Obstetrics & Gynecology:
Quality of Life and Sexual Function After Hysterectomy in Women With Preoperative Pain and Depression
Hartmann, Katherine E. MD, PhD*†; Ma, Cindy MPH†; Lamvu, Georgine M. MD, MPH*; Langenberg, Patricia W. PhD*‡; Steege, John F. MD*; Kjerulff, Kristen H. MA, PhD§
From the *Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; †Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, North Carolina; ‡Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, Maryland; and §Department of Gynecology and Obstetrics, Johns Hopkins Medical Institutions, Baltimore, Maryland.
The Maryland Hysterectomy Study was supported by Grant HS06865 from the Agency for Health Care Policy and Research.
Address reprint requests to: Katherine E. Hartmann, MD, PhD, Center for Women's Health Research, The University of North Carolina, CB#7590, 725 Airport Road, Chapel Hill, NC 27599–7590; e-mail: firstname.lastname@example.org.
Received April 9, 2004. Received in revised form July 5, 2004. Accepted July 8, 2004.
OBJECTIVE: We sought to examine differences in quality of life and sexual function after hysterectomy among women with preoperative pain and depression.
METHODS: We analyzed data from a cohort study of 1,249 women who had hysterectomies for benign conditions. Participants were interviewed, before surgery and at 5 intervals after, regarding pelvic pain, depression, quality of life, and sexual function. We compared quality of life and sexual function at 6 and 24 months among women with preoperative pelvic pain alone, depression alone, both pelvic pain and depression, or neither.
RESULTS: At 24 months, women with pain and depression had reduced prevalence of pelvic pain (96.7% decreased to 19.4%), limited physical function (66.1% to 34.3%), impaired mental health (93.3% to 38.1%), and limited social function (41.1% to 15.1%). Women with pain only improved in pelvic pain (95.1% to 9.3%) and limited activity level (74.3% to 24.2%). The group with depression only had improvement in impaired mental health (85.1% to 33.1%). Dyspareunia decreased in all groups. Compared with women who had neither pain nor depression, women with depression and pain had 3 to 5 times the odds of continued impaired quality of life: odds ratio (OR) 2.73, 95% confidence interval (CI) 1.78–4.19 for limited physical function; OR 3.41, 95% CI 2.13–5.46 for impaired mental health; OR 5.76, 95% CI 2.79–11.87 for limited social function; OR 4.91, 95% CI 2.63–9.16 for continued pelvic pain; and OR 2.41, 95% CI 1.26–4.62 for dyspareunia.
CONCLUSION: Women with pelvic pain and depression fare less well 24 months after hysterectomy than women who have either disorder alone or neither. Nevertheless, these women improve substantially over their preoperative baseline in all the quality of life and sexual function areas assessed.
LEVEL OF EVIDENCE: II-2
Pelvic pain that is unresponsive to medical management often leads to surgical intervention, including hysterectomy. In the United States, more than 600,000 hysterectomies are performed each year; of these, 10% of women have pelvic pain as the primary preoperative indication for the surgery.1–3 Although hysterectomy often is successful in relieving complaints associated with pathology (eg, fibroids, endometriosis), it may have the highest failure rates in patients with pelvic pain as an indication for surgery. Previous reports have shown that as many as 22% of patients with pelvic pain before hysterectomy continue to have pain after surgery.4
Emotional and cognitive factors play a major role in determining the extent, characteristics, and tolerance of pain. Factors such as chronicity of the pain, use of narcotic pain medications, history of sexual abuse and/or sexual dysfunction, and current mental health status influence an individual's interpretation, response, and ability to cope with pain.5–12 Depression is among the most common conditions known to accompany pain.13 Although the direction of the causal link is often difficult to assess (ie, did depression precede the onset of pain, or did the pain contribute to depression?), clinical care may still be informed by understanding the association between depression and pelvic pain as it relates to operative outcomes.
Our goal was to examine potential differences in recovery from hysterectomy in a prospective cohort of 1,299 women who had hysterectomy for benign disease. Specifically, we examined a panel of functional outcomes that included presence of pain, health-related quality of life, and sexual function at 6 months and 24 months after hysterectomy, to answer these research questions: (1) How do operative outcomes vary when comparing women with pelvic pain only, women with depression only, and women with both pain and depression with women who have neither pain nor depression present before hysterectomy? (2) Do near-term (6 months) outcomes differ compared with long-term (24 months) outcomes?
This study was approved by the Institutional Review Board at the University of Maryland and at each of the participating hospitals. All participants provided written informed consent. Between February 1992 and December 1993, 1,299 women enrolled in the Maryland Women's Health Study. A woman was eligible if she was aged 18 years or older, spoke English, and was scheduled for hysterectomy for a benign indication, including cervical dysplasia and endometrial hyperplasia. Participants with cancer identified at hysterectomy were retained (n = 40; 3.1%).
The data were obtained from 28 hospitals randomly sampled from 49 Maryland hospitals performing hysterectomies. A total of 272 gynecologists of 663 in the state provided participants for the study. Sampling methods have been fully described in a previous publication.14
During recruitment, 1,823 women were referred for potential enrollment. Interviewers were able to locate 88% of the referred women (n = 1,604), of whom 81% agreed to participate (n = 1,299). Information available concerning nonparticipants included age, race, indication for hysterectomy, date of posting, and date of scheduled hysterectomy. Comparison of participants with nonparticipants indicated that nonparticipants did not differ significantly in age, race, or indication but were significantly more likely to have been scheduled for hysterectomies within 1 week of their posting dates.14 The usual time elapsed between the date of posting and the date of surgery was 2 to 4 weeks.
Participants were interviewed shortly before surgery (n = 1,299) and were interviewed again at 3, 6, 12, 18, and 24 months afterward; 1,249 women (96%) provided complete interview data for all the questionnaire measures required for this analysis. Precautions were taken to ensure that responses were not shared with the medical team taking care of the participants. Medical records from each participant's hospital stay were abstracted by trained medical-records abstractors. A 5% random sample of all interviews and a 10% sample of medical-record abstractions were validated for quality control of accuracy on an ongoing basis.
Depression was assessed using the Profile of Mood States, which has been reported to perform well in studies of its reliability and validity in a variety of populations.15–17 Scales from this index were used for this report. As previously described, the depression–dejection total scores were rescaled from 0 (absence of the mood disorder) to 10 (maximal mood disorder) on continuous scales.14 A score of 2.6 or greater indicates moderate-to-severe levels of depression. This cutpoint delineates women with no mood disorder, or mild levels of these mood disorders, from those with moderate-to-severe levels.14,15 In addition, at each stage of the study, women were also asked, “In the past 3 months, have you seen a psychiatrist, psychologist, or other type of therapist for psychologic or emotional problems such as depression or anxiety?”
Aspects of quality of life were measured by using the physical function, social function, and health perception scales from the Medical Outcome Study Short-Form General Health Survey.18 As previously described, scores were rescaled to range from 0 (maximal impairment) to 10 (no impairment) on continuous scales.14 These cutoffs chosen were based on the potential range of scores and previous reliability and validity studies of instruments. For the physical function scale, a score of 8.2 or less (having limitations performing moderate to vigorous activities for more than three months) indicated poor physical function. For the activity level scale, a score of 7.9 or less indicated feeling physically able to do desired activities little or none of the time. For the mental health scale, a score of 6.7 or less indicated feeling downhearted and blue more often than happy, calm, and peaceful. For the social function scale, a score of 5.0 or less (limited all, most, or a good bit of the time) indicated limitation in social function. For the health perceptions scale, a total score of 7.0 or less (corresponding to the lowest 20% of scores in a general population sample) indicated that the respondent perceived herself as being in poor health. These cut offs are equivalent to those suggested by Stewart et al.18
Additional measures of functional status at 6 and 24 months included presence of pelvic pain, limited sexual function, and patient satisfaction with surgery. Patients were asked, “How much of a problem during the last month did you have with pain, cramps, or discomfort in the pelvic abdominal area?” We used the same item to define postoperative “presence of pain” as in past analyses, which was having a “big problem” or “medium problem” with “pain, cramps, or discomfort in the pelvic or abdominal area in the last month.”
Three measures of sexual function were examined as dependent variables in this analysis: not being sexually active, having a low frequency of sexual intercourse, and experiencing pain during sex (dyspareunia). Women who were not sexually active since the last interview were excluded from the analyses for the remaining 2 measures of sexual function. Women who reported any sexual activity were asked, “Since our last interview, how frequently have you had sexual relations?” Those who had sexual relations since the last interview “1 day a month,” “less than 1 day a month,” “once in last 3 months,” or “not at all” were considered to have low sexual frequency. Women were also asked, “In the last month, how frequently have you experienced pain during sexual relations?” Dyspareunia was defined as having pain during sex “all of the time,” “most of the time,” “a good bit of the time,” or “some of the time.”
During the 6- to 24-month posthysterectomy interviews, patients were also asked, “In general, were the results of the hysterectomy better than you expected, about what you expected, or worse than you expected?” Dissatisfaction with results of surgery was defined as “worse than expected.” Women were also asked, “Has your recovery from your hysterectomy been faster than you expected, slower than you expected, or about as fast as you expected?” Dissatisfaction with recovery from surgery was defined as “slower than expected.”
Statistical analysis was conducted by using SAS 8.1 (SAS Institute, Cary, NC). All tests were 2-tailed. Multivariable logistic regression and the χ2 statistic were used to assess the odds ratio (OR) describing the association between each outcome and the main exposure. The 4 main exposure categories were defined by all possible combinations of pain and depression. Patients were scored as depressed if their total preoperative Profile of Mood States score was 2.6 or greater. Having “pelvic pain” was defined by combining intensity with frequency of pelvic pain, ie, having “moderate,” “severe,” or “very severe” pelvic discomfort or pain for 14 days or more in the last month. The following groups of women were compared: those with depression and pelvic pain, those with depression only, those with pain only, and those with neither depression nor pain.
Univariate distribution of the outcomes, main exposure, and covariates were assessed. Differences in distribution for each covariate by exposure status were assessed using Cochran–Mantel–Haenszel test of general association for categorical or dichotomous variables and Tukey's test of multiple comparisons for continuous variables. Unadjusted analysis of depression–pain categories and outcomes was performed. The following were examined as potential confounders of negative outcomes: age, race, marital status, income, body mass index, current smoking status, type of surgery (vaginal, laparoscopic, or abdominal hysterectomy, with or without bilateral or unilateral oophorectomy; with oophorectomy further subclassified as resulting in surgical menopause or not), menopausal status, hormone replacement therapy use in postmenopausal women, prolapse as reason for hysterectomy, and experiencing hot flushes after hysterectomy. Confounding was assessed by determining whether exposure was associated with each covariate and whether the outcome was associated with each covariate among unexposed. Additionally, changes between crude estimates for the main exposure and outcome and estimates adjusted by each covariate were assessed. Effects of clustering by hospital and/or provider were not identified and thus did not require incorporation into models.
Unconditional logistic regression models were built to predict 4 types of outcomes assessed at 6 and 24 months follow-up: limited quality of life, presence of pelvic pain, limited sexual function, and poor satisfaction with results from hysterectomy. Model fit was assessed by the likelihood ratio test.19 To determine the best fitting model, we used a backward stepwise regression procedure starting with all variables chosen as candidate confounders based on the literature or found significant from the bivariate analysis. Covariates were kept in the model if they changed 1 or more of the β estimates for the exposure groups by more than 10%. Any covariate found to be a confounder was adjusted for in the model for each of the outcomes. Finally, tests of additive and multiplicative interaction were conducted by calculating predicated interaction estimates between pelvic pain and depression and comparing them with observed estimates of combined effects.
At baseline, 1,249 women had information available for us to assess depression and pelvic pain status (Table 1). The reference group (women with neither depression nor pain) included 673 (53.9%) women; 176 (14.1%) women were in the “depressed-only” group, 237 (19.0%) women in the “pain only” group, and 163 (13.1%) women in the “depressed with pain” group. The “depressed with pain” group was the youngest in age at 38.2 years. Race did not differ substantially among the 4 groups. The “depressed-only” group was least likely to have attended school at the college-level or higher (40.9%), to have a total household income of greater than $50,000 a year (23.2%), and to be married or living with a partner (61.4%) compared with other women. The average social function score, a self-reported measure of quality of relationships and social support, was lower for the “depressed with pain” and “depressed-only” groups (4.1 to 4.2) and higher for the “pain only” and “not depressed without pain” groups (4.7 to 4.8). Women having neither depression nor pain were most likely to be postmenopausal (14.7%) and least likely to be obese. Women who were depressed with pain were least likely to be postmenopausal (2.5%). The “depressed with pain” group had twice as many current smokers (41.7%) as the reference group (20.1%). Having received psychological therapy in the last 3 months was most frequent in the groups that met criteria for depression, with 12–16% reporting being in therapy. Overall, the majority of women identified with symptoms of depression were untreated. The top 2 reasons for hysterectomy were the same for all groups: fibroids (50.3–59.7%) and menstrual problems, eg, menorrhagia and dysmenorrhea (15.3–22.2%). Endometriosis was the most frequent preoperative diagnosis in the “depression and pain” group. Being sexually active at baseline was similar in all 4 groups (85.2–90.8%). Women who were expecting a good recovery were more likely to not be depressed (94.0–96.1%).
Proportions of women with deficits in functional status changed between 6 and 24 months of follow-up, with an overall trend toward continued improvements (Table 2). At 6 months postoperatively, the “depressed with pain” group had the highest proportion of patients with poor functional status, although they experienced large improvements from baseline. This group continued to experience large improvements at 24 months compared with baseline: pelvic pain as a problem decreased from 96.7% to 19.4%; limited physical function from 66.1% to 34.3%; impaired mental health from 93.3% to 38.1%; and limited social function from 41.1% to 15.1%. Women in the “pain-only” group also improved from baseline to 24 months, most notably for pelvic pain as a problem (95.1% to 9.3%), poor health perception (90.2% to 31.8%), and limited activity level (74.3% to 24.2%). “Depressed-only” patients improved most for impaired mental health (85.1% to 33.1%), poor health perception (88.1% to 39.0%), and limited activity level (75.0% to 26.6%). The proportion of women who were “not sexually active” or experienced “low sexual frequency” increased in all groups from baseline to 24 months after hysterectomy. However, the frequency of women with “pain during sexual relations” decreased from 71.7% to 15.2% in the “depressed with pain” group, from 43.8% to 5.3% in the “depressed-only” group, from 59.2% to 9.2% in the “pain-only” group, and from 29.2% to 6.0% in the “not depressed without pain” group. Fewer than 25% of women in all groups reported having a recovery “slower than expected” and fewer than 13% of women described their surgical results as “worse than expected” at 24 months.
In almost every instance, women with either pain, depression, or both had an elevated risk of limited physical function, limited activity level, impaired mental health, poor health perception, and limited social function at baseline, both 6 and 24 months after surgery when compared with women without pain or depression (Table 3). Odds of limited quality of life in these groups decreased during the course of time, most notably between baseline and 6 months. Women with depression and pain had the highest risk for poor outcomes in almost every category (except impaired mental health at 6 months) at both time periods after hysterectomy (Table 3) with approximately 3 to 5 times the odds of continued impaired quality of life compared with women without either condition (OR 2.73, 95% confidence interval [CI] 1.78, 4.19 for limited physical function; OR 3.75, 95% CI 2.45–5.73 for limited activity level; OR 3.41, 95% CI 2.13–5.46 for impaired mental health; OR 2.99, 95% CI 1.99–4.49 for poor health perception; OR 5.76, 95% CI 2.79–11.87 for limited social function). Women with “depression only” were 3 times as likely as the reference group to have continued impaired mental health (OR 3.14, 95% CI 1.97–4.99) at 24 months and were 1.6 to 1.7 times as likely to have continued impaired physical function (OR 1.60, 95% CI 1.03–2.46), limited activity level (OR 1.66, 95% CI 1.07–2.56), and poor health perception (OR 1.72, 95% CI 1.16–2.57). Women with “pain only” had odds ratios of 1.3–1.6 in all categories of limited quality of life at 24 months after surgery. At baseline, an interaction effect between depression and pain was identified, such that the effects are greater than the multiplicative effect of either alone, for all quality of life outcomes except for limited physical function. At 6 and 24 months, interaction was identified for all quality of life outcomes except for impaired mental health.
Similar patterns of outcomes across exposure groups were identified in logistic models for the effect of pain and depression on residual pain, sexual function, and participant satisfaction (Table 4). For women in the “depressed with pain” group, the odds of continued pelvic pain being reported as a problem remained substantial at 24 months (OR 4.91, 95% CI 2.63–9.16). This group also continued to be more likely to report pain during sex (OR 2.22; 95% CI 1.09–4.51), results worse than expected (OR 2.41; 95% CI 1.26–4.62), and recovery slower than expected (OR 2.35; 95% CI 1.46–3.76) at 24 months. At baseline, women with “depression only” had greater odds than women without pain or depression (1.59–2.12) for continued postoperative pelvic pain as a problem, not being sexually active, and pain during sex, but by 24 months none of their outcomes were significantly different from the reference group. Women with “pain only” had elevated odds ratios for pelvic pain as a problem and pain during sex, but only severe or moderate pelvic pain had an OR that remained important 24 months after hysterectomy (OR 2.2, 95% CI 1.17–4.23).
Interaction analysis confirms that the combined predictive strength (on both the additive and multiplicative scale) of depression and pelvic pain on each outcome was larger than that predicted by depression or pain alone. In other words, the observed differences in outcome among women with both pain and depression were greater than would have been predicted by summing the absolute difference in risk observed among women with only pain or only depression and also greater than multiplying the odds of the outcome among women with only pain or only depression. This is consistent with a synergistic effect.
Gynecologic surgeons are appropriately concerned that patients who are struggling with depression and/or pain before surgery may be at especially high risk for poor operative outcomes such as slow recovery, persistent pain, or developing new symptoms. It is reasonable to worry that intervening in the setting of depression, pain without known tissue pathology, or both, has potential to worsen a patient's health status. In addition, we fear a high probability of dissatisfaction with surgical outcomes related to subjective factors such as quality of life and sexual function that are in large part beyond our control as surgeons.
This large prospective cohort study demonstrates that women with both pelvic pain and depression at the time of their hysterectomy fare less well during the subsequent 24 months than their counterparts who have either disorder alone or neither. This confirms clinical instincts. However, women with preoperative depression and pain did have substantial improvement from their preoperative baseline status in all areas of quality of life and sexual function assessed. The magnitude of these improvements in scores is consistent with individually meaningful, clinically relevant improvements in quality of life and sexual function across domains from physical activity, social contacts, mental health, self-perception of overall health status, and enjoyment of intercourse. The consistency of improvements and coherence of improvement across multiple inter-related areas suggest that overall we do not do harm when we perform hysterectomies for these complex patients.
Our findings are consistent with prior studies showing that 76–96% of women undergoing hysterectomy are cured or substantially improved at follow-up, including those with pain.14,20–23 It is important to note that measurement of baseline status in the immediate preoperative window—a potentially stressful time when operative patients may be most focused on symptoms—may bias results toward finding improvement. However, despite overall, and in some areas large improvements, depression and pain did temper how women in this cohort interpreted their surgical outcomes. Twelve percent of women with both depression and pain (17/139) felt the results of their surgery were “worse than expected” at 24 months, compared with 6% of those with depression, 4% with pain, and 5% with neither (full data not shown; P = 004). Women with both conditions were also more likely to report their recovery as “slower than expected” despite similar time to return to work and other activities (data not shown; P = 000). Among those with depression and pain, one quarter (35/139) felt their recovery had been slow compared with 15% of both those with depression and pain alone and 12% with neither. This suggests that a large proportion of all women underestimate what the recovery trajectory will be like after hysterectomy.
The study is unique for the size and composition of the cohort and its methods—a large sample with representation of all socioeconomic strata, prospective use of reliable measures, and long-term follow-up. Nonetheless, our findings must be noted to be based entirely on patient self-report without corroboration by medical or mental health evaluation. We lacked the level of detail required to further categorize severity and duration of pain and women with pain cohort. The majority of women with pain had additional preoperative indications for hysterectomy and thus are likely to differ in important and unmeasured ways from women with only chronic pelvic pain. Furthermore, we would have liked to have had more information about care received for depression and also cannot determine the extent to which partner factors contributed to potential involuntary abstinence among those not having intercourse. Much work remains to be done that could not be accomplished in this cohort to investigate how pain, documented through physiologic measures (eg, visceral or somatic pain thresholds), and depression with and without pharmacologic intervention, modifies the experience of and recovery from surgery.
We were pleasantly surprised to find that the majority of participants with pain, depression, or both, report that their symptoms, quality of life, and sexual function improved substantially. To protect and further enhance operative outcomes and quality of life for our gynecologic surgery patients, it is imperative that we continue to study screening and treatments strategies that might be used before surgery to improve the results in the highest-risk groups. For example, if depression is present, does treatment with medications and/or psychotherapy before surgery modify outcomes? How long should depression be well controlled, if possible, before surgical intervention? If pain is of especially long chronicity, should ancillary pain treatment modalities be employed before surgery, or should surgery be done first and the remaining symptoms treated later? Finally, is hysterectomy more effective in the long term than multidisciplinary care for women with depression and chronic pelvic pain? Until we have answers to these questions, this study provides some initial data to use in counseling patients with pain and/or depression and who are considering hysterectomy about postoperative expectations. Furthermore, those providing care for women with pain and/or depression who are seeking hysterectomies may wish to explicitly describe surgery as just one step in a more broadly based treatment and rehabilitation plan focused on restoring their overall quality of life to mitigate the perception that surgery will be a panacea.
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