DeCherney, Alan H. MD; Bachmann, Gloria MD; Isaacson, Keith MD; Gall, Stanley MD
Fatigue is a common symptom of many diseases and their related treatments that results in diminished energy and mental capacity and weakened physiologic status.1 Pain, difficulty sleeping, concern about one's condition, medication, psychologic dysfunction, and physiologic conditions may contribute to fatigue.1,2 In patients with cancer or human immunodeficiency virus infection, the physical and mental/emotional consequences of disease‐and treatment‐related fatigue can have a significant adverse impact on quality of life, interfering with daily activities, relationships, and treatment compliance.3–7
Women who undergo pelvic surgeries, especially hysterectomies, can experience preoperative fatigue from the underlying disease or anemia resulting from long‐standing blood loss. In addition, fatigue is a common and often lingering postoperative symptom that may undermine the patient's ability to resume normal daily activities.8–10 In the Maine Women's Health Study, a prospective cohort study of 418 women undergoing hysterectomy for nonmalignant conditions, most patients (91%) reported that postoperative fatigue was a “medium” or “big” problem.8 Although the extent of postoperative fatigue has been shown to decrease with time after hysterectomy, continued fatigue for up to 12 months or longer may be problematic in some patients.8 Numerous factors (eg, anemia, pain, hormonal and metabolic changes, and psychosocial issues) may contribute to postoperative fatigue; however, the relative contributions of each remain unclear in most cases.2,11
The effects of postoperative fatigue on patient recovery, satisfaction, and quality of life after hysterectomy have not been well characterized. Such characterization would be useful in developing strategies to optimize patient recovery after hysterectomy and other surgical procedures, as has been developed for patients undergoing orthopedic surgery. A patient‐ and caregiver‐based instrument was recently developed for assessing postoperative vigor, which was defined as energy level, readiness to leave the hospital, and ability to perform routine daily activities. This instrument was shown to correlate well with objective measures of recuperative power, specifically muscle strength and hematocrit, in patients undergoing elective total joint arthroplasty, and it is currently being evaluated in a prospective clinical study.12
To better characterize postoperative fatigue and its impact on patient recovery after hysterectomy, a retrospective descriptive survey was performed. The survey was designed to 1) estimate the prevalence, severity, and impact of fatigue in posthysterectomy patients; 2) define fatigue from the patient's perspective and how it is experienced during the recovery period; 3) identify the consequences of postoperative fatigue and its effects on normal daily activities; and 4) develop insights into how physicians can achieve a better understanding of the impact of postoperative fatigue on their hysterectomy patients and enhance related patient communications.
MATERIALS AND METHODS
A quantitative descriptive survey assessing the prevalence and impact of fatigue on patients after hysterectomy was conducted in June 1999 by Wirthlin Worldwide Research (New York), in accordance with methods prescribed by the Council for American Survey Organizations. A total of 300 patient interviews was planned. Patients who underwent hysterectomy or myomectomy procedures within the past 2 years were recruited randomly from two nationally representative, random samples of households: one of women aged 25–50, and a second of women taking hormone replacement therapy (HRT).
The age‐targeted sample was based on active telephone exchanges/numbers obtained from a national database of households. The sample of women taking HRT was obtained to complete the planned total of interviews in a cost‐effective and logistically feasible manner and was based on self‐reported household data from a national database. Only women in these households who were in the target age group and had undergone a hysterectomy or myomectomy within the past 2 years were eligible to participate in the approximately 25‐minute interview. No monetary or other incentives were offered or provided to the participants.
The interview was conducted by trained interviewers and contained 41 questions. Patients were asked questions regarding their medical history leading up to and including surgery (eg, prior symptoms, reason for hysterectomy, type of hysterectomy), as well as an overall recovery profile concerning type, severity, and duration of symptoms. Patients were also asked about discussions with their physician regarding surgery‐related issues. Those patients reporting fatigue (defined as a general feeling of debilitating tiredness or loss of energy) during the first few weeks after surgery were asked a series of questions to determine the extent and duration of this symptom and its impact on physical and mental function and routine daily activities. The economic impact of the recovery period on the patients and their caregivers also was assessed. Finally, patients' perceptions of the origins of their postoperative fatigue and the extent to which they discussed fatigue and its treatment with their physicians after surgery were examined.
Demographic variables and patient responses were summarized using descriptive statistics. Differences in responses between the two samples were tested for statistical significance using t tests. Statistical significance was defined as P < .05.
More than 45,000 women were contacted. A total of 300 women completed the interview. Of these, 200 were recruited from a national sample of women between 25 and 50 years, and 100 were recruited from a national sample of women taking HRT who also met the target age range. The response rate among women who met the participation criteria was 32% (300 of 945). The margin of error for this sample size was ±5.7%.
Patient baseline characteristics in the two samples were generally similar (Table 1). The statistically significant differences in type of procedure and main reason for surgery were not considered of clinical relevance. Overall, the survey population was representative of the hysterectomy population. Two hundred ninety‐two patients (97%) reported having a hysterectomy and eight patients (3%) reported having a myomectomy within the last 2 years. The most frequent reasons for hysterectomy were fibroid tumors (22%), excessive bleeding/endometrial hyperplasia (21%), and endometriosis (20%). Most of the hysterectomy patients had a hysterectomy with bilateral oophorectomy (48%) or total hysterectomy (39%); 10% had a radical hysterectomy.
Symptoms reported by at least 5% of all patients before either hysterectomy or myomectomy included excessive bleeding (52%), pain (47%), painful menstruation (7%), and pelvic pain/pressure (5%). Only 3% of patients reported having preoperative fatigue. When asked about recovery time, patients reported an average duration of 10 weeks before they were able to resume normal activities.
Prevalence and Duration of Fatigue
Fatigue was experienced more frequently than any other symptom reported during recovery, with 74% (95% confidence interval [CI] 69%, 79%) of patients reporting moderate‐to‐severe fatigue within the first few weeks after surgery, compared with 63% (95% CI 58%, 68%) experiencing pain, and 45% (95% CI 39%, 51%) experiencing emotional instability (eg, feelings of frustration, depression). Sixty‐one percent of patients (95% CI 55%, 67%) said they continually or often felt fatigue during the first few weeks after surgery (Figure 1). Overall, fatigue was the most persistent symptom, lasting more than twice as long as pain (average of 10.7 weeks versus 4.5 weeks, respectively), the next most prevalent symptom. At 2 months posthysterectomy, 29% of patients were still experiencing moderate fatigue, and 12% of patients had severe fatigue (Figure 2). An average duration of fatigue of approximately 6 months was experienced by 34% of those with postoperative fatigue.
Physical and Emotional Impact of Fatigue
The majority of patients (69%) (95% CI 64%, 74%) with postoperative fatigue also reported frustration or interference with usual daily activities. Fatigue complaints included feeling tired (58%) or lethargic (37%) and needing to rest often (10%) or sleep more frequently or longer (12%) (Figure 3). The most frequent physical manifestations of postoperative fatigue included a general sense of sluggishness or tiredness (84%), significantly diminished energy level (82%), and the need to rest between tasks (76%) (Figure 4). Seventy percent of patients (95% CI 65%, 75%) experiencing fatigue reported that this symptom moderately or severely affected their ability to complete daily activities. When patients were asked which postoperative symptom most interfered with their daily routines, fatigue was ranked the highest (37%) (95% CI 32%, 42%) (Figure 5).
Daily activities that could not be performed normally in the first few weeks after surgery because of fatigue are summarized in Figure 6. Fatigue prevented normal function in several activities, including housekeeping (72%), child/family care (55%), and returning to work (50%). Fifteen percent of patients experiencing fatigue described it as a “change in emotional state.” Fatigue contributed substantially to feelings of frustration (52%) and depression or hopelessness (37%) and to difficulty in concentrating or being attentive (42%) (Figure 4). A substantial proportion (34%) of the patients experiencing fatigue identified surgery as its cause; no other perceived individual cause (eg, medication, pain, depression) was identified by more than 9% of survey participants.
Economic Impact of Recovery Time
Thirty‐six percent of patients reported loss of wages as a result of the surgical recovery time. Patients employed at the time of their surgery (n = 220) reported missing an average of 5.8 weeks of work postoperatively. Based on patient estimates, 43% of caregivers missed an average of 1.2 weeks of work to care for the patient. Sixty‐nine percent of patients (n = 286) also reported that they required 2 or more weeks of assistance from their care‐giver. Only 9% of patients employed at the time of their surgery reported not missing any work themselves.
According to patients, preoperative physician counseling addressed recovery time (94%) and activity restrictions or limitations during the first few weeks (94%) or first few months (92%) of recovery expected changes in emotional stability (66%), and sexual function (61%). The issue of postoperative fatigue (ie, possible changes in energy level) was addressed by 68% of the patients' physicians before surgery, but approximately one‐third (31%) of patients stated that this issue was discussed very little or not at all with their physician.
During the postoperative period, many patients (57%) discussed fatigue with their physicians. These patients were significantly more likely to have frequent or continuous fatigue (77% versus 46%; P < .001; χ2), severe fatigue (43% versus 30%; P = .025; χ2), and a longer‐than‐expected recovery time (28% versus 17%; P = 024; χ2) compared with patients who did not discuss fatigue. The most common reasons why patients (43%) did not discuss fatigue with their physicians were because they felt that it was an inevitable result of surgery (91%) and that it would diminish soon after surgery (86%), or that their fatigue could not be alleviated (50%). In patients who experienced postoperative fatigue, the most frequent treatment recommendations were oral iron therapy (22%) and dietary supplements (12%). However, no treatments or recommendations were offered to alleviate fatigue in more than half (52%) of the patients.
This descriptive survey was conducted to estimate the prevalence, severity, and impact of fatigue and other symptoms from the patient's perspective during the course of recovery after hysterectomy or myomectomy. Because self‐reported evaluation of fatigue is a subjective measure, the survey included questions concerning daily activities to improve the objectivity of the results.
Our findings indicate that posthysterectomy fatigue is highly prevalent, with a substantial adverse impact on patient well‐being and quality of life. The prevalence rate of fatigue was 74% in this survey and is consistent with the 60–90% range reported previously in patients after hysterectomy.8–10 Fatigue was more frequent and, on average, persisted more than twice as long as pain. These findings are similar to those of the Maine Women's Health Study, in which women who underwent hysterectomy for nonmalignant conditions experienced postoperative fatigue more often and for a longer duration than any other postoperative symptom, with the exception of abdominal swelling.8 Of all postoperative symptoms in the present survey, fatigue interfered with patient activities the most, impairing the ability to undertake a wide range of daily activities and responsibilities or producing consequent feelings of frustration regarding this impairment in the majority of patients.
In this survey, the average duration of postoperative fatigue in patients experiencing this symptom (10.7 weeks) was consistent with previous reports.2,8 In a comparison study of alternative measures of fatigue among hysterectomy patients, Kjerulff and Langenberg reported on 1205 hysterectomy patients who rated their level of fatigue using three separate single‐item measures and the Profile of Mood States (POMS) Fatigue Scale.2 Approximately 24% of patients in that study were still experiencing fatigue “most to a good bit of the time” to “all of the time” at 6 months postsurgery.2 In the Maine Women's Health Study, 35% of women reported moderate‐to‐severe fatigue 3 months after surgery and 23% still reported fatigue “very often” or “fairly often” 12 months after surgery.8 Similarly, in one third of patients in this survey, fatigue lasted an average of 6 months. Because fatigue may be prolonged or may develop late in the postoperative period (4 or more months after surgery),9 extended monitoring for posthysterectomy fatigue appears to be warranted. It has been suggested that prospective studies after hysterectomy should be at least 2 years in duration to account for the “sleeper effect” in which sequelae such as fatigue do not develop for 6–12 months postsurgery.13
The results of the present survey underscore the need for more communication between patients and their physicians about fatigue and for greater patient education in this area both before and after hysterectomy. Although the majority of patients had discussions about postoperative fatigue with their physicians before surgery, almost a third of patients indicated that this issue was discussed little or not at all preoperatively. Discussions before surgery may better prepare patients psychologically for the occurrence of fatigue and enhance follow‐up communication regarding its management.
In the present survey, patients who discussed fatigue with their physicians postoperatively were more likely to suffer from fatigue more frequently and to a greater degree than those who did not have such discussions. Similarly, Kjerulff and Langenberg reported that the extent to which patients perceived their fatigue to be problematic was the strongest predictor of physician contact after hysterectomy.2 In that study, patients who were experiencing moderate‐to‐severe fatigue or who were substantially limiting their activities because of fatigue 6 months posthysterectomy had significantly more frequent physician contact and were significantly less satisfied with the outcome of surgery.2 Thus, it may be important to the patient's recovery and satisfaction to obtain more information regarding the presence and severity of postoperative fatigue and to receive recommendations for its management.
The importance of discussing fatigue‐related issues with patients after hysterectomy was highlighted in the present survey by patients' misconceptions about the origin of their fatigue and lack of knowledge of available treatment options. Many patients did not discuss fatigue with their physicians because they considered fatigue to be an inevitable or untreatable consequence of the surgery. Similarly, more than half of patients with fatigue in the present survey received no treatments or recommendations to alleviate their fatigue after hysterectomy, suggesting that greater efforts are needed to adequately address this important and often long‐lasting postoperative symptom, in part through improved communication between patients and their physicians.
Potential factors that can contribute to fatigue (eg, anemia, pain, anxiety/depression) should be evaluated posthysterectomy, and appropriate treatments should be considered and discussed with patients. Of these factors, pain is well recognized as an energy‐depleting symptom. In most cases, pelvic pain is relieved by hysterectomy and rarely develops as a new symptom after surgery; however, it may persist in a small percentage of patients, particularly those undergoing the procedure for chronic pain.8 In the Maine Women's Health Study, fatigue remained a “medium” or “big” problem at 12 months after surgery in 22% of patients who underwent hysterectomy for chronic pelvic pain.8 Acute postsurgical pain or pelvic/abdominal pain that persists may be effectively alleviated with appropriate analgesic therapy.
Fatigue also can be commonly associated with anxiety or major depression in both healthy and chronically ill individuals. Although early reports suggested that hysterectomy was associated with an increased incidence of postoperative depression or psychologic distress,10,13 subsequent prospective studies have not provided supporting evidence.14–16 Psychologic symptoms are often relieved by hysterectomy, but anxiety or depression may persist or develop postoperatively in some patients.8 If these disorders are evident, anxiolytic or antidepressant therapy may be appropriate.
Anemia may be present before hysterectomy and may be exacerbated or develop postsurgery. Anemia due to iron or folate deficiency, hemolysis, or gastrointestinal bleeding should be managed appropriately. Knowledge gained from anemia‐directed interventions in patients with cancer17–19 or those undergoing total joint arthroplasty20–22 may be useful in patients undergoing hysterectomy. In anemic patients with cancer who are receiving chemotherapy, treatment with epoetin alfa increased hemoglobin levels, and the increases were correlated with improvements in functional capacity and quality of life, including specific measures of fatigue.17–19 Further studies would be helpful to evaluate correlations among hemoglobin levels, fatigue, functional status, and quality of life in patients after hysterectomy.
Recovery time from hysterectomy appears to have a substantial adverse economic impact on many patients. In the present survey, more than one third of patients reported that their finances suffered because of the surgical recovery time. Because fatigue is highly prevalent and is associated with more prolonged recovery and patient perceptions of surgical outcome, it likely contributes to the negative economic impact.
Although results of the present survey are consistent with those of previous studies of posthysterectomy fatigue, there are important limitations, including the retrospective nature of the survey. The results relied on recollections of patients over a period of up to 2 years. The collective results were based on two samples of recruited patients who met the eligibility criteria. Although patient characteristics were generally similar in the two samples, patients were not questioned about comorbidities or concurrent medications that may have contributed to their fatigue. At least one third of the patients were receiving HRT; it was not determined whether patients in the targeted age group were treated with such therapy. It seems unlikely, however, that this would significantly influence the results; if HRT was decreasing postoperative fatigue, the prevalence and impact of the symptom would tend to be underestimated. In addition, an objective measure of fatigue was not used in this survey. Although only subjective measures were used to assess and characterize fatigue, such measures have been correlated with objective measures of fatigue after elective surgery.12,23
Although additional, prospective studies are needed, these data suggest that posthysterectomy fatigue has substantial adverse effects on physical and psychosocial function and patient well‐being during the recovery period. Efforts to improve the quality of life of recovering patients require a greater understanding of the causes and impact of fatigue, improved communication between physicians and their patients before and after surgery, and more frequent consideration of potential treatment interventions to lessen the effects of this common symptom.
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© 2002 by The American College of Obstetricians and Gynecologists.