Post-operative Quality of Life Assessment after Total Abdominal Hysterectomy

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Volume 1 | Issue 3 | 1 of 5
Gynecol Reprod Health, 2017
Post-operative Quality of Life Assessment after Total Abdominal
Hysterectomy
Research Article
1Senior Lecturer, Department of Obstetrics and Gynaecology,
Faculty of Medicine, University of Colombo, Sri Lanka.
2Consultant Obstetrician and Gynaecologist, District Base
Hospital, Rikillagaskada, Sri Lanka.
3Registrar – Obstetrics and Gynaecology, Department of Obstetrics
and Gynaecology, Faculty of Medicine, University of Peradeniya,
Sri Lanka.
4Registrar – Obstetrics and Gynaecology, Teaching Hospital –
Peradeniya, Sri Lanka.
5Temporary Lecturer, Department of Obstetrics and Gynaecology,
Faculty of Medicine, University of Peradeniya. Sri Lanka.
*Correspondence:
Gunasena GGA, Consultant Obstetrician and Gynaecologist,
District Base Hospital, Rikillagaskada, Sri Lanka, Tel:
+94777704780; E-mail: asankagunasena@gmail.com.
Received: 13 August 2017; Accepted: 09 September 2017
Jayasundara Chandana1, Gunasena Asanka2*, Gihan Champika3, Bandara Sajith4 and Dissanayake
Kushangi5
Gynecology & Reproductive Health
Research Article
Citation: Chandana J, Asanka G, Champika G, et al. Post-operative Quality of Life Assessment aer Total Abdominal Hysterectomy.
Gynecol Reprod Health. 2017; 1(3): 1-4.
ABSTRACT
Rationale: Hysterectomy is one of the commonest major gynecological surgeries carried out in Sri Lanka for benign
gynaecological conditions. As a denitive treatment method, it is important to assess whether total abdominal
hysterectomy improves the domains of patient’s quality of life.
Objective: The main objective was to assess the improvement in quality of life after total abdominal hysterectomy
(TAH).
Method: This was a descriptive cross sectional study, carried out in two centres; a teaching hospital and a peripheral
hospital at central province, Sri Lanka. Data were collected from a total of 46 patients who underwent TAH. The
health related quality of life (HRQoL) was assessed by using a pre-tested, interviewer guided questionnaire based
on the Standard Form-36 (SF-36) prior to surgery and six months after the surgery.
Results: Majority of patients had TAH for non-malignant conditions (89%). Out of 46 patients, 38 (82.6%) reported
an improvement in their general health while 8 (17.4%) did not experience any improvement. Those who had
limitations in their routine activities reported a notable improvement; travelling by 90.7%, dressing by 93.7% and
bathing by 96.2%. On a scale of 1 to 10, mean improvement in psychological status was 9.15 (±1.93). Improvement
in women’s participation in social gatherings was 21.5%. Impact on work attendance was shown by a reduction in
number of women taking leave being dropped to zero from 15.2%. There was no signicant improvement in sexual
frequency, dyspareunia and interaction with the sexual partner. The mean level of post-surgical satisfaction, which
was assessed by a scale of 1 to 10, was 9.2 (±1.2).
Conclusion: In symptomatic women with poor response to conservative treatment, total abdominal hysterectomy
may improve quality of life and reduce psychiatric symptoms.

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Keywords
Benign gynaecological conditions, Health-related quality of life,
Total abdominal hysterectomy.
Introduction
Total abdominal hysterectomy involves removal of the uterus
together with cervix using an abdominal approach. Most commonly
it is performed in women of reproductive age [1]. About 40% of
women all over the world will have hysterectomy by the age of 64
years and indication for the majority will be to relieve symptoms
and improve quality of life [2]. More than half of all hysterectomies
are carried out because of abnormal uterine bleeding, which is
associated with a wide range of diagnoses including leiomyomas,
endometriosis, adenomyosis, ovulatory dysfunction, coagulopathy
and disorders of endometrial haemostasis, some of which were
previously classied as dysfunctional uterine bleeding [3]. These
conditions can cause a diversity of physical symptoms and can
have an immense inuence on a woman's quality of life.
It is now generally recognized that the functional impact of clinical
interventions on patients’ lives is important in predicting demand
for services, and that it is not sucient to simply measure outcome
of clinical intervention in terms of morbidity and mortality [4]. In
most studies reporting on surgical procedures, emphasis often lies
on morbidity outcome measures such as operation time, surgical
complications, hospital stay, and recurrence rate. However, from
the patient’s point of view, outcome measures related to health
status and quality of life such as symptom resolution, return to
normal activities, and patient satisfaction are at least as important
as the classical outcomes [5]. These Health-related quality of life
(HRQoL) variables measured prospectively and concurrently,
complement mortality and morbidity measures [4].
Health-related quality of life (HRQoL) is a multi-dimensional
concept that encompasses domains related to physical, mental,
emotional and social aspects related to a disease or its specic
therapeutic approaches [6]. According to the denition introduced
by the World Health Organization, quality of life is dened as
“individuals’ perception 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 concerns” [7].
Quality of life is an important outcome variable especially
in surgery for benign gynaecological conditions, as medical
interventions can aect it in both positive and negative ways.
Most women reported a reduction in physical symptoms and
pain and an increase in health perceptions after hysterectomy [8].
However, hysterectomy may also result in the development of
new problems such as pelvic/abdominal pain, urinary problems,
constipation, weight gain, fatigue, lack of interest or enjoyment in
sex, depression, anxiety and negative feelings about oneself as a
woman [9].
Although there is a paucity of information regarding HRQoL,
hysterectomy is still one of the commonest major gynecological
surgeries carried out in Sri Lanka. Therefore, as a denitive
treatment method, it is important to assess whether total abdominal
hysterectomy improves the domains of patient’s quality of life.
As HRQoL refers to an individual’s total wellbeing, having a
proper understanding on this subject allows provision of accurate
information to the patient during pre- and postsurgical counseling,
thereby enhancing the appropriateness of treatment and care.
Methods
This was a descriptive cross sectional study, carried out in two
centres; a teaching hospital and a peripheral hospital at central
province, Sri Lanka. The main objective was to assess the
improvement in quality of life after total abdominal hysterectomy
(TAH). A sample size of 50 was obtained by using the relevant
formula. All women undergoing TAH were oered participation
in the study. The consented patients were interviewed prior
to the surgery. General information like age, marital status,
educational status, occupation, menstrual history and indication
for surgery were collected rst. Their health related quality of life
(HRQoL) was assessed by using a pre-tested, interviewer guided
questionnaire based on the Standard Form-36 (SF-36) [10]. The
questionnaire assessed the health in general, physical impact of
symptoms on activities of daily living, impact on sexual health,
psychological impact, social and occupational impact.
Total abdominal hysterectomy was carried out in all patients by a
consultant gynaecologist or by a post-graduate trainee in obstetrics
and gynaecology (registrar or senior registrar) under the direct
supervision of the consultant gynaecologist. All the patients were
interviewed six months after the surgery to assess the health related
quality of life with reference to the same domains of HRQoL
which were assessed pre-operatively.
Data was entered into an on-going Microsoft Excel work sheet.
The statistical analysis was done by using SPSS statistical
software v20. Between the pre-operative and post-operative
assessments, the percentage dierence in the domains of HRQoL
were analysed. The percentage improvement or worsening in
general health, physical symptoms (e.g. abdominal pain, bleeding
and pelvic pain), and limitation of activities of daily living, sexual
health and psychological health were analysed before and after
surgery. Similar analysis was carried out with regard to social
and occupational aspects as well. Mean level of post-surgical
satisfaction was assessed by a scale of 1 to 10.
Results
Data was collected from a total of 46 patients as 4 patients were
not available for follow-up. The mean age of the group was 46.7
(±7.2) years and 7 (15.2%) out of them were post-menopausal.
Main indication for surgery was leiomyoma; 19 (41%) patients,
followed by dysfunctional uterine bleeding in 15 (37%) patients
(Figure 1). Patients with no denable structural or histological
cause for bleeding were classied as dysfunctional uterine
bleeding.
Out of 46 patients, 38 (82.6%) reported an improvement in
their general health while 8 (17.4%) did not experience any

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improvement. None of the patients complained about worsening of
general health after TAH. The improvement in general health was
assessed as fair (28%), good (30%) and very good (25%) (Figure
2).
Figure 1: Indication for Total Abdominal Hysterectomy.
Figure 2: Improvement in general health.
There was a remarkable improvement in symptoms following
total abdominal hysterectomy. A 100% improvement was noted in
vaginal bleeding following surgery while pelvic pain improved by
82.8% and abdominal pain improved by 70.4% compared to the
previous status (Figure 3).
Figure 3: Improvement in symptoms following total abdominal
hysterectomy.
We also observed an improvement in activities of daily living
following total abdominal hysterectomy. Those who had limitations
in their routine activities reported a remarkable improvement;
travelling by 90.7%, dressing by 93.7% and bathing by 96.2%
(Figure 4).
Figure 4: Improvement in activities of daily living.
There was no signicant improvement in the sexual frequency,
dyspareunia or interaction with the sexual partner. 13 out of 46
patients (28.2%) had dyspareunia prior to surgery. 7 patients
(53.8%) reported a complete recovery from dyspareunia while rest
of the 6 patients (46.2%) had a partial recovery.
31 (67.4%) patients suered from psychiatric disturbances due to
their illnesses prior to surgery. On a scale of 1 to 10, the mean
improvement in psychological status following TAH was 9.15
(±1.93).
The impact on work attendance was shown by a reduction in
number of women taking leave being dropped to zero from 15.2%
pre-operatively. There was a 21.5% improvement in women’s
participation in social gatherings after the TAH. Mean level of
post-surgical satisfaction, which was assessed by a scale of 1 to
10, was 9.2 (±1.2).
Discussion
As evident by this study, majority of hysterectomies are carried out
for non-malignant conditions where health-related quality of life
becomes an important outcome variable. Concerning the health
in general, 38 (82.6%) patients did experience an improvement
in their general health with more than 50% reporting a good or a
very good improvement. Only 8 (17.4%) patients remained at the
same general health six months after the TAH. In this group, the
presence of other health co-morbidities might have contributed to
the sense of general health. None of the patients complained about
worsening of general health after TAH. This explains that majority
of women who have undergone a hysterectomy benet from the
procedure with a minority not experiencing a dierence. Previous
studies have shown that around 8% of the women who underwent
hysterectomy reported the same or increased number of symptoms
[11].
The main contributor for the improvement in general health

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was the relief from the agonizing symptoms. In the absence of
surgical complications, all patients were totally cured from
abnormal vaginal bleeding. A remarkable improvement was
noticed in abdominal and pelvic pain following surgery which
could have been a major factor towards a better quality of life.
Quality of life could be severely hampered by the limitations in
the activities of daily living; a fact we observed in our subjects.
Six months following TAH, our patients reported an outstanding
improvement in routine daily activities especially travelling,
bathing and dressing. Recovery from these limitations of activities
and disabling symptoms is reected on the fact that none of the
patients had to take leave o work due to their illnesses following
surgery. They also reported an improvement in participation in
social gatherings which was previously restricted by their illness.
Similar results in returning to normal health and bodily functions
are observed in related research [12,13].
Though we expected to nd a major improvement in sexual
function after surgery, this study did not prove a statistically
signicant change in quality of sexual life after the operation with
regard to sexual frequency, dyspareunia and interaction with the
sexual partner. Although previous study data support viewpoint
that most probably women will neither lose their sexual desire after
hysterectomy, nor they will lose their feminine shape or style [14],
there might be other contributory factors to explain this nding.
The social and cultural background, negative thoughts about
sexuality after long-standing suering from the disease and lack
of accurate information might be implicated in quality of sexual
life after the TAH. However, sexuality after hysterectomy is still
a cause of great anxiety among patients and continuous ambiguity
for health care providers.
Hysterectomy has traditionally been considered to be associated
with adverse psychiatric sequelae [15]. However, most of the earlier
studies were retrospective analyses with inadequate measures
of outcome. More recent studies have shown that hysterectomy
does not lead to a signicant increase in symptoms of psychiatric
illness [16,17]. Indeed, some studies have found that psychiatric
symptoms decreased after hysterectomy for all women, regardless
of type of hysterectomy whether subtotal or total (4). In our study,
31 (67.4%) patients suered from psychiatric disturbances due to
their illnesses prior to surgery and they all reported an improvement
in psychological status after the surgery. On a scale of 1 to 10, the
mean improvement in psychological status following TAH was
9.15 (±1.93).
This study has a number of limitations. Although only two
centers were involved, a variety of surgeons performed the
operations. Majority of operations were performed by Consultant
Gynaecologists and post-graduate trainees performed the
operation under direct supervision of a Consultant Gynaecologist.
Nevertheless, this may well limit the external validity of the study.
The possibility of surgical complications associated with a major
gynaecological surgery like TAH should not be under-estimated
although we did not encounter any during the study period.
It is possible that women may have improved regardless of surgery
within the six-month follow-up period and we were unable to
assess this in the absence of a control group of women who did
not undergo surgery. Therefore, we acknowledge that our results
should be replicated on a wider scale before our recommendations
can be generalized.
Laparoscopic hysterectomy is gaining popularity in many countries
and some studies have observed that with a follow-up of 4 years,
patients who underwent laparoscopic hysterectomy reported better
quality of life compared with patients undergoing abdominal
hysterectomy [18]. In Sri Lanka, laparoscopic hysterectomy is
not widely available and it is hard to nd an adequate number of
patients for comparison.
Conclusion
In symptomatic women with menstrual or related disorders where
conservative treatment has failed, total abdominal hysterectomy
may improve quality of life and reduce psychiatric symptoms.
However, the complications associated with a major gynaecological
surgery should not be under-estimated.
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© 2017 Chandana J, et al. is article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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