Depression, anxiety, hostility and hysterectomy

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Depression, anxiety, hostility and hysterectomy Article in Journal of Psychosomatic Obstetrics & Gynecology · October 2005 DOI: 10.1080/01443610400023163 · Source: PubMed

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Journal of Psychosomatic Obstetrics & Gynecology, September 2005; 26(3): 193–204

Depression, anxiety, hostility and hysterectomy

˚ RTEN KVIST3, S. BE´ATRICE M. EWALDS-KVIST1, TOIVO HIRVONEN2, MA ¨1 KAARLO LERTOLA4, & PIRKKO NIEMELA 1

Department of Psychology, University of Turku, Finland, 2 Department of Obstetrics and Gynaecology, Turku University Central Hospital, Finland, 3Department of General Practice, University of Turku, Finland, and 4Department of Statistics, University of Turku, Finland (Received 20 June 2003; accepted 2 November 2004)

Abstract Sixty-five women (aged 32 – 54 yrs) were assessed at 2 months before to 8 months after total abdominal hysterectomy on four separate occasions. Beck’s Depression Inventory (BDI), Taylor’s Manifest Anxiety Scale (TMAS), the Buss-Durkee Hostility Inventory (BDHI), Measurement of Masculinity-Femininity (MF), Likert scales and semantic differentials for psychological, somatic and sexual factors varied as assessment tools. High-dysphoric and low-dysphoric women were compared with regard to hysterectomy outcomes. Married nulliparae suffered from enhanced depression post-surgery. Presurgery anxiety, back pain and lack of dyspareunia contributed to post-surgery anxiety. Pre-surgery anxiety was related to life crises. Pre- and post-surgery hostility occurred in conjunction with poor sexual gratification. Post-hysterectomy health improved, but quality of sexual relationship was impaired. Partner support and knowledge counteracted hysterectomy aftermath. Post-hysterectomy symptoms constituted a continuum to pre-surgery signs of depression, anxiety or hostility.

Keywords: Total abdominal hysterectomy, depression, anxiety, hostility, sexuality, nulliparous

Approximately 9000 hysterectomies are performed annually in Finland. The annual incidence of hysterectomy is 348/100 000 women of whom 90% are operated on for a benign condition [1]. The prevalence in Finland (Turku) for women aged 59 years is 26% [2]. Both incidence and prevalence of hysterectomy is higher in Finland than in other Nordic countries but is approximately the same as in most European countries [2]. Consequently, there is an ongoing interest in hysterectomy aftermath and the topic has been extensively studied [3,4]. It is a known fact that there are emotional sequelae, including depression, anxiety, and guilt to the surgery on female reproductive organs [5]. For decades researchers have been occupied with the question whether hysterectomy causes depression in some women [6] or whether the surgery provokes a pre-existing disposition for depressive symptoms [4,7], often expressed simultaneously with anxiety [8], and comes to light in forms of psychological discomfort, somatic pains and complaints as well as sexual malfunctioning [9,10]. Further, a change in a mood state expressed in the form of hostility in conjunction to abdominal hysterectomy is currently the focus of interest. Increased anger as a mood factor related to hysterectomy is previously recorded

[11]. Hostility by means of the Buss-Durkee Hostility Inventory [12] is now assessed for the first time in relation to hysterectomy. The beneficial effects of the removal of an unhealthy uterus implying a decrease in psychopathology have also been addressed [13,14]. Research has indicated improved sexual functioning in terms of decreased dyspareunia and enhanced sexual arousal or libido in some women [15–19], but also reported in 20% of the women deterioration in their overall sexuality following hysterectomy for benign conditions [20]. Factors known to provoke an underlying tendency to alter the mood state after hysterectomy comprise pre-existing symptoms of depression to unfortunate events such as surgery on the reproductive organs [5]. In addition, young age, emergency hysterectomy [4,8], a continuous desire to bear children [16], lack of education [21], unsatisfactory knowledge about the reproductive organs [22], denial of the significance of the loss of the uterus and a sense of impaired femininity [23], as well as lack of uterus pathology [4], are all known factors contributing to a poorer post-surgery quality of life. The establishment of an adequate comparison group for the hysterectomized is known to be

Correspondence: S. Be´atrice Ewalds-Kvist, Korpgatan 3 D, 20610 Turku, Finland. Tel: 358 2 240 24 33. E-mail: [email protected] ISSN 0167-482X print/ISSN 1743-8942 online # 2005 Taylor & Francis DOI: 10.1080/01443610400023163

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S.B.M. Ewalds-Kvist et al.

difficult. This fact is due to incompatibility between separate types of pelvic surgery conveying differing meanings at a subconscious level to the patient as well as to the patient’s mistaken belief that the hysterectomy would solve problems unrelated to her health condition [24]. Presently, this problem was addressed by comparing two groups of women that had reached the decision to undergo total abdominal hysterectomy. A female group with some pre-surgery cognitive, affective, or vegetative symptoms of depression indicating a potential for an increase in these symptoms, when effectively threatened by body damage [25], served as comparison group to women lacking these symptoms. The two groups were compared with regard to their levels of psychological, sexual and somatic functioning at two to four different occasions ranging from at least 2 months before, to at least 8 months after the surgery. Assessments with regard to depression, anxiety, hostility, angst, femininity as well as attitude towards female functions were carried out. Age, marital status, number of children, crises prior to surgery, and knowledge about the female reproductive organs were factors taken into account. The following hypotheses were tested: 1.

2. 3. 4. 5.

Post-hysterectomy symptoms constitute a continuum of pre-surgery signs of depression, anxiety or hostility. Post-surgery depression is related to marital status and parity. Post-surgery anxiety is related to being subject to life crises prior to hysterectomy. Post-surgery hostility and poor pre-surgery sexual satisfaction are connected. Knowledge and partner support counteract impaired sexuality post-hysterectomy.

Method Subjects Altogether 85 patients seeking hysterectomy at the Department of Obstetrics and Gynaecology, Turku University Central Hospital (TUCH) were asked to participate in the present research. Four left for the private sector. Of the remaining women aged 32–54 years (Table I), 80% (65/81) agreed with informed consent to participate in the present research. They were rewarded with the chance to win a cruise from Finland to Sweden. Our participants were collected and operated on during a period of 21 months for a benign condition and not expected to have an oophorectomy. The women underwent total abdominal hysterectomy; the most commonly used surgical method for removal of the uterus in Finland [26]. A diagnosis of myomata uteri was found in 58% (38) of the women; 27% (18) suffered from menorrhagia, 5% (3) from dysmenorrhea and of 5% (3) endometriosis, respectively. The remaining 5% (3) were

diagnosed with differing benign conditions. All were expected to menstruate. The women were asked to permit removal of their ovaries if considered necessary in case of adhesions, endometriosis or oophoritic cysts. Post hoc surgery 14% (9/65) of the women were unilaterally and 14% (9/65) bilaterally oophorectomized. The group was occasionally computed separately. Emergency hysterectomies and malignancies were excluded. The women were thus left with a minimum preparation time for surgery of two months [9]. The committee at Turku University Central Hospital ethically approved the study. Questionnaires The questionnaires assessed the participants’ psychological, sexual and somatic functioning pre- and post-surgery, their level of knowledge about their reproductive organs and their perception of feminine functions [5,7,8]. Some of the questionnaires have earlier been proven useful in Turku [27,28]. The women’s socio-demographic data (age, number of children, marital status, education, sexual partner) and life crisis during the year before the hysterectomy (close death, disease, divorce, other) were completed. The women’s attitudes towards menses, pregnancy and childbirth were assessed by means of Likert 5-step scales ranging from ‘‘extremely unpleasant’’ to ‘‘extremely pleasant’’. Knowledge about the reproductive organs was tested with a figure (0–8 scores), i.e., the patient completed five questions by naming the parts of the organs on the drawing and three open-ended questions by a description of the menstrual flow, the function of the uterus and the ovaries. Further, the complete Beck Depression Inventory (BDI) (Beck et al. 1961; rtt = 0.93) [29] was used. The BDI comprises a 21-item questionnaire that assesses the cognitive, affective, and vegetative symptoms of depression rated on a 4point scale from 0 to 3. The clinical cut-off point is 14 scores. The BDI is a well validated and widely used measure of depression. Two comparison groups were established on the basis of the average BDI score (X = 5.9, SD = 5.5) recorded for Finnish women aged 40 + / 7 1 yr. (Mattlar et al. [27]). Those high-dysphoric patients who scored 7 or higher were considered to have a potential to exhibit some signs out of a total of 21 cognitive, affective, or vegetative symptoms of depression (Table I) as opposed to low-dysphoric women scoring 6 or less on BDI and considered to lack such a potential. The psychological form also included 20 questions from Taylor’s Manifest Anxiety Scale (TMAS) (Taylor 1953; Finnish version by Lea Pitka¨nen 1971, based on F, K and L scales of the Minnesota Multiphasic Personality Inventory, MMPI, split-half rtt = 0.87) [28,30] and 20 questions from the Buss-Durkee Hostility Inventory (BDHI) (Buss & Durkee, 1957; rtt = 0.81) [12] comprising four dimensions of hostility (i.e.,

Psyche & hysterectomy

195

Table I. Patients’ characteristics. Variable Age Marital Status

Number of Children

Family Situation Sexual relationship Total Abdominal Hysterectomy

Occupational Classification

Educational Level

Pre-surgery Aggression Anxiety Depression

Crises Knowledge Sexual Identity

a

Item

Single Married Widowed Divorced 0 1–2 3–5 Living with partner Living alone Sexual relationship No sexual relationship Without oophorectomy

na

M

SD

Range

65 6 43 2 11 10 41 10 44 6 55 7 47

43.1

4.8

32–54 yr.

1.7

1.2

0–5 child.

41.6

4.0

32–47 yr.

43.2 50.6

3.4 2.7

37–47 yr. 49–54 yr.

Unilateral oophorectomy Bilateral oophorectomy 0. Technical, physical, social science, humanist & artistic work 1/2. Administrative, managerial, clerical & sales work 3/5. Agriculture, forestry, fishing, transport & communication work 6/7. Manufacturing & related work 8/9. Service work, work & workers not elsewhere classified Primary school Junior or basic high school Senior high school or vocational training Institute or vocational college College or University

9 9 4 27 9

Buss-Durkee Hostility Inventory (BDHI) Taylor’s Manifest Anxiety Scale (TMAS) Beck Depression Inventory (BDI) Low-dysphoric group High-dysphoric group 1–2 About reproductive organ Marke-Gottfries: Masculinity - Femininity Feminine Masculine Androgynous

60 61

6.3 6.3

3.4 3.5

1–14 scores 0–16 scores

23 29 18 62

2.3 11.1

1.8 4.2

0–6 scores 7–22 scores

2.8

0–8 scores

56 3 4

10.2 3.3 0

3.2 2.4 0

3–15 scores 0–8 scores

5 9 25 8 11 16 1

4.97

If n is smaller than 65 then information is not available.

guilt, indirect hostility, irritation, and negativity. In addition, 16 questions from the Measurement of Masculinity-Femininity (MF), by Marke and Gottfries (1967); parts with good sex discrimination power validated for women (‘‘Drawings’’: rpbis = 0.59, rtt = 0.61, and ‘‘Animals’’: rpbis = 0.62, rtt = 0.75) [31] were used. Semantic differentials presently used measured 0–69 mm. Zero mm indicated a complete lack as opposed to 69 mm showing very much of something. The variables were continuous and the computed rtt was 0.81. Markings were made diagonally between the two extremes and measured in mm with a ruler. The assessments of self-ratings comprised six psychological (angst, annoyance, fatigue, fear, happiness and relaxation), 10 sexual (dyspareunia, fear of pregnancy and its impact on coitus, frequency of coitus, partner’s sexual satisfaction, patient’s quality and satisfaction of coitus, satisfaction with orgasm, sexual arousal). For example, ‘‘quality of coitus’’ was recorded as

0 mm = ‘‘extremely unpleasant’’ to 69 mm = ‘‘extremely pleasant’’, for ‘‘orgasms’’ 0 mm = ‘‘never’’ to 69 mm = ‘‘several subsequent orgasms’’. Also 16 somatic variables (abdominal pain, back pain, defecation problems, dizziness, flatulence, general health, headache, hot flushes, insomnia, nausea, perspiration, shortness of breath, tachycardia, tremor, urinary problems, wound pain), for example, ‘‘insomnia’’ were recorded as 0 mm for ‘‘never’’ continuing to 69 mm for ‘‘very frequent’’. Two ratings about femininity (not at all feminine to very much), two questions about the availability of social support (partner’s or other person’s) and one about the perceived necessity to have a hysterectomy (‘‘not at all’’ to ‘‘extremely important’’), one about the length of sick leave as well as one question regarding whether they would agree to have the hysterectomy redone from ‘‘never’’ continuing to ‘‘with pleasure’’ were completed. In addition, the women were presented with a diffuse gray-scaled picture as a

196

S.B.M. Ewalds-Kvist et al. cal and somatic self-ratings were completed by the hysterectomized and again supposed to reflect the subjection to the surgery with regard to pain and discomfort. D) Post-surgery forms were mailed to the women after an average time of 8.7 months. The timing of last assessment ensured both that the patients hardly remembered their earlier markings on the questionnaires as well as possible low spirits might be at hand [8]. This form comprised BDI, TMAS, BDHI and MF, knowledge about the reproductive organs, self-rated psychological, sexual and somatic functioning, satisfaction with length of sick leave as well as willingness to resubjection to hysterectomy. The women also re-evaluated the content of Figure 1. Altogether 57/65 (80.7%) patients completed and returned the mailed postsurgery forms. Statistical analysis

Figure 1. Picture presented to the patients the day prior to hysterectomy as well as at the end of the observational period.

projective test designed by the first author in order to reveal awareness of being at risk of injury or death in conjunction with the surgery (Figure 1). The projective test was interpreted within the Freudian frame of reference [32]. Procedure The clients completed questionnaires at four separate times: 2 months and 1 day before surgery, 6 days and 8 months after the hysterectomy [16]. The questionnaires differed from occasion to occasion as follows: A) A minimum time of two months before hysterectomy was considered sufficient, during which time the assessed functioning were not expected to be affected by worries about the upcoming surgery [9]. At this time when the surgery was decided on, the patients completed the demographics, experienced crises, attitudes towards female functions, knowledge about the reproductive organs, TMAS, BDHI, and psychological, sexual and somatic self-ratings. On the basis of these assessments pre-surgery baselines for psychological, sexual, somatic functioning and knowledge were established. B) At the hospital ward the day before surgery the subjects completed again both forms comprising knowledge about the reproductive organs, TMAS, BDHI and MF as well as depicted the content of Figure 1. Questionnaires about angst, anxiety, hostility and the content of Figure 1 were supposed to reflect feelings of the upcoming surgery. Knowledge was supposed to be increased. C) Six days post-hysterectomy TMAS, BDHI, psychologi-

The statistical analyses used were the Linear Regression Models using Mallows Cp selection for independent variables, the GLM Repeated Measures Analysis of Variance, Fisher’s Exact Test, Spearman Correlation Coefficients, Mann-Whitney’s U-test, the Wilcoxon Matched-Pairs Signed-Ranks Test as well as the independent and dependent Student ttest. When considered necessary the effect of the multiple comparisons for two levels (1df) using the Bonferroni corrections was computed. The computations were carried out by means of SAS (8.2) and SPSS (9.0) for MS Windows.

Results Background variables Age. Two age groups were compared: the younger women between 30 to 39 yrs were thought to be more distressed by a hysterectomy [4] than women between 45 and 54 yrs. The latter group decreased their BDI scores over time (t (24) = 2.152, p = 0.042) as opposed to the former. Outcome of age and changes in sexuality as well as somatic functioning over the observational time are presented in Table II that shows that the older women reported a decline in their quality of coitus. Marital status. Nineteen women were single, widowed or divorced (Table I). They had experienced more crises prior to surgery than married women (t (47) = 2.695, p = 0.010) who also reported more support from their partner (t (16.2) = 2.393, p = 0.029). However, six days post-surgery single women suffered less from urinary problems than married women (t (59) = 3.447, p = 0.001) and they exhibited a decrease over time both in BDI scores (t (15) = 4.226, p = 0.001) as well as in fatigue (t (11) = 3.665, p = 0.004). Eight moths post-surgery, single, widowed and divorced women were less anxious and

Table II. Summary of changes in somatic and sexual functioning from before to after hysterectomy. Factor

Group

Age

30–39 yrs old

Marital status

Family size

Somatic functioning

Abdominal pain General condition (Bonferroni corrected value = 0.022) 45–54 yrs old Abdominal pain Tremor (Bonferroni corrected value = 0.016) Married Abdominal pain Dizziness (Bonferroni corrected Single, Back pain widowed & divorced (Bonferroni corrected Nulliparae

Crisis

Depression

Bilaterally oophorectomized

I 4 II I 4 II

25 24

I 4 II I 4 II

36 37

I 4 II

14

Pre-(I) to post-(II) hysterectomy

n

Quality of coitus (t (21) = 2.321, p = 0.030)

I 4 II

22

Quality of sexual relationship (Bonferroni corrected p = 0.05)

I 4 II

35

Sexual arousal (Bonferroni corrected p = 0.04) Fear of pregnancy (Bonferroni corrected p = 0.014)

I 4 II

6c

I 4 II

42

Sexual arousal (t (11) = 2.257, p = 0.038) Fear of pregnancy (Bonferroni corrected p = 0.02)

I 5 II

12

I 4 II

29

I 4 II

14

I 4 II

22

I 4 II

25

p = 0.000) p = 0.048)

4 II 4 II 4 II 4 II

43 43 37 42

I 5 II

6

I 4 II

12

I 4 II I 5 II

28 29

I 4 II

15

I 4 II I 4 II I 4 II

28 28 27

Sexual arousal (t (13) = 2.727, p = 0.017) Frequency of coitus (t(21) = 2.475, p = 0.022)

I 4 II I 4 II

22 23

Dyspareunia (Bonferroni corrected p = 0.024)

Abdominal pain

I 4 II

33

Perspiration (Bonferroni corrected p = 0.030) Back pain (t (8) = 3.252, p = 0.014)

I 4 II

32

I 4 II

9

Observed Power computed for small samples: 0.836; b0.828; c726.

I I I I

197

a

10a 9b

p-

Abdominal pain Back pain Dizziness Tremor (Bonferroni corrected p = 0.04) Uninformed General condition (0–1 score) (t (5) = 2.753, p = 0.040) Informed Dizziness (t (12) = (8 scores) 2.535, p = 0.026) Non-stressed Abdominal pain General condition (Bonferroni corrected p = 0.005) Stressed with Perspiration (Bonferroni corrected p = 0.048) Low-dysphoric Abdominal pain (0 to 6 BDI Back pain scores) Tremor (Bonferroni corrected p = 0.045) HighAbdominal pain dysphoric Dizziness (Bonferroni corrected (7 to 22 BDI scores) p = 0.044) nonoophorectomized

I 4 II I 4 II

Sexual functioning

Psyche & hysterectomy

Oophorectomy

n

p-

Parae

Knowledge

Pre-(I) to post-(II) hysterectomy

198

S.B.M. Ewalds-Kvist et al. 2 months before/after hysterectomy Married nulliparae

11.33

Married with children

5.9

Unmarried nulliparae

4.7

Unmarried with children

10.67

17.33 5.2 1.5 6.83

Figure 2. Changes in depression over time in unmarried or married women. Married nulliparous women (age X = 43.33, SD = 2.31) were at risk of suffering from post-hysterectomy depression.

irritated (Bonferroni corrected p value = 0.026, df = 46.3–47) and suffered less from dyspareunia (t (47) = 2.469, p = 0.017) than married women who also reported a decline in quality of their sexual relationship (Table II). Sexual relationship. Seven women were not engaged in a sexual relationship (Table I). Of these, three were single, one widowed and three divorced. Presurgery these women were more lacking in support from a partner (Bonferroni corrected p value = 0.006, df = 53) than other women but six days after surgery these women were healthier with regard to hot flashes, tachycardia and urinary problems (Bonferroni corrected p value = 0.024, df = 18.4–58.6) than other women. The divorced women of this group decreased their BDI scores over time (z = 2.386, p = 0.017). Sexual identity. The women’ sexual identity was assessed by means of the Measurement of Masculinity-Femininity (MF) at least two months prior to the hysterectomy. Fifty-six women exhibited a feminine identity (MF). A feminine identity was reflected in a positive attitude towards being pregnant, as opposed to that of androgynous or masculine women (n = 7; Table I), (t (49) = 3.237, p = 0.002). On the other hand, women with an androgynous or masculine identity were more satisfied with their relationship post-surgery compared to feminine women (t (50) = 2.695, p = 0.010). Nulliparous women’s sexual identity was masculine (MannWhitney U-test = 154, p = 0.000), more so than that of parae. Parity. Both single, widowed, divorced and married women had experienced childbirth. Ten women

were nulliparae: of these five fell into the lowdysphoric group and five into the high-dysphoric group (Table I). An interaction between the state of being childless and marital status is indicated in Figure 2. Nulliparae lacked pre-surgery fears related to pregnancy and were not as disturbed by fear of pregnancy during coitus (Bonferroni corrected p-value = 0.012, df = 35.3) than the other women. Pre-surgery nulliparae endured abdominal pain (t (38.4) = 3.883, p = 0.000), more so than parous women. Six days after surgery, nulliparae felt more at ease at the hospital and experienced less urinary problems (Bonferroni corrected p value = 0.016, df = 58) than parous women. Nulliparae became less happy over time (z = 2.028, p = 0.043) but at the last assessment they experienced fatigue to a lesser extent than the other women (t (49) = 2.340, p = 0.023). Parous women decreased their BDI scores over time (t (44) = 2.695, p = 0.010). Crisis. The year prior to the hysterectomy 18 women were stressed with at least one life crisis (Table I, Figure 4) and were initially more anxious (TMAS) than non-stressed women (t (25.2) = 3.637, p = 0.001). Four women were stressed both by divorce and death of a significant person and were more dysphoric (BDI) and anxious (TMAS) than nonstressed women (Bonferroni corrected p-value = 0.001, df = 38–39). Eight months later the former women were still more dysphoric (Bonferroni corrected p-value = 0.008, df = 32) than the latter. Although TMAS scores of the stressed women decreased over time (t (15) = 2.756, p = 0.015) these women experienced a decrease in their sexual arousal (Table II). At the end of the observational period non-stressed women enhanced their sense of femi-

199

Psyche & hysterectomy Table III. Linear regression models with the dependents variables of post-hysterectomy depression, anxiety and hostility. Dependent variable Depression n = 43

Anxiety n = 42

Hostility n = 42

Explanatory variables

R2

Parameter estimate

SE

t

Standardized estimate

p

6.692 1.272

2.608 0.102

2.606 12.52

0 1.253

0.0154 5 0.0001

1.185 70.054 70.109 0.056 0.092 70.127 3.776 78.029 3.825

1.44 0.028 0.03 0.033 0.024 0.031 1.269 2.089 1.143

3.03 71.92 73.65 1.71 3.87 74.13 2.97 73.84 3.34

0.262 70.152 70.316 0.151 0.334 70.394 0.268 70.345 0.262

0.005 0.064 0.001 0.097 0.0005 0.0003 0.0056 0.0006 0.002

10.550 0.320

3.748 0.134

2.81 2.39

0 0.367

0.008 0.023

0.318

0.160

1.98

0.312

0.056

70.106 70.048 70.048 70.073 0.052 71.85

0.074 0.027 0.025 0.023 0.016 0.872

71.43 71.75 71.93 73.19 3.34 72.12

70.161 70.215 70.248 70.419 0.374 70.243

0.163 0.088 0.062 0.003 0.002 0.041

2.747 0.645

1.795 0.141

1.53 4.57

0 0.583

5 0.0361 5 0.0001

0.347

0.189

1.83

0.242

0.0762

0.689 70.097 0.052 70.066 70.053

0.304 0.028 0.021 0.022 0.021

2.27 73.48 2.44 73.01 72.55

0.198 70.418 0.260 70.294 70.216

0.0306 0.0015 0.0207 0.0051 0.0161

0.068 0.042

0.035 0.018

1.97 2.35

0.177 0.237

0.0581 0.0253

0.881 Intercept Pre-surgery depression Parity Orgasm Dyspareunia General health Abdominal pain Tremor Crisis 1 Crisis 2 Married 0.661 Intercept Pre-surgery anxiety 6 days postsurgery anxiety Age Quality of coitus Orgasm Dyspareunia Back pain Crisis 1 0.801 Intercept Pre-surgery hostility (2 months) Pre-surgery hostility (1 day) Parity Orgasm Sexual arousal Dyspareunia Quality of sexual relationship Fearfulness Abdominal pain

ninity (t (27) = 2.102, p = 0.045) and lost their fear of pregnancy (Table II). Occupation, education and knowledge The majority of the women were educated on a primary school level, were occupied in administrative, managerial, clerical or sales work and knew on average 4.9 out of 8 scores about their reproductive organs (Table I). The day prior to surgery the women’s knowledge rose to 6.03 and at the end of the observational period they scored 6.19 out of 8. It was revealed by means of repeated measures analysis of variance that a marginal time effect existed (Greenhouse-Geisser Epsilon = 0.7894, F (2,100) = 5.57, corrected p = 0.0095) and that the increase in knowledge from the first to the last assessment was significant (F (1,50) = 5.27, p 5 0.026). Two groups of women were compared with regard to knowledge: uninformed (scoring 0–1 out of 8) were compared to informed, scoring a maximum of 8

on knowledge. The uninformed and informed women’s level of knowledge and education correlated reasonably (rs = 0.426, p = 0.019). Pre-surgery the uninformed women were more dysphoric (t (23) = 2.532, p = 0.002) and at the last assessment they were still more dysphoric and found their sick leave of six weeks too short (Bonferroni corrected pvalue = 0.042, df = 18) compared to the informed women. Post-surgery the informed women experienced to a greater extent sexual arousal than the uninformed (t (17) = 3.766, p = 0.002). From Table II it can be observed that the informed women increased their sexual arousal over time. Also their sense of femininity (t (11) = 2.579, p = 0.026) was enhanced over time. Partner support The women were divided into two groups on the basis of their rated partner support at the last assessment. Women rating their partner’s support

200

S.B.M. Ewalds-Kvist et al. Time 1

Time 2

Time 3

Two crises

13.3

9.8

7.5

Time 4 8.5

One crisis

7.6

6.1

4.8

5.0

No crisis

5.1

5.8

4.6

4.8

Figure 3. Crisis-related anxiety (TMAS) in women assessed 2 months and 1 day before total abdominal hysterectomy as well as 6 days and 8 months after the surgery. Women who experienced two crises were X = 37.8 (SD = 5.12) years old.

as poor (4 25 mm on a scale from 0 to 69 mm, n = 10) were compared with those who rated their partner support as very satisfying (5 55 mm, n = 19). Women supported by their partner were happy and felt feminine (Bonferroni corrected p value = 0.024, df = 27) compared to women lacking this kind of support. The impact of good partner support was reflected in a greater sexual satisfaction compared to women lacking such support. Group differences were revealed (Bonferroni corrected p value = 0.008, df = 27) with regard to rated partner’s satisfaction with sexual relationship, own satisfaction with the sexual relationship, orgasms, coitus, quality and frequency of coitus. Women poorly supported by their partner indicating a decline in their coital satisfaction (t (9) = 2.413, p = 0.039) post surgery. Beck’s Depression Inventory (BDI) Pre- and post-surgery depression (BDI) correlated (rs = 0.634, p = 0.000). Both measures of BDI correlated with anxiety (TMAS) (rs = 0.559 and rs = 0.519, p = 0.000, respectively) and hostility (BDHI) (rs = 0.504, p = 0.000 and rs = 0.382, p = 0.002, respectively). In addition pre-surgery depression correlated with pre- and post-surgery self-rated angst (rs = 0.428, p = 0.000 and rs = 0.398, p = 0.002, respectively) and pre-surgery fearfulness (rs = 0.444, p = 0.000). At the last assessment post-surgery depression correlated with self-rated angst (rs = 0.428, p = 0.001) and fearfulness (rs = 0.434, p = 0.000), too. It was revealed that bilaterally oophorectomized women did not differ from the other women with regard to BDI, TMAS and BDHI. The women were divided on the basis of their pre-surgery BDI scores into two groups (Table I). The low-dysphoric group comprised women not exhibiting BDI symptoms and

the high-dysphoric group those exhibiting a few BDI symptoms. Pre-surgery high-dysphoric women suffered from self-rated angst, fatigue, tremor and unhappiness (Bonferroni corrected p = 0.03, df = 42–57), as well as from back pain (Bonferroni corrected p = 0.032, df = 57.8) at a greater level than low-dysphoric women. At the end of the observational period women in the low-dysphoric group were more happy and relaxed (Bonferroni corrected p-value = 0.032, df = 51), less angst-laden, annoyed and fearful (Bonferroni corrected p = 0.039, df = 41.7–50) than those in the high-dysphoric group. Further, low-dysphoric women were less hostile (BDHI) and less anxious (TMAS) (Bonferroni corrected p = 0.02, df = 47.1– 51) than those high dysphoric. However, a decrease in BDI scores over time was found in high-dysphoric women (t (28) = 2.528, p = 0.017). With regard to somatic functioning the highdysphoric women suffered at the last assessment from a worse general condition and more dizziness (Bonferroni corrected p = 0.008, df = 51) but considered it more necessary to have a hysterectomy (t (50) = 2.309, p = 0.025), than low-dysphoric women. However, abdominal pain decreased in both groups as well as dyspareunia in the high-dysphoric group (Table II). A linear regression model with the dependent variable of post-hysterectomy depression was computed. Explanatory independent variables were selected by using Mallows Cp. The results are presented in Table III. Pre-surgery depression, abdominal pain, the state of being married as well as parity contributed significantly to post-surgery depression. By means of repeated measures analysis of variance no marginal time effect was uncovered. However, an interaction between ‘‘marital status x children’’ was disclosed. In other words ‘‘time x married’’ (Wilks’

Psyche & hysterectomy Time 1

Time 2

Time 3

Time 4

Poor orgasms

7.9

7.5

7.0

7.7

Moderate orgasms

5.7

5.8

5.3

5.4

Satisfactory orgasms

5.8

5.3

5.4

4.8

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Figure 4. Hostility (BDHI) scores in women with differing levels of orgasm satisfaction recorded 2 months and 1 day before the surgery as well as 6 days and 8 months after the hysterectomy. Women with poor orgasms were aged X = 44 (SD = 6. 26) years.

Lambda (df = 1,47) = 0.826, F = 9.93, p = 0.0028) and ‘‘time x children’’ (Wilks’ Lambda (df = 1,47) = 0.878, F = 6.51, p = 0.014) were findings revealed. The interaction ‘‘married x children’’ was significant at a level of p = 0.0008 (F (1,47) = 12.98). Further, the main effect of marriage per se was significant (F (1,47) = 4.28, p = 0.044) From Figure 2 it can be seen that married nulliparous women (n = 3) became more depressed as a function of time. Married women with children exhibited no change in BDI over time and matched the average BDI score of the Turku women (BDI 5.9). Unmarried nulliparous women were those women least prone to depression post-hysterectomy. Anxiety (TMAS) Pre- and post-surgery anxiety (TMAS) correlated, besides with BDI, with hostility (BDHI) (rs = 0.383, p = 0.001 and rs = 0.436, p = 0.000, respectively). A decrease in TMAS scores over time was found in women subjected to crisis (t (15) = 2.756, p = 0.015). As a general rule, high-dysphoric women were more anxious at the end of the observational period at each of the other three assessments (t (59) = 3.419, p = 0.001; 3.428, p = 0.001 and t (57.7) = 3.427, p = 0.001, respectively), more so than low-dysphoric women. A linear regression model with the dependent variable of post-hysterectomy anxiety was computed. Explanatory independent variables were selected by using Mallows Cp. The results are shown in Table III. Thus, pre-surgery anxiety, back pain and lack of dyspareunia are factors contributing to post-surgery anxiety. With regard to TMAS, it was revealed by means of repeated measures analysis of variance that a marginal time effect existed (Wilks’ Lambda

(df = 3,40) = 8.77, p = 0.0001, F (3,6) = 9.26, p 5 0.0001). Also an interaction between ‘‘time x crisis’’ was discovered (F (3,6) = 2.99, p = 0.0091). Women stressed by two crises (death of significant person and divorce) displayed TMAS values of 13.25, 9.75, 7.5 and 8.5 scores over time. Thus, at the end of the observational period their TMAS level was still higher than the TMAS levels exhibited by the other female groups. Women stressed by one crisis the year prior to hysterectomy exhibited values of 7.64, 6.14, 4.79 and 5.00 over the observational period. Women who had no crisis the year prior to surgery varied their TMAS-level over the four recording occasions from 5.08, 5.83, 4.64 and 4.80 out of a maximum of 20 TMAS scores. The day before surgery their TMAS level was at its maximum (Figure 3). Hostility (BDHI) A linear regression model with the dependent variable of post-hysterectomy hostility was computed. Thus, pre-surgery hostility, orgasmic dysfunction, poor quality of sexual relationship, abdominal pain and lack of pathology in terms of dyspareunia are the best contributors to post-surgery hostility (Table III). When analyzed by means of repeated measures analysis of variance no marginal time effect was found. However, 3 different levels of hostility were uncovered for women exhibiting three different levels of satisfaction with orgasms (F (2,48) = 3.46 = 0.0396). These levels remained stable over time. By means of multiple comparisons it was found that women who rated their orgasms as poor (0–25 out of 69 mm) differed from women who rated their orgasms as moderately satisfactory (26– 54 mm) (F (1,39) = 5.43, p = 0.05). The difference

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was found to originate from the first recording of BDHI (p = 0.046). Furthermore, it was often indicated by means of repeated measures of variance that those women found to be more hostile had been subjected to the death of a significant person prior to hysterectomy (F (1,40) = 3.91, p = 0.0549). Women rating their orgasms as poor (n = 18, 22, 22, 20) exhibited hostility levels of 7.94, 7.45, 7.00 and 7.7 at four different assessments, respectively. Women who rated their orgasms as moderately satisfactory (n = 31,31,31,25) exhibited hostility levels of 5.68, 5.77, 5.32 and 5.48, respectively. Women who were very satisfied with their orgasms (n = 10, 10,10,10), (55—69 mm) exhibited hostility levels of 5.80, 5.30, 5.40 and 4.80, respectively (Figure 4). Projection The participants were presented with a picture that reveals patient’s awareness of being at risk of injury or death in conjunction with surgery (Figure 1). The picture was introduced to the women on the day prior to surgery as well as at the end of the observational period. The women projected onto the picture an attic, cabin, castle, cellar, cottage, hospital, museum with an old-fashioned delivery bed, prayer room or prison as well as the absence or presence of death (sometimes in the form of a skeleton) or a feeling of tranquility, respectively. Patients pre-surgery focusing on death tended to be more hostile at two out of four BDHI assessments, that is the day before surgery (t (23) = 2.046, p = 0.052) in the form of negativity (t (23) = 2.149, p = 0.042) and six days after the hysterectomy (t (23) = 2.652, p = 0.014) in the form of guilt (t (23) = 2.246, p = 0.035) than women conveying a feeling of tranquility. As a function of time, the death theme increased and that of tranquility decreased (Fisher’s Exact Test (2-sided) p = 0.034). At the end of the observational period women projecting death onto the picture were found to be more hostile (BDHI) during their stay on the hospital ward (t (19) = 2.707, p = 0.014) and eight months later (t (19) = 2.107, p = 0.049) in the form of annoyance (t (17.5) = 3.657, p = 0.002). They also tended to be more dysphoric (BDI) than those women conveying a feeling of tranquility (t (16.8) = 2.089, p = 0.053). The BDI level of the deathfocusing women correlated with their TMAS level (rs = 0.762, p = 0.004). Willingness to reconsider a hysterectomy When asked whether they would reconsider to have the surgery, the women’s mean was 52,6 (SD = 13.11; n = 55, range 14–69) out of 69 possible. Zero meant ‘‘never’’ and 69 ‘‘with pleasure’’. One woman wrote: ‘‘As an experience never, based on the outcome with pleasure’’.

Discussion The present study confirmed earlier findings that the most important determinant of hysterectomy aftermath is pre-surgery signs of low mood and anxiety [7,20]. In addition, pre-surgery hostility constituted a continuum to post-surgery hostility, presently observed in conjunction with unsatisfactory sexuality in terms of poor orgasms and poor quality of sexual relationship. Some women’s hostile feelings might have covered the loss of a significant person [34]. Death of significant others and divorce are the worst human stressors [35] and multiple reality problems are known to cause anxiety indicating that a person’s coping ability is on the decline [34]. This was particularly obvious in women subjected to serious life crises prior to the hysterectomy. Furthermore, pain in terms of back pain occurred in conjunction to anxiety, in contrast to abdominal discomfort linking to depression [13] and hostility. Descending nerve pathways modulates physiologically incoming pain signals to the spinal cord but anxiety and depression can inhibit this action [36]. Childbearing may no longer be the central component in the sense of femininity but the emotional response to a hysterectomy may nevertheless reflect the symbolic meaning attributed to the uterus. Also persons who have never expressed conflicts about disease or death may become aware of the value of a resected organ [23,33]. When the women at hand were presented with a picture for projection, they depicted different types of rooms. Rooms especially symbolize the uterus in the Freudian school [32]. The emotional response may comprise the conscious or unconscious fear of death that accompanies every major operation [25]. A feeling of being at risk of death was evident in women who depicted the presence of the death, and this sinister theme increased over time. The women depicting death themes were found at times to score higher on hostility than women conveying themes of tranquility. During their stay at the hospital the component ‘‘guilt’’ was predominating in their hostility. Hysterectomy has sometimes been perceived as a punishment for guilt-laden, not solely sexual, activities involving the womb [23]. Presently, a small group of high-dysphoric married nulliparae increased their symptoms of feeling low post surgery, bringing our findings into line with previous observations [8,21]. Presently, an interaction of being married and childlessness was decisive for this kind of aftermath regardless of age [11]. Previously, the state of being married rather shielded a hysterectomy candidate from low mood [37]. The post-surgery depression of the married nulliparae may be due to their unfulfilled desire for a child [33,38]. But nulliparity per se was not related to postsurgery dysphoria [6]. Our unmarried childless women exhibited a total lack of symptoms of this kind post-hysterectomy [13]; according to a previous

Psyche & hysterectomy finding [38] this group of women was perhaps liberated by a hysterectomy. The surgery finally released their mental energy from the immobility caused by futile hopes, which from this point may be sublimated in other things [38]. Lack of organic pathology, presently in the form of dyspareunia, has traditionally been regarded as a risk factor for hysterectomy aftermath [11,33]. In this study dyspareunia decreased most in high-dysphoric women, most vulnerable for hysterectomy aftermath. Total abdominal hysterectomy is known to decrease dyspareunia [9,15] but the surgery may also adversely affect sexuality [10,19,20]. The destruction of and scar tissue in the vaginal cuff and damage to the uterovaginal plexus as well as lack of the positional change of the uterus usually explain this during sexual arousal [39]. Psychologically, sexual malfunctioning may be due to the mistaken belief that hysterectomy resolves marital and sexual problems [24]. Also fear of pregnancy may facilitate the decision to have a hysterectomy. In this study an association between stress and decreased sexual arousal was found in women subjected to crisis prior to the hysterectomy, but also low-dysphoric women experienced a decreased frequency of coitus over time. Presently, good partner support counteracted post-surgery adverse effects in terms of a greater satisfaction with the women’s sense of femininity, experience of orgasms, quality and frequency of coitus, compared to the ratings of women lacking partner support [19]. Also knowledge is known to shield women from hysterectomy aftermath [13,24]. Accordingly, women with excellent knowledge about their reproductive organ felt increased sexual arousal [17] and their sense of femininity was enhanced post surgery. These women were able to differentiate between the reproductive and erotic aspects of their sexuality. Limitations of the study Sexuality is a particularly delicate issue and random missing data in Table I indicates that some women did not agree to answer all of the questions. The women were rather low educated. The more educated and probably better paid possibly left for the private sector or they were not attracted by the chance to win a rather common reward in Turku in the form of a cruise from Finland to Sweden. The groups of married and unmarried nulliparae were very small and the study should be repeated with larger groups of these women. Conclusion Post-surgery symptoms constitute a continuum of pre-existing symptoms of depression, anxiety or hostility. A small group of married nulliparae was at risk for low mood. Post-hysterectomy anxiety comprised pre-surgery anxiety, back pain and lack of

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dyspareunia. Pre- and post-surgery hostility occurred in conjunction with poor sexual gratification. Married women reported impaired quality of sexual relationship. High-dysphoric women experienced decreased dyspareunia but also a decrease in the frequency of coitus. Good partner support and excellent knowledge about the reproductive organs counteracted hysterectomy aftermath.

Acknowledgements The authors are indebted to M. Koskela, instructional nurse, for collecting the data. We are grateful to Silja Line and Viking Line for the donated cruises. M. Kvist is obliged to the Perklen’s Foundation for Medical Research.

References 1. Luoto R, Kaprio J, Keskima¨ki I, Pohjanlahti JP, Rutanen EM. Incidence, causes and surgical methods for hysterectomy in Finland 1987–1989. International Journal of Epidemiology 1994;23:348–358. 2. Ma¨kinen J, Salmi T, Pirhonen J, Gro¨nroos M, Vuento M. Cross-sectional description of gynecological anamnesis of women aged 59 in Turku. Finland Medical Journal 1992;27:2496–2497. 3. Rikala K. Hysterectomy, psyche and sexuality. Helsinki: Yliopistopaino; 1995. pp 1–4. 4. Wijma K. Psychological functioning after non-cancer hysterectomy: a review of methods and results. Journal of Psychosomatic Obstetrics & Gynaecology 1984;3:133–154. 5. Daly MJ. Psychological impact of surgical procedures on women. In: Sadock BJ, Kaplan HI, Freedman AM, editors. The sexual experience. Baltimore, Maryland: Williams & Wilkins; 1976. pp 3081–3113. 6. Richards DH. A post-hysterectomy syndrome. Lancet 1974;26:983–985. 7. Carlson K. Outcomes of hysterectomy. Clinical Obstetrics & Gynaecology 1997;40(4):939–946. 8. Lalinec-Michaud M, Engelsmann F. Anxiety, fears and depression related to hysterectomy. Canadian Journal of Psychiatry 1985;30:44–47. 9. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual functioning. JAMA : the journal of the American Medical Association 1999;282:1934–1941. Retrieved December 2, 2002, from the World Wide Web. Available: http://www.jama.ama-assn.org/issues/v282n20/ffull/ htlm 10. Saini J, Kuczynski E, Gretz III HF, Sills ES, Supracervical hysterectomy versus total abdominal hysterectomy: perceived effects on sexual function. BMC Women’s Health 2002;2:1. Retrieved October 2, 2003, from the World Wide Web. Available: http://www.biomedcentral.com/1472–6874/2/1 11. Gath D, Cooper P, Bond A, Edmonds A. Demographic psyciatric and physical factors in relation to psyciatric outcome. British Journal of Psychiatry 1982;140:343–350. 12. Buss AH, Durkee A. An inventory for assessing different kinds of hostility. Journal of Consulting Psychology 1957;21:343– 349. 13. Harris W. Complications of hysterectomy. Clinical Obstetrics & Gynecology 1997;40(4):928–938. 14. Lambden MP, Bellamy G, Ogburn-Russell L, Preece CK, Moore S, Pepin T, Croop J, Culbert G. Women’s sense of well-being before and after hysterectomy. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1997;26(5):540–548.

204

S.B.M. Ewalds-Kvist et al.

15. Kjerulff KH, Langenberg PW, Rhodes JC, Guzinski GM, Stolley PD. Effectiveness of hysterectomy. Obstetrics & Gynecology 2000;95:319–326. 16. Lalinec-Michaud M, Engelsmann F, Marino J. Depression after hysterectomy: A comparative study. Psychosomatics 1988;29:307–314. 17. Virtanen HS. Sequelae of operations related to uterine removal. Turku: Annales Universitatis Turkuensis, Ser. D, Tom. 168; 1994. pp 1–67. 18. Virtanen H, Ma¨kinen J, Tenho P, Kiiholma P, Pitka¨nen Y, Hirvonen T, Effects of abdominal hysterectomy on urinary and sexual symptoms. British Journal of Urology 1993;72:868–872. 19. Roovers JP, van der Bom JG, van der Vaart CH, Heintz AP, Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. British Medical Journal 2003;327(7418):774. Retrieved February 26, 2004, from the World Wide Web. Available: http://gateway1.ovid.com/ovidweb.cgi 20. Bernstein SJ, Fiske ME, McGlynn EA, Gifford DS. Hysterectomy. A review of the literature on indications, effectiveness and risks. Southern California Health Policy Research Consortium. RAND, R-592/2, 1998:4966. Retrieved April 2003 from the World Wide Web. Available: http://www.rand.org/ publications/MR/MR592.2/MR592.ch4.pdf. 21. Tsoh JMY, Leung HCM, Ungvari GS, Lee DTS. Brief acute Psychosis Following hysterectomy in etnopsychiatric context. Singapore Medical Journal 2000;41:359–362. 22. Chynoweth R, Abrahams MJ. Psychological complications of hysterectomy. Australian and New Zealand Journal of Obstetrics & Gynaecology 1977;17:40–44. 23. Drellich MG, Bieber I. The psychological importance of the uterus and its functions. The Journal of Nervous and Mental Disease 1958;126:322–336. 24. Ewalds-Kvist SBM, Rantala M, Nikkanen, V, Selander RK, Lertola K. The response of the Finnish man to vasectomy. Psychology and Health Medicine 2003;8:355–369. 25. Kanto, J. Fear and tension related to anesthesia and surgery. Finland Medical Journal 1996;51:104. 26. Luoto R. Hysterectomy in Finland. Occurrence, indications, and association with cardiovascular morbidity. NAWH, 1995, Research Reports 49.

27. Mattlar C-E, Raitasalo R, Putkonen A-R, Hyyppa¨ M-T, Englund Ch, Helenius H. The association with depression with various functions in the Finnish population. Presented at the XI European Conference of the International Neuropsychological Society, July 1988;Lahti, Finland. 28. Rauramo L, Lagerspetz K, Engblom P, Punnonen R. The effect of castration and per oral estrogen therapy on some psychological functions. Acta Obstetrica et Gynecologica Scandinavica Suppl. 1975;51:3–15. 29. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry 1961;4:561–571. 30. Taylor JA. A personality scale of manifest anxiety. Journal of Abnormal and Social Psychology 1953;48:285–290. 31. Marke S, Gottfries I. Measurement of masculinity-femininity. Psychology Research Bulletin 1967;7:1–51. 32. Chiriac, J. Symbol and Symbolism with Freud and Jung. Retrieved April 24, 2003, from the World Wide Web. Available: http://www.freudfile.org/psychoanalysis/symbolism. htlm 33. Nadelson CC, Notman MT, Ellis EA. Psychosomatic aspects of obstetrics and gynecology. Obstetrics & Gynecology 1983;24:871–884. 34. Kew D. Psychological stress. Retrieved April 24, 2003, from the World Wide Web. Available: http://www.derek-kew.co.uk/ psychologicalstress.htlm 35. Holmes TH, Rahe RH. The social readjustment scale. Journal of Psychosomatic Research 1967;11:213–218. 36. Pediani R.World Wide Wounds. What has pain relief to do with acute surgical wound healing? 2001. Retrieved May 4, 2003, from the World Wide Web. Available: http:// www.wolrdwidewounds.com/2001/march/Pediani/pain-reliefsurgical-wounds.htlm 37. Barker MG. Psychiatric illness after hysterectomy. British Medical Journal 1968;2:91–95. 38. Deutsch H. The psychology of women. A psychoanalytic interpretation. Motherhood. Vol. 2. New York: Grune & Stratton; 1945. pp 457–491. 39. Kilkku P. Abdominal hysterectomy versus supravaginal uterine amputation. Medical Faculty of the University of Turku, Dissertation, Turku; 1982. pp 1–30.

Current knowledge on this subject From intensively having been studied hysterectomy aftermath: depression and anxiety somatic pains and sexual malfunctioning, researchers address beneficial effects of the removal of an unhealthy uterus implying a decrease in psychopathology. Further, improved sexual functioning in terms of a decrease in dyspareunia and enhanced sexual arousal has been indicated in some women undergoing hysterectomy for benign conditions. What this study adds Hostility by means of the Buss-Durkee Hostility Inventory was assessed for the first time in relation to hysterectomy. Pre- and post-surgery hostility was related to poor sexual gratification. A small group of married nulliparae was found to be at risk for post-hysterectomy depression. In general married women reported impaired quality of sexual relationship. Although highdysphoric women experienced decreased dyspareunia they also reported a decrease in the frequency of coitus. Good partner support and excellent knowledge about the reproductive organs counteracted hysterectomy aftermath.

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