K. Thilagavathi
Krishnasamy1, Rajeswari Vaidyanathan2
1Ph.D.
Scholar in National Consortium for Ph.D. Nursing, Bangalore, India
2Research
Guide in National Consortium for Ph.D. Nursing, Bangalore, India
Corresponding Author Email: thilagaindia74@gmail.com
ABSTRACT:
Objectives: To
measure the change in quality of life of women before and after hysterectomy.
Methods: This
prospective observational cohort study consisted of a convenience sample of 100
women scheduled for elective hysterectomy. Women between the age group of 30-60
years, those living with partner, premenopausal/postmenopausal age, who undergo
abdominal/vaginal hysterectomy with or without salphingo
oophorectomy for nonmalignant reason, were included.
Women were recruited preoperatively and followed for four months after surgery.
World Health Organization-Quality of life (WHO-QOL) Questionnaire was completed
preoperatively and at four months postoperatively. Analysis included univariate statistics, paired t test and Chi-square tests.
Results: The
mean age of women in the study cohort was 43.71 years; majorities had primary
education (49.5%), performed coolie work(71.6%), had 2 children(40%) ,duration
of complaints were less than 3 months.(29.5%).42.1%of them were diagnosed with
Fibroid uterus and 58.9% have undergone Total abdominal Hysterectomy with
Bilateral SalphingoOophorectomy.89.5% did not attain natural menopause before
surgery. Overall, there was marked improvement in quality of life mainly in
Physical health and psychological status at 4 months after surgery as compared
to preoperative period. Paired t test showed significant difference(
p˂0.001) in quality of life scores among samples between preoperative
period and at four months after surgery. There was significant association
between social relationship in preoperative period with selected demographic
variables (Age, preoperative diagnosis and type of surgery undergone). However,
it was highly significant with age (p˂0.001) as compared to preoperative
diagnosis (p˂0.05) and type of surgery undergone (p˂0.01).
Conclusion: Quality
of life improved considerably from the preoperative period to four months postoperative
in women who underwent hysterectomy.
KEYWORDS: Quality
of Life (QOL), Total abdominal hysterectomy, vaginal hysterectomy, Bilateral Salphingo Oophorectomy (BSO)
INTRODUCTION:
The uterus has been regarded as
the regulator and controller of important physiological functions, a sexual
organ, a source of energy and vitality as well as a maintainer of youth and
attractiveness among women. Hysterectomy is the second most
frequently performed major surgical procedures on women all over the world,
next to caesarean section1.
In
the US more than half million women undergo hysterectomy each year and it is
estimated that by the age of 65, one third of women will have had their uterus
surgically removed. In Australia, the incidence is 4.8 per 1,000 women. In UK
one in five women after the age of 60 will have hysterectomy. In India, only
extrapolated figures are available which was 23, 10,263 out of 1,06,50,70,607,
according to international database, 20042.
Hysterectomies are undertaken for non-life
threatening conditions (other than cancer) and are performed to improve quality
of life3.This surgery provide relief from long term physical
symptoms in women.Quality
of life is defined as individuals' perceptions of their position in life in the
context of the culture and value systems in which they live and in relation to
their goals, expectations, standards and concerns4.
An important
study was published in 1994 (The Maine Women’s health study) that examined how
women felt both physically and emotionally before and after hysterectomy. More
than four hundred women were interviewed before they had a hysterectomy and
then followed for a year after their surgery. Likewise, a separate group of 380
women who had similar Gynecologic problems, but chose not to have hysterectomy,
were interviewed. The study found that a substantial number of women had a
marked improvement in their symptoms following hysterectomy, including symptoms
such as Pelvic pain, Urinary problems, bleeding, fatigue and Psychological and
Sexual problems. And after hysterectomy, many of the women reported a marked
improvement in the quality of their lives.
Therefore, for some women, especially those who have significant
symptoms as a result of gynecologic problems, hysterectomy may be beneficial5.
Several
western studies showed there are improvement in general health, psychological
status and social relationships on quality of life after hysterectomy. In
Indian settings there are less studies undertaken on this issue. So researcher
undertaken this study to build a new body of evidence in this area. The
objectives of this study was (1) to measure the change in QOL before and after
hysterectomy, and (2) to find association on the level of QOL in preoperative
period with their selected demographic variables(age, preoperative diagnosis
and type of surgery undergone).
METHODS:
This
Prospective observational cohort study was conducted in the District
Headquarter government hospital in Salem District, Tamilnadu,
India. A Convenient sample of 100 women scheduled for elective hysterectomy was
recruited preoperatively and followed at four months after surgery. Inclusion
criteria consist of women between the age group of 30-60 years, Women those who
are living with partner, women at premenopausal/postmenopausal age, women who undergo
abdominal/vaginal hysterectomy with or without salphingo
oophorectomy for nonmalignant reasons. Exclusive
criteria include women with debilitating illness and psychiatric illness, and
women undergo hysterectomy for emergency reason. Ethical clearance certificate
from IERB was obtained. Formal permission was got from hospital authorities
before starting the study.
Participants
were approached in the same day after admission in the gynecology ward.
Informed written consent was obtained from samples after explaining the nature and
objectives of the study. Baseline demographic and clinical variables related to
their age, education, occupation, family monthly income, No of children, chief
complaints and its duration, preoperative diagnosis, type of surgery planned,
presence of urinary symptoms before surgery and associated co-morbid illness
was obtained. Followed by WHO-QOL-BREF Questionnaire comprises of 26 items was
administered to each sample. Questions pertain to all four domains namely
physical health, Psychological status, Social relationship and Environment was
asked, their response was noted. Each item was graded in 1-5 scale as in
ascending/descending order as per item. Raw Scores for each individual domain
was converted to transformed scores in 0-100 (as instructed) and interpreted as
follows, 0-44: Poor; 50-75: Moderate; 81-100: Good. During follow up, at 4
months after surgery the samples were reassessed with the same questionnaire in
the home settings.
Univariate statistics were used to describe the demographic data, Paired t
test was used to find the difference on QOL between preoperative period and at
four months after surgery. Chi square test was used to find the association
between QOL on each domain in preoperative period with their selected
demographic variables (age, preoperative diagnosis and type of surgery
undergone).
Figure 1: Domain wise quality of life among samples in preoperative
period
Table 1:
Baseline characteristics of samples (n=95)
|
Characteristics |
Frequency n(%) |
|
1.Age in years a.31-35
years b.36-40
years c.41-45
years d.46-50
years e.51-55
years f.56-60
years |
08(8.4) 30(31.6) 33(34.7) 13(13.7) 06(6.3) 05(5.3) |
|
2.Educational status a. Illiterate b. Primary school c. Middle school d. Secondary school |
32(33.7) 47(49.5) 12(12.6) 04(4.2) |
|
3.Occupation a. Housewife b. Coolie worker |
27(28.4) 68(71.6) |
|
4.Family monthly income in rupees a. Below 2000 b.2001-4000 c.4001-6000 |
02(2.1) 77(81.1) 16(16.8) |
|
5.Number of children a.0 b.1 c.2 d.3 e.4 |
04(4.2) 04(4.2) 38(40) 35(36.8) 14(14.7) |
|
6.Duration of complaints a. Less than 3 months b.3-6 months c.6-12 months d.1-3 year e.3-6 year |
28(29.5) 22(23.2) 19(20) 23(24.2) 03(3.2) |
|
7.Preoperative Diagnosis a. Fibroid uterus b.DUB c. Adenomyosis d. Genital prolapse |
40(42.1) 33(34.7) 15(15.8) 07(7.4) |
|
8.Type of surgery undergone a. TAH b. TAH+BSO c. Vaginal Hysterectomy d. VH with Pelvic Floor repair |
12(12.6) 56(58.9) 20(21.1) 07(7.4) |
|
9.Attained natural menopause a. Yes b. No i).if yes, duration of
menopause a. Within 1 Year b.1 -3 year c.3-6 year |
10(10.5) 85(89.5) 4(40) 3(30) 3(30) |
|
10.Associated urinary symptoms a. Yes b. No i)If present ,type of urinary
incontinence *Stress Incontinence a. Yes b. No *Urge Incontinence a. Yes b. No *Mixed Incontinence a. Yes b. No |
12(12.6) 83(87.4) 12(12.6) 83(87.4) 12(12.6) 83(87.4) 12(12.6) 83(87.4) |
|
11.Co-morbid illness a. No Illness b. Hypertension c. Diabetes mellitus d. Diabetes Mellitus+ HTN |
83(87.4) 07(7.4) 04(4.2) 01(1.1) |
RESULTS:
Out of 100
women recruited in the preoperative period, researcher could not access 5
samples (attrition) during follow up at 4 months after surgery. So the sample
size became 95 at the end of data collection.
Baseline
demographic and clinical variables are summarized in Table.1.The mean age of
the study participants was 43.71 years, and the majority had primary education
(49.5%),were doing coolie work(71.6%),had 2 children(40%), duration of
complaints were less than 3 months(29.5%),42.1%of them were diagnosed with
Fibroid uterus and 58.9% have undergone Total abdominal Hysterectomy with
Bilateral Salphingo Oophorectomy,89.5% did not attain
natural menopause before surgery,12.6% of samples had urinary problems before
surgery in which 50% had Stress Incontinence,33.3% had Urge Incontinence and
Remaining 16.7% had mixed
incontinence,87.4% of samples had no co-morbid illness in the
preoperative period.
The
preoperative period and four months postoperative QOL scores are shown in the
Figure (1,2). In regard to physical health 90.5% of them had poor and 9.5% had
moderate QOL in preoperative period .But at 4 months after surgery it was
drastically raised in which 64.2%had moderate, 35.8% had good QOL scores and
none of them scored poor physical health. This could be due to relief from physical
symptoms experienced before surgery. 37.9% had poor, 62.7% had moderate scores in psychological
status in preoperative period, but it was improved a little postoperatively in
which 2.1% had good, 84.2 had moderate and 13.7% had poor scores.
Related to
Social relationship scores, 34.7 % had poor; 65.3% had moderate level in
preoperative period and in postoperatively, 53.7% of them had poor and 46.3%
had moderate level. None of them had good QOL scores. Environment scores were
34.7% had poor;65.3% had moderate level preoperatively, however postoperatively
33.7% had poor and 66.3% had moderate level. Above findings clearly point out
that not much changes happened in social relationships and environment scores.
Figure 3
shows the domain wise mean QOL scores among samples in preoperative period and
at 4 months after surgery. It clearly depicts that mean QOL scores on physical
health increased evidently at 4 months after surgery as compared to
preoperative period. Line graph shows the decline in mean QOL scores in social
relationships and environment as compared to preoperative period.
Figure 2:Domain wise quality of life among samples at 4 months after
surgery
Figure 3:
Domain wise Mean QOL scores among samples in preoperative period and at 4
months after surgery
Table 2: Comparison of quality of life among samples at preoperative
period and 4 months after surgery (n=95)
|
Domain in QOL |
Preoperative period |
4 months after surgery |
Mean difference |
Paired ‘t ‘ test value |
||
|
Mean |
SD |
Mean |
SD |
|||
|
1.Physical
health |
41.74 |
5.139 |
71.43 |
8.927 |
29.69 |
31.700*** |
|
2.Psychological
status |
53.36 |
9.703 |
58.75 |
12.347 |
5.39 |
4.672*** |
|
3.Social
relationship |
48.42 |
13.643 |
43.92 |
14.401 |
4.5 |
4.334*** |
|
4.Environment |
58.38 |
11.590 |
48.56 |
8.293 |
9.82 |
12.767*** |
***-Highly Significant (p<0.001)
Table 3: Association between level of quality of life in preoperative
period with selected demographic variables
(n=95)
|
S.no |
Domains inQOL |
Age |
Preoperative Diagnosis |
Type of surgery undergone |
|
1. 2. 3. 4. |
Physical
health Psychological
status Social
relationship Environment |
5.428NS 4.484NS 55.187*** 3.729NS |
3.556NS 9.908* 9.418* 2.108NS |
10.811* 9.675* 13.117** 2.279NS |
*-Significant
(p<0.05) **-Significant (p<0.01) ***-Significant (p<0.001) NS-Not
Significant
Table 2
depicts the paired difference on QOL scores among samples in preoperative
period and at four months after surgery. Overall, the assessment within subject
effects over the preoperative period and at four months postoperatively was
significant for all domains (p<0.001). However mean difference for physical
health was 29.69; Psychological status was 5.39; Social relationship was 4.5;
Environment was 9.82.When comparing all domains in QOL, physical health scores
had drastic improvement.
Table 3 briefly
presents about the association between domain wise QOL in preoperative period
with selected demographic variables (age, preoperative diagnosis and type of
surgery undergone). Physical health was found to be significant (p<0.05)
only with type of surgery undergone. Psychological status was found to be
significant (p<0.05) with preoperative diagnosis and type of surgery
undergone. In regard to social relationship, it was found to be significant
with all variables. However it was highly significant with age(p<0.001) as
compared to preoperative diagnosis(p<0.05) and type of surgery undergone (p<0.01).
In regard to environment it was not statistically significant with any variables.
DISCUSSION:
Present study
was undertaken to measure the changes in QOL on women before and after
hysterectomy. Findings of the study suggested that there was statistically
significant difference (p<0.001) on
QOL scores in physical health, Psychological status, Social relationships and
environment. When comparing the mean difference between preoperative period and
postoperative status, the physical health scores improved from poor to moderate
level. But the psychological status remained moderate level in both
measurements. However there were declined scores in social relationship and
environment in postoperatively as compared to preoperative period.
Above
findings are supported with a study conducted among 112 diabetic patients along
with 81 healthy controls without diabetes. Study findings showed the HRQOL of
patients with diabetes was lowest in the social domain. When compared with the
control group the HRQOL of patients was lower in all domains except the
environment domain (P=0.6478)6.
CONCLUSION:
Present study
findings highlights that there is improvement in physical health among women
after hysterectomy. Further it emphasizes the need to provide structured
information about various aspects of hysterectomy which may be beneficial to
improve the psychological status and social relationships postoperatively.
REFERENCE
1.
Wu, Wechter, Geller, Nguye. Visco. Hysterectomy rates
in the United States, 2003. Obstetrics and Gynaecology.2007;
110(5).p.1091–1095.
2.
Saving the uterus-Article available from
http://healthcare.financialexpress.com/ 201007/knowledge01.shtml
3.
Ontario Women’s Health Council: Expert Panel on Best Practices in the
Use of Hysterectomy. Achieving best practices in the use of hysterectomy. 2002.
Available at: http://www.hdl.handle.net/1873/4024.
4.
The WHO QOL Group. (1994). The development of the World Health
Organization quality of life assessment instrument (the WHOQOL). In J. Orley and W. Kuyken (Eds) Quality of Life Assessment: International
Perspectives. Heidelberg: SpringerVerlag.
5.
Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Women's
Health Study: I. Outcomes of hysterectomy. Obstet
Gynecol. 1994. Apr;83(4):556-65.
6.
V Odili, L Ugboka,
A Oparah. Quality Of Life Of People With
Diabetes In Benin City As Measured With WHOQOL- BREF. The Internet Journal
of Law, Healthcare and Ethics. 2008. Volume 6 .Number 2.
Received on 02.12.2014 Modified on 12.12.2014
Accepted on 23.12.2014 © A&V Publication all right reserved
Asian J. Nur.
Edu. and Research 5(1): Jan.-March 2015; Page108-112
DOI: 10.5958/2349-2996.2015.00023.3