication for hysterectomy

Uterine descent^a 7 (20.0) 16 (26.2) b0.0001 Perimenopausal DUB and

no response to treatment^b

9 (25.7) 21 (34.4) b0.0001 Fibroid, either uterine or

cervical^b

12 (34.2) 20 (32.7) b0.0001 Other (benign ovarian

tumors, pyometria, adenomyosis)^b

7 (20.0) 4 (6.5) 0.002

Abbreviation: DUB, dysfunctional uterine bleeding. Values are given as number (percentage) unless otherwise indicated.

aPerformed by vaginal hysterectomy.

b Performed by abdominal hysterectomy.

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shown inTable 1. The indication for the 23 women (24.0%) who underwent vaginal hysterectomy was uterine prolapse.

Of the 73 women who underwent abdominal hysterectomy 30 (31.3%) had perimenopausal dysfunctional uterine bleeding nonresponsive to treatment, 32 (33.3%) had uterine or cervical myomas, and 11 (11.5%) had other indications.

There were 35 women (36.5%) in group 1, the group with psychiatric comorbidity at baseline, and 61 women (63.5%) in group 2, the group without psychiatric comorbidity at baseline (Fig. 1). There were no statistically significant differences between the 2 groups for age, duration of marriage, or level of education (Table 1). The indications for hysterectomy between the groups were statistically significant except for those performed for“other”indications.

One month after the operation, the women in group 2 were rescreened with the GHQ-28. Of these 61 women, 48 (78.7%) scored 4 or higher and were reclassified as group 2A, signifying that they now had psychiatric comorbidity, whereas 13 (21.3%) scored less than 4 and were reclassified as group 2B, signifying that they still had no psychiatric comorbidity (Fig. 2).

As assessed by BDI, 15 (42.9%) of the 35 women in group 1 had depressive symptoms before hysterectomy and 29 (60.4%) of the 48 women in group 2A had depressive symptoms after hysterectomy. The severity of depressive symptoms before and after hysterectomy in group 1 is shown in Fig. 3. In group 1, the depressive symptoms were mild in 7 (46.7%) of the 15 women with such symptoms before hysterectomy; after hysterectomy, however, the symptoms of 8 (53.3%) of the 15 women were severe.

As assessed by HAMA, 20 (57.1%) of the 35 women in group 1 had anxiety symptoms before hysterectomy and 19 (39.6%) of the 48 women in group 2A had anxiety symptoms after hysterectomy. The severity of anxiety symptoms before and after hysterectomy in group 1 is shown inFig. 4. In group 1, the symptoms of anxiety were mild in 10 (50%) of the 20 women with such symptoms before hysterectomy; after hysterectomy, however, the symptoms of 8 (40%) these 20 women were severe.

Figure 1 Preoperative screening for psychiatric comorbidity using GHQ-28 in the 96 study participants.

Figure 2 Postoperative screening for psychiatric comorbidity using GHQ-28 in women without psychiatric comorbidity (group 2).

Figure 3 Pre- and postoperative severity of depressive symptoms in women with psychiatric comorbidity (group I) assessed by BDI.

Figure 4 Pre- and postoperative severity of anxiety symptoms in women with psychiatric comorbidity (group 1) assessed by HAMA.

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In group 2, the group with no psychiatric comorbidity at baseline, parity was correlated with depression or anxiety after hysterectomy (Table 2). Among the 61 women con- stituting the original group 2, 27 (44.2%) had depression and 18 (29.5%) had anxiety 1 month after hysterectomy, and these symptoms were the most common among the 11 nulliparous women. Of these, 7 (63.6%) had symptoms of depression and 3 (27.3%) had symptoms of anxiety. Among the 31 women in group 2 with a parity of 5 or higher, 12 (38.7%) had symptoms of depression and 9 (29.0%) had symptoms of anxiety 1 month after hysterectomy. Their symptoms of depression were less frequent than those of nulliparas, although those of anxiety were slightly more frequent.

Overall, of the 16 women free from psychiatric comorbidity, those with a parity of 5 or higher (n= 10) made up the largest group.

4. Discussion

This work stemmed from our observation of the different psychological responses after hysterectomy and the wide indications for this operation.

We evaluated the effect of hysterectomy for benign indications in patients with and without psychological comorbidity before hysterectomy. There were significant differences in indications for the operation between groups 1 and 2, which may confound our preoperative or postoperative findings.

Depressive symptoms were present in 15 women (42.9%) before and 29 women (60.4%) after hysterectomy. The prevalence of severe depression significantly increased after the operation in group 1, which supports the findings of Vomvolaki et al.[21], and postoperative anxiety symptoms were significantly more prevalent in group 1 (57.1%) than group 2A (39.6%).

We also observed a significant difference between the preoperative (20%) and postoperative (40%) prevalence of severe anxiety in group 1, which mirrors the results of Jawor et al.[17]. However, the difference between the preoperative (30%) and postoperative (35%) prevalence of moderate anxiety was not significant in this group.

There was a significant increase in the prevalence of depression in nulliparous women (63.6%) after hysterectomy.

However, the prevalence of depression decreased with increasing parity, as 42.1% of the women with a parity of 1 to 4 and 38.7% of those with a parity of 5 or higher had symptoms of depression after hysterectomy. This may be explained by the strong desire for a child in nulliparous women in this population. Ewalds-Kvist et al. [22]also re-

ported that married nulliparous women experienced more severe depression after hysterectomy.

Except for parity, there were no statistically significant differences across demographic groups. Yang et al. [23]

found education to be positively associated with good psychological outcome after hysterectomy, and our study may not contradict this finding as its population had a low overall level of education.

Studies have found psychological morbidity such as anxiety and depression to be associated with hysterectomy [16,17]. Flory et al. [9] reported that hysterectomy had negative short- and long-term psychological consequences for some women. According to Ceausu et al.[18], long after the procedure several psychological symptoms were still more common among women who had undergone hysterectomy. On the other hand, recent prospective studies have determined that no negative effects resulted from it overall [9], and some authors have even found positive effects of hysterectomy on the psychosocial and sexual well-being of women[7,8]. Donoghue et al.[19]concluded that preoperative depression improved in many women after hysterectomy. In at least 1 study, no differences were noted at 6 months in the psychological well-being of women who underwent laparoscopic compared with women who underwent abdominal hysterectomy [20]. Such differences in outcome may result from differences in study design, including retrospective vs prospective design, length of follow-up, and population selection.

Moreover, most of these studies were conducted in industrialized countries. Lalinec-Michaud and Engelsmann[24]

suggested that cultural factors may contribute to the reaction to hysterectomy of women from different ethnic backgrounds, thereby influencing the findings across study populations. Fertility in women is valued highly in traditional Egyptian society and masculine roles are more dominant. At Ain Shams Maternity Hospital in Egypt, hysterectomy rates increased from 9.8 per 1000 admissions in 1995 to 13.8 per 1000 admissions in 2000 [25]. Although gender norms and roles may be changing, adapting to these changes may be a source of anxiety for women and conflict for others, especially those undergoing surgical hysterectomy for benign indications. Conserving their uterus may be important for gender identity, sexuality, marital relations, and self-esteem for many women in our population.

There are limitations to this study. First, the findings may not be generalized given the cultural differences across countries. Second, the low level of education in our study population may have influenced expectations following hysterectomy. Third, our follow-up duration was short, and answers could have been influenced by postoperative com- plaints. A longer follow-up would be needed to reflect long- term psychiatric changes. Fourth, although all patients underwent hysterectomy for benign indications, the differences in percentages for the various indications were significant between the groups.

Despite these limitations, there was a significant correla- tion between hysterectomy and psychiatric morbidity in our study population. Given these findings and those of other studies, we recommend that gynecologists make great effort to use less invasive treatments, many of which are becoming more available, as alternative options to hysterectomy for benign conditions.

Table 2 Relationship between parity and depression and anxiety after hysterectomy in women without psychiatric comorbidity (group 2)

Parity Total (n= 61)

Depression (n= 27)

Anxiety (n= 18)

No psychiatric comorbidity (n= 16) 0 11 (18.0) 7 (63.6) 3 (27.3) 1 (9.1)

1–4 19 (31.1) 8 (42.1) 6 (31.6) 5 (26.3)

≥5 31 (50.8) 12 (38.7) 9 (29.0) 10 (32.3) Values are given as number (percentage).

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