PSYCHIATRIC EFFECTS OF HYSTERECTOMY

Abstract

An excess of psychiatric symptoms in post-hysterectomy women have been reported by some authors but denied by others. Thirty six women undergoing hysterectomy for non-malignant pathologies were compared with equal number of comparable patients who underwent other gynaecological operations. Patients were assessed pre- and post-operatively by semi-structured psychiatric interview, Sinha's anxiety scale and Hamilton's depression rating scale. Patients undergoing hysterectomy were significantly more anxious and depressed both pre- and post-operatively as compared to the control patients. Hysterectomy was not associated with significantly higher psychiatric morbidity.

Introduction

The uterus has been of special interest to medical men since ancient times and many magical and mystical properties were attributed to its functions [1]. Not surprisingly therefore a number of studies had reported that hysterectomy was followed by adverse sequelae including psychosis [1], depression [2, 3, 4], agitation and insomnia [5], anxiety [6], reduced psychosexual functioning [7, 8] and psychosomatic disorder [9]. On the other hand a few prospective studies concluded that hysterectomy seldom led to psychiatric disorders [10, 11, 12]. Two Indian studies [4, 13] also came to diametrically opposite conclusions. In view of the contradictory results, the present study was undertaken to assess the psychiatric effects of hysterectomy.

Material and Methods

The patient sample included thirty six consecutive patients who underwent hysterectomy for nonmalignant pathologies at a large base hospital during the period 01 Mar 90 to 29 Feb 92. Equal number of patients admitted for gynaecological surgery other than hysterectomy and matching as closely as possible with the hysterectomy patients formed the control group. Patients with chronic physical illnesses like diabetes mellitus, hypertension and psychiatric disorders were excluded from the study. A specially designed proforma was used for evaluation of the patients. It included socio-demographic data, past and family history, detailed gynaecological history and examination, psychiatric history and mental status examination. The following psychological instruments were used in addition, to quantify the levels of anxiety and depression in the subjects.

Sinha's Anxiety Scale (SAS) : SAS is utilised to measure overall anxiety as well as anxiety in various areas such as social, psychological, economic and physical. The test consists of 100 items with forced choice response alternatives of yes or no. The possible range of score varies from 0 to 100. The higher the score of the subject on the test, the greater is his level of anxiety. A subject with a very high score, namely above the 75th percentile may be considered a hyperanxious person. Such high anxiety is likely to have a disruptive influence on the patient's performance of complex tasks and requires therapy. Low scores, namely below the 25th percentile, indicate people who are undermotivated, sluggish and possessing low drive level. The middle group of scores represent “normal” individuals with moderately good drive level to stimulate performance without proving an interference. It is a clinically useful instrument for quick estimate of manifest anxiety [14].

Hamilton Depression Rating Scale (HDRS): HDRS is a 17 item observer rating scale for the measurement of depression. The items cover depressed mood, guilt, suicide, retardation, agitation, psychic anxiety, hypochondriasis, somatic symptoms, working capacity, loss of interest and insight. Each item is scored 0–2 or 0–4. The scores are summed to give a total score. The possible range of score varies from 0–52. The higher the score of the subject the greater is his level of depression. A score of 0–7 indicates absence of depression, a score of 8–15 indicates minor depression, a score of 16 or more means major depression. The scale has high validity against global judgement and high reliability [15]. The scale has been validated for Indians [16].

All patients were interviewed one week before surgery and four weeks after surgery. The husband and wife were interviewed separately. The psychiatric diagnoses were made according to ICD-9. Statistical comparisons were done using the chi square test and median test.

Results

The hysterectomy group and the control group were comparable on almost all socio-demographic characteristics (Table 1). The indications for hysterectomy were: uterovaginal prolapse 14 (38.9%), dysfunctional uterine bleeding 12 (30.6%), unhealthy cervix 2 (5.6%), invasive mole 1 (2.8%). Abdominal hysterectomy was performed in 33 (91.7%) patients while 3 (8.3%) patients underwent vaginal hysterectomy. All operations were performed under spinal anaesthesia.

TABLE 1.

Socio-demographic variables in hysterectomy and control groups

Variable	Hysterectomy group (n = 36)	Control group (n = 36)
Mean age (in years)	42.5	39.2
Range of age	28–60	20–50
Marital status:
Married	34	36
Widowed	2	—
Education
0 – 5	24	19
6 – 10	9	13
11 and above	3	4
Religion
Hindu	32	33
Muslim	2	1
Sikh	1	1
Christian	1	1
Domicile
Rural	29	28
Urban	7	8
Family income (in rupees)
< 2000/- month	9	12
2001 – 3000/-month	23	22
>3000/- month	4	2

After surgery, psychiatric morbidity occurred in five hysterectomy patients and one control patient. The psychiatric diagnosis were: unspecified psychosis (n=l), neurotic depression (n=2) and anxiety state (n=2) in the hystersctomy group while one control subject developed anxiety state (Table 2). There was no statistically significant difference between the two groups regarding the incidence of psychiatric morbidity following surgery.

TABLE 2.

Post-operative psychiatric morbidiry in the hysterectomy group (n=36) and control group (n=36)

Diagnostic category	Hysterectomy group	Control group
	No of cases (%)	No of cases (%)
Unspecified psychosis	1 (2.78)	—
Neurotic depression	2 (5.56)	—
Anxiety state	2 (5.56)	1 (2.78)
Total	5	1

X² = 1.64; df = 1; p > 0.10

Not significant

Scores of SAS and HDRS in the study and control groups are shown in Table 3. It indicates that the hysterectomy patients had statistically significantly higher levels of anxiety and depression as compared to the control group both preoperatively and postoperatively. After surgery, there was a trend towards reduction of anxiety and depression levels in both the groups. However apart from significant reduction of anxiety in the hysterectomy patients, the remaining differences were not statistically significant.

TABLE 3.

Sinha's Anxiety Scale (SAS) and Hamilton's Depression Rating Scale (HDRS) scores in hysterectomy group (n=36) and control group (n=36) before and after surgery.

	Preoperative		Post operative
	Hysterectomy group	control group	Hysterectomy group	control
SAS score	44.421	35.942	39.863	33.084
HDRS score	7.345	6.306	6.977	5.538

Results of statistical comparisions:

1 vs 2 – p < 0.01; 1 vs 3 – p < 0.01; 2 vs 4 – Not significant; 3 vs 4 – p < 0.01; 5 vs 6 – p < 0.05; 5 vs 7 – Not significant; 6 vs 8 – Not significant; 7 vs 8 – p < 0.01.

Discussion

In the present study hysterectomy was not followed by a statistically significant increase in psychiatric morbidity. None of the patients showed a clearcut post-hysterectomy syndrome. Contrary results were reported by some earlier workers [2, 3, 4, 7]. A 7% psychiatric referral rate following hysterectomy was reported by Barker [2]. Richards [3] observed that 73% of hysterectomized women (n=56) were depressed following the operation as against 29% of age matched women undergoing major surgery. Vyas et al [4] observed a statistically significant increase in neurotic disorders following hysterectomy. Ackner [7] found that 30% of women under 40 years of age undergoing hysterectomy for benign lessions had psychiatric complaints. However our findings are in agreement with a few prospective studies which concluded that hysterectomy seldom led to psychiatric disorders [10, 11, 12, 13]. The high psychiatric morbidity reported in some studies [2, 3, 6] were most probably due to methodological shortcomings including the fact that patients were not evaluated pre-operatively [2, 3], not using standardised scales for the assessment of emotional disturbances [6], studying only psychatric referrals of hysterectomised patients [2], studying only prescriptions of medications by general practioners [3] and studying mixed samples, for example, patients undergoing hysterectomy for prolapse, cancer or in combination with abortion or childbirth [2]. In both study and control groups, the levels of anxiety and depression were higher before the procedure and decreased after surgery. The finding is in agreement with a few prospective studies [11, 13] which also concluded that there is no post-hysterectomy increase in depression or neuroticism. The high levels of preoperative anxiety and depression in hysterectomy patients may therefore be attributed to other factors like the discomfort and handicap resulting from prolonged illness, stress of hospitalisation, fear of operative procedure and personality factors and may not be related to hysterectomy.

We conclude from our study that hysterectomy seldom results in increased anxiety, depression or psychiatric morbidity in the long run.