Despite the proliferation in recent years of effective, less invasive, and cheaper surgical and nonsurgical alternatives to treat menorrhagia,1 hysterectomy remains the most common major gynecological operation performed in the United States2 and in the United Kingdom.3 This is because research has shown that it is a definitive cure for a wide range of gynecological disorders with a low perioperative morbidity, high satisfaction rate,4 and improved quality of life.5 An enduring debate in the late 1980s and the 1990s was whether subtotal abdominal hysterectomy (sub-TAH) might confer advantages over total abdominal hysterectomy (TAH) with regard to sexual, urinary, and bowel function because the former entails minimal neuroanatomical disruption. However, in a large, prospective, randomized controlled trial,6,7 we found no advantages for sub-TAH apart from a reduction in short-term postoperative complications, operative time, and blood loss. Further randomized studies8–11 and a recent Cochrane review12 concurred with our findings. However, the reported benefits of hysterectomy to date are based largely on short-term follow-up. Thus, there is an inadequate evidence base to inform the clinician and patient on long-term outcomes. The aim of this study was to prospectively evaluate, in the same group of patients we previously studied and using the same tools, the long-term effects of abdominal hysterectomy, again comparing TAH and sub-TAH on quality of life, psychological status, and bladder, bowel, and sexual function. We also added a validated tool,13 not available at the time of our original study, to evaluate pelvic organ prolapse. This article reports the results of a 7- to 11-year (mean 9 years) follow-up of women who had sub-TAH and TAH.
MATERIALS AND METHODS
Between April 2005 and October 2006, women who had participated in a previously published6,7 randomized, double-blind, multicenter trial comparing sub-TAH and TAH (n=279) were invited to participate in this study. All women who participated provided written informed consent. The research ethics committee at each participating hospital approved the study. Informed consent was obtained from all patients.
All women were sent a letter indicating that they would be contacted with a view to arranging a hospital appointment as part of a long-term follow-up. After 2–3 weeks, the participants were contacted by telephone and an appointment made. If a woman had moved from her old address, the national database was accessed to obtain the new contact details. Women who were unable to attend were sent the questionnaire by mail. The women completed questionnaires used in the previous study to assess urinary, bowel, and sexual function, psychological function (General Health Questionnaire-28),14 and quality of life (Short Form-36).15 Urinary frequency was defined as urination more than seven times a day. Nocturia was defined as waking twice or more at night to micturate. Dysuria, straining to void, poor stream/interrupted stream, incomplete emptying of bladder, urge incontinence, stress incontinence, and urgency were defined as a score of 2 or higher on a 4-point scale (1, never; 2, occasionally; 3, weekly; 4, always). Constipation was defined as fewer than three bowel movements per week. All other variables were scored on a 6-point scale (0, never; 1, occasionally; 2, often; 3, one to three times a week; 4, most days; 5, every day). For straining, use of laxatives, urgency, and incontinence of flatus, the symptom was considered to be present if the score was 3 or higher; a score of 2 or higher indicated the presence of hard stools. Orgasm and multiple orgasm were scored on a 4-point scale (1, never; 2, rarely; 3, mostly; 4, always). Relationship with partner was scored as: 1, very satisfactory; 2, satisfactory; 3, not very satisfactory; 4, extremely unsatisfactory. Vaginal lubrication and deep or superficial dyspareunia were scored as present or absent. Pelvic organ prolapse was assessed using the validated pelvic organ prolapse quantification system proposed by the International Continence Society.13
Data analysis was undertaken using SPSS 11 (SPSS, Inc., Chicago, IL). Data screening indicated that some variables were significantly skewed, so nonparametric statistics were used to examine differences between groups (χ2 for categorical data, Mann-Whitney for remaining variables). Where parametric tests were necessary, such as longitudinal analyses of group differences and changes over time (analysis of variance), variables were transformed to attempt to restore normality, but this was unsuccessful in most cases, especially when a variable was skewed only at one or two time points. Results are therefore reported for raw data.
Women were followed up over a period of 7 to 11 years from the date of operation (mean 9.04 years, standard deviation 1.11). The number of women recruited and followed up is shown in Figure 1. The sub-TAH and TAH groups did not differ in age, weight, or parity. Mean age at follow-up was 52.7 years (range 37 to 69, standard deviation 6.28). In 87%, the indication for hysterectomy was menorrhagia and/or dysmenorrhea. There were no significant differences between the groups on rates of salpingo-oophorectomy or hormone replacement therapy. Of the original 279 women, 181 (65%) completed the long-term follow-up. Of the rest, five were deceased, 23 declined to participate, 36 had relocated, and 34 were untraceable. Of the 181 women who completed the study, 47 returned postal questionnaires because they had moved out of the area or did not wish to come to the hospital. Therefore, 132 women (TAH=60 and sub-TAH=72) had an examination for evaluation of pelvic organ prolapse.
We compared women who completed the follow-up with women who did not participate in this study but had participated in previous time points, and the results are shown in Table 1. Women who completed the follow-up did not differ from women who dropped out in demographic characteristics, physical health and operation measures, or symptoms of psychopathology. However, women who dropped out reported significantly better social functioning months after the operation using ranked scores (Mann-Whitney test), although median scores for the two groups did not differ.
Table 2 shows that there were no significant differences between women who had sub-TAH and those who had TAH in quality of life and mental health. Compared with before the hysterectomy, women in both groups reported improved mental health (F(3,441)=19.67, P=.001), less role limitation due to physical problems (F(3,438)=15.22, P<.001), less role limitation due to emotional problems (F(3,438)=6.83, P<.001), improved social functioning (F(3,441)=86.65, P<.001), more energy and vitality (F(3,441)=39.78, P<.001), less pain (F(3,444)=32.6, P<.001), and improved general health (F(3,405)=52.56, P<.001). Women who had TAH reported consistently more pain than women who had sub-TAH at all time points (F(1,148)=4.39, P=.038), including before the hysterectomy. When analyses were redone controlling for possible confounding effects of age, there were no longer significant changes over time in mental health, physical functioning, role limitation due to physical problems, social functioning, and general health perception. However, less role limitation due to emotional problems and pain remained significant when age was controlled for.
Examination of changes in mental health, as measured by the General Health Questionnaire, showed that women in both groups reported fewer symptoms postoperatively. However, once age was controlled for, there were no significant changes over time in symptoms of anxiety (F(3,399)=1.18, P=.292), somatic symptoms (F(3,399)=0.92, P=.432), or depression (F(3,393)=0.15, P=.93). Social dysfunction showed a significantly different pattern of change over time for women in the sub-TAH and TAH groups, as shown in Figure 2 (F(3,393)=3.35, P=.019).
Table 3 shows urinary function for the sub-TAH and TAH groups. More woman who had TAH reported nocturia than did those who had sub-TAH. Nocturia was not significantly associated with age. There were no significant differences in other urinary function variables or in prolapse. Urinary function variables also did not change significantly over time for women in the sub-TAH and TAH groups.
Table 4 shows that there were no significant differences in bowel function between sub-TAH and TAH. Bowel function variables also did not change significantly over time for women in the sub-TAH and TAH groups.
In the sub-TAH group, 18 women were not sexually active (16 because of lack of partner, one because of patient preference, and in one because of partner’s sexual dysfunction). In the TAH group, 23 women were not sexually active (16 because of lack of partner, six because of partner’s sexual dysfunction, and one because of urinary incontinence). Therefore, analyses of postoperative sexual function were restricted to women who were sexually active (sub-TAH=73, TAH=67). Table 5 gives details of sexual function for the sub-TAH and TAH groups. Results found that women who had sub-TAH reported significantly higher frequency of intercourse when using ranked scores (Mann-Whitney test), although the median frequency of intercourse was the same in both groups. This was, therefore, examined including all time points, as shown in Figure 3; this was not significant when all time points were considered (F(1,108)=3.15, P=.07). Analysis of frequency of intercourse 7 to 11 years after hysterectomy was repeated to examine whether bilateral salpingo-oophorectomy (BSO) or hormone replacement therapy mediated this effect. This showed that there was a significant interaction between operation type and whether women had BSO on frequency of intercourse (F(6,123)=5.32, P=.023), as shown in Figure 4. If women had BSO, their frequency of intercourse was similar regardless of type of hysterectomy. However, for women who did not have BSO, those who had sub-TAH reported more frequent intercourse. There were no other significant differences in sexual function between sub-TAH and TAH.
Examination of changes in sexual function over time showed a similar pattern to that in Figure 3. Women in both groups reported decreases in frequency of intercourse (F(3,324)=9.18, P<.001), frequency of sexual desire (F(3,342)=9.39, P<.001), ease of attaining orgasm (F(3,309)=10.70, P<.001), strength of desire (F(3,351)=4.22, P=.006), and the quality of their sexual relationship with their partner (F(3,321)=3.34, P=.02). Analyses examining whether reduced sexual function was due to age found that being older was associated with less frequent orgasms (Pearsons r −0.23, P=.009). Similar analyses of the effect of BSO found that women who had BSO reported less frequent intercourse (U=1,855, P=.019), less sexual desire (U=1,497, P=.002), less initiation of intercourse (U=1,682.5, P=.046), fewer orgasms (U=1,616, P=.005), and less strength of sexual desire (U=1,598.5, P=.001).
In the TAH group, with regard to the overall incidence of reoperation, two women had carcinoma of the breast, one had inguinal hernia, one had a laparotomy and ovarian cystectomy, and one had surgery for renal calculus. In the sub-TAH group, one woman had carcinoma of the breast, three had laparoscopic adhesiolysis, two had a laparotomy and ovarian cystectomy, one had surgery for renal calculus, one had vaginal bleeding that resolved spontaneously, one had removal of cervical stump for prolapse and subsequently had an anterior and posterior repair for prolapse, and one who had a stump removal within the first 12 months of surgery required an anterior and posterior repair in the long-term follow-up.
The vast majority of hysterectomies the world over are performed for benign indications, and therefore it is vital to evaluate the short-term and long-term effect of this operation on women’s health. In our original study,6 we reported that at 12 months neither TAH nor sub-TAH adversely affected pelvic organ function and we found an improvement in quality of life and psychological symptoms. Furthermore, there was no difference between TAH and sub-TAH. On long-term follow-up, 7 to 11 years later, we found no significant deterioration in either and no difference between the two procedures. Furthermore, using the validated pelvic organ prolapse quantification method, we have demonstrated that there is no significant difference in pelvic organ prolapse or in symptoms of prolapse between women who had sub-TAH compared with those who had TAH and that hysterectomy does not appear to predispose to prolapse. This is contrary to the report by Virtanen et al,16 who found that prolapse occurred more commonly in women who had sub-TAH compared with those who had TAH. The women in our original study did not have prolapse because this was an exclusion criterion. It therefore appears that hysterectomy, whether total or subtotal, does not increase the risk of prolapse in the long term, although the influence of age may become apparent later. It is interesting to note that the two women who required cervical stump removal for prolapse subsequently underwent further pelvic floor surgery, suggesting that it is unlikely to be the hysterectomy that predisposed them to genital prolapse. It is possible that our study population was at a low risk of prolapse because the hysterectomy was performed by the abdominal route. A recent study17 has shown that, although compared with a control group of women without hysterectomy the risk of prolapse was higher in patients with hysterectomy, the highest risk was in women who had had a hysterectomy by the vaginal route. Contrary to our findings, there have been two recent publications18,19 that have reported an increased risk of urinary symptoms after hysterectomy. The first was a systemic review that showed a 60% increase in symptoms of stress incontinence after hysterectomy in women 60 years old or older compared with those younger.18 None of the participants in our original study were 60 years old or older, and the association may become apparent in the years to come. The second was a large, population-based cohort study19 in which it was reported that hysterectomy performed for benign indication, regardless of surgical technique, increases the risk of subsequent stress urinary incontinence surgery; the authors blamed the surgical trauma caused when the uterus and the cervix are severed from the pelvic floor supportive tissues at hysterectomy for this association. It is not readily possible to explain the variance in our findings, but we eagerly await the results of long-term follow-up studies of research that corroborated the findings of our original study.8,10
The vast majority of women who were not sexually active were so because of lack of partner or because of partner sexual dysfunction, thus suggesting that hysterectomy was not to blame. Although we found no difference in sexual function between TAH and sub-TAH, our data suggest deterioration in sexual function 7 to 11 years after hysterectomy. Further analyses showed that being older was associated only with less frequent orgasms. However, women who had BSO did demonstrate deterioration in sexual function, suggesting hormonal influences as contributory. The mean age of our study population was 53 years, and hence they are likely to be in the climacteric, which is associated with diminution in sexual function.20 Although sexuality is a complex issue to study, such that it is often difficult to tease out physical from psychological influences, our data suggest that, in the long-term, sub-TAH does not confer any benefits over TAH with respect to sexual function. We acknowledge the limitations of our questionnaire, which was not validated and which did not measure sexuality in a woman without a partner. We did find an improvement in quality of life after hysterectomy. However, only reduction in role limitation due to emotional problems and pain remained significant when age was controlled for.
The limitations of this study include a response rate of only 65%, failure to assess all women for pelvic organ prolapse, and lack of a control group of women without hysterectomy. The latter means that we are unable to confidently attribute the outcomes to hysterectomy. However, the participants were interviewed using the same questionnaires as in the original study to assess quality of life and pelvic organ function. We also used a validated method to evaluate prolapse.
Retaining the cervix is associated with the fear of cancer in the cervical stump21 and other complications such as obstructive mucocele of the cervix22 and macrocyst.23 The risk of developing cervical stump carcinoma in a woman with previous normal smears before hysterectomy is less than 0.03%.21 Moreover, cervical screening reduces the risk of cancer of the cervix.24 However, in countries with inadequate cervical screening programs, conserving the cervix would not be an appropriate option. This study adds vital data that enable the gynecologist to provide evidence-based counseling to patients on the long-term outcomes of an operation that remains the most frequently performed major procedure in gynecological surgery. Our current advice to women undergoing hysterectomy for benign indications is that neither operation has adverse effects on pelvic organ function, that sub-TAH is technically easier and associated with quicker recovery, but that 7% of women experience cyclical vaginal discharge or bleeding. In the absence of a randomized study, there is no reason to believe that these results cannot be extrapolated to a hysterectomy performed by the laparoscopic approach. Our article is supported by a recent opinion article published by the American College of Obstetricians and Gynecologists that concluded that sub-TAH should not be recommended by the surgeon as superior to TAH when hysterectomy is indicated for benign disease.25
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