{"paper_id":"4a4a110c-1981-4d82-ab5b-aa6eef5abf05","body_text":"1 \n \n \nAN EVALUATION OF RECOVERY AFTER \nHYSTERECTOMY \n \n \n \n \nBY \nDR MANJEET SHEHMAR \n \n \n \n \nA thesis submitted to the University of Birmingham for the \nDEGREE OF MD \n \n \n \n \nInstitute of Metabolism and Systems Research \nUniversity of Birmingham \nAugust 2016 \n \n  \n\n \n \n \n \n \n \n \n \n \nUniversity of Birmingham Research Archive \n \ne-theses repository \n \n \nThis unpublished thesis/dissertation is copyright of the author and/or third \nparties. The intellectual property rights of the author or third parties in respect \nof this work are as defined by The Copyright Designs and Patents Act 1988 or \nas modified by any successor legislation.   \n \nAny use made of information contained in this thesis/dissertation must be in \naccordance with that legislation and must be properly acknowledged.  Further \ndistribution or reproduction in any format is prohibited without the permission \nof the copyright holder.  \n \n \n \n\n2 \n \nAbstract \nBackground \nA hysterectomy for benign disease can be vaginal, abdominal or laparoscopic depending \non the incision used. The recovery from each type is traditionally believed to be different \nby health care professionals based principally on the incision used. We know that the \nbeliefs of health care professionals are an important determinant of recovery from surgery \n(2).It may be that differences in recovery from types of hysterectomy are due to different \nadvice from health care professionals prior to surgery, rather than the different incisions \nalone.  \nAims:  \nWhat are the beliefs and experiences of women who have a hysterectomy and the \npractices and beliefs of health care professionals? \nWhat is the evidence for psychological preparation for surgery? \nMethods \n1. To examine factors which might affect return to work after a hysterectomy. \nA quantitative retrospective structured questionnaire  \n2. To examine the beliefs and practices of health care professionals with respect \nto hysterectomy through the abdominal, vaginal and laparoscopic routes.  \nA quantitative retrospective structured questionnaire  \n3. To explore the expectations, beliefs and experiences of women who have a \nhysterectomy through the abdominal, vaginal and laparoscopic routes. \n\n3 \n \nQualitative semi -structured interviews  and validated quality of life \nquestionnaires, anxiety and specific disease related questionnaires at various time \npoints before and after hysterectomy.  \n4. To compare the literature on psychological interventions for surgical \nrecovery  \nSystematic review of literature. \n \nResults \nThere was no significant difference in return to work experience for women based on \ntype of employment and incapacity pay. There is a great deal of variation between the \nadvice given for recovery by UK gynaecologists and nurses at Birmingham Women’s \nhospital, particularly after 1 week post-surgery. Regardless of the route of surgery, the \nexpectations and fears of women are similar and that they rely on health care \nprofessionals to guide them with advice. Their experience confirmed conflicting advice \nfrom health care professionals and varied recovery experiences based on the individual \nrather than route of surgery. Women who had a vaginal hysterectomy had specific \nconcerns around sitting, the group who had a laparoscopic route had a lower length of \nstay and women who had an abdominal hysterectomy had higher anxiety scores (P \n0.003). Mean quality of life scores by EQ5 were not different based on route of surgery \n(pre-surgery P 0.4446, 1 week P 0.447, 4 weeks P 0.876,12 weeks P 0.850). Fewer \nwomen felt steady at 3 months after an abdominal hysterectomy than after a vaginal or \nlaparoscopic hysterectomy. The systematic review to compare psychological \ninterventions for recovery after gynaecological shows a reduced length of stay [P 0.03, \n\n4 \n \n5.65 (-10 82 to -0.48)] and reduced trait anxiety intervention [P <0.00001, mean \ndifference 7.78 (7.19, 10.61)] for women who have psychological interventions. The \ninterventions themselves were varied.  \n  \n\n5 \n \n \nDedication \n \nThis thesis is dedicated to my son Arran who grew up with my work, spent research days \nat home with me instead of the usual play dates and remains my motivation. To John who \nendured many years of work and to Duncan who has supported me to complete this work. \n \n  \n\n6 \n \nAcknowledgments \nI would like to acknowledge the contribution of my second supervisor at the time, Rachel \nPowell for her contribution to the outline and plan of literature search for the systematic \nreview in chapter 7. It was part of a larger registered and published Cochrane review \nprotocol.  \nDr Manjo Doug, Research Fellow UHB for the second reviewer on the systematic review \nchapter.  \nProf J.K. Gupta as my first supervisor. \n \n \n  \n\n7 \n \nContents  \n           Page \n \n \n \nList of tables          2 \n \nList of figures          5 \n \nList of appendices         10 \n \nChapter 1  Overview        11 \n     \n \nChapter 1b Methodologies       24 \n \nChapter 2  Return to work: a qualitative analysis.    33 \n \nChapter 3 Health care professionals’ beliefs and practices about recovery  52 \n after hysterectomy: A quantitative cross sectional study   \n. \n \nChapter 4  Experiences of women who have a hysterectomy: a qualitative 97  \ninterview study \n \nChapter 5 Validated health status questionnaires to women who   176 \nhave had a hysterectomy \n \nChapter 6 Anxiety and surgery: a validated survey to women who  242 \nhave had a hysterectomy \n \n \nChapter 7 A systematic review of psychological preparation    258 \nfor recovery after gynaecological surgery \n \nChapter 8 Discussion and conclusions      296 \n \nReferences          306 \n \nAppendices          316 \n \n\n8 \n \nList of tables         Page number \n \nChapter 2 \nTable 2.1  Return to work after hysterectomy for    49 \nheavy menstrual bleeding      \nTable 2.2 Mean time back to work according    50 \nto type of organisation      \nTable 2.3 Type of sick pay according to     50 \n  employment in public or private organisation    \nTable 2.4 Mean time back to work according to type   51 \n  of sick pay         \nTable 2.5 Mean time of return to work after hysterectomy   51 \nwith consultants        \nChapter 3 \nTable 3.1 Number of inpatient days gynaecologists would   63 \nroutinely advise after different types of hysterectomy    \nTable 3.2 Advice about number of weeks patients will need care  65 \nat home after different types of hysterectomy  \nTable 3.3 Advice after abdominal hysterectomy for    66 \nphysical recovery         \nTable 3.4 Advice after vaginal hysterectomy for physical   69 \n  recovery         \nTable 3.5 Advice after laparoscopic hysterectomy for physical  71 \n  recovery \n \n\n9 \n \nTable 3.6 How would you routinely counsel your patients  82 \n  regarding numbers of post-operative days stay in hospital?   \n      \nTable 3.7 How many weeks of care at home would you advise  84 \nTable 3.8 Number of weeks for advice after abdominal   86 \n  hysterectomy  for physical recovery       \nTable 3.9 Number of weeks for advice after vaginal hysterectomy 88 \n  physical recovery        \nTable 3.10 Number of weeks for advice after laparoscopic   90 \nhysterectomy physical recovery      \n   \nChapter 4 \nTable 4.1 Codes of analysis      106 \nChapter 5 \nTable 5.1 Participants       181 \nTable 5.2 Number of women who reported problems \n  in EQ5 at each time point     181 \nTable 5.3 Mean EQ5 scores at each time point    182 \nTable 5.4 ANOVA for mean EQ5 VAS scores according to   183 \n  route of hysterectomy and time point      \nTable 5.5 Total outcome scale scores     235 \nTable 5.6 Quality of life/satisfaction scale scores   236 \nTable 5.7 ANOVA of mean change in global evaluation \n  Of symptoms before and after surgery   237 \nTable 5.8 ANOVA for mean scores by route of surgery  237  \n       \n\n10 \n \nChapter 6 \nTable 6.1 Demographics       248 \nTable 6.2 Mean STAI scores at time points    249 \nTable 6.3 Significant ANOVA by question and route \n  of hysterectomy for STAIT anxiety    250 \nTable 6.4 Significant ANOVA by question and route of   252 \n  Hysterectomy for trait anxiety, 1 week post operation  \nTable 6.5 Significant ANOVA by question and route of   253 \nHysterectomy STAIT and TRAIT anxiety 3 months post operation  \n  \nChapter 7 \nTable 7.1 Characteristics of included studies    256 \n  \n\n11 \n \nList of figures         Page number \nChapter 1 \nFigure 1.1 Schematic difference between qualitative    29 \n  And quantitative research methodology \nChapter 2 \nFigure 2.1 Box plot of mean return to work time by     42 \n  operating consultant        \nFigure 2.2 Perception of return to work, actual mean time   44 \n  Of return to work and operating consultant    \nFigure 2.3 Patient perception of return to work and     46 \n  actual mean time of return       \nChapter 3 \nFigure 3.1 Regional distribution of responses     73 \nFigure 3.2 Proportion of gynaecologists who perform     74 \ntypes of hysterectomy        \nFigure 3.3 Regional variation in decision for route of hysterectomy  75 \nFigure 3.4 Experience level and decision for route of hysterectomy  76 \nFigure 3.5 Regional variations in offering a routine follow up   77 \n  appointment         \nFigure 3.6 Variations in follow up appointment and grade   78 \nFigure 3.7 Regional variations in reasons to offer routine follow   79 \n  up appointment        \nFigure 3.8 Variations in decision making for offering \n  A follow up appointment and experience in grade   80 \n \n\n12 \n \nChapter 5 \nFigure 5.1 SF12 1 pre-surgery       186 \nFigure 5.2 SF12 2 pre-surgery       187 \nFigure 5.3 SF12 3 pre-surgery       188 \nFigure 5.4 SF12 4 pre-surgery       189 \nFigure 5.5 SF12 5 pre-surgery       190 \nFigure 5.6 SF12 6 pre-surgery       191 \nFigure 5.7 SF12 7 pre-surgery       192 \nFigure 5.8 SF12 8 pre-surgery       193 \nFigure 5.9 SF12 9 pre-surgery       194 \nFigure 5.10 SF12 10 pre-surgery       195 \nFigure 5.11 SF12 11 pre-surgery       196 \nFigure 5.12 SF12 12 pre-surgery       197 \nFigure 5.13 SF12 1 at 1 week       198 \nFigure 5.14 SF12 2 at 1 week       199 \nFigure 5.15 SF12 3 at 1 week       200 \nFigure 5.16 SF12 4 at 1 week       201 \nFigure 5.17 SF12 5 at 1 week       202 \nFigure 5.18 SF12 6 at 1 week       203 \nFigure 5.19 SF12 7 at 1 week       204 \nFigure 5.20 SF12 8 at 1 week       205 \nFigure 5.21 SF12 9 at 1 week       206 \nFigure 5.22 SF12 10 at 1 week       207 \nFigure 5.23 SF12 11 at 1 week       208 \n \n\n13 \n \nChapter 5 \nFigure 5.24 SF12 12 at 1 week       209 \nFigure 5.25 SF12 1 at 2 months        210 \nFigure 5.26 SF12 2 at 2 months       211 \nFigure 5.27 SF12 3 at 2 months       212 \nFigure 5.28 SF12 4 at 2 months       213 \nFigure 5.29 SF12 5 at 2 months       214 \nFigure 5.30 SF12 6 at 2 months       215 \nFigure 5.31 SF12 7 at 2 months       216 \nFigure 5.32 SF12 8 at 2 months       217 \nFigure 5.33 SF12 9 at 2 months       218 \nFigure 5.34 SF12 10 at 2 months       219 \nFigure 5.35 SF12 11 at 2 months       220 \nFigure 5.36 SF12 12 at 2 months       221 \nFigure 5.37 SF12 1 at 3 months       222 \nFigure 5.38 SF12 2 at 3 months       223 \nFigure 5.39 SF12 3 at 3 months       224 \nFigure 5.40 SF12 4 at 3 months       225 \nFigure 5.41 SF12 5 at 3 months       226 \nFigure 5.42 SF12 6 at 3 months       227 \nFigure 5.43 SF12 7 at 3 months       228 \nFigure 5.44 SF12 8 at 3 months       229 \nFigure 5.45 SF12 9 at 3 months       230 \nFigure 5.46 SF12 10 at 3 months       231 \nFigure 5.47 SF12 11 at 3 months       232 \n\n14 \n \nFigure 4.48 SF12 10 at 3 months       233 \nChapter 7 \nFigure 7.1 Process from initial search to final inclusion for  \npsychological preparation in gynaecology surgery   270 \nFigure 7.2 Pain at 24 hours measured by visual analogue scale   277 \nFigure 7.3 Pain measured by morphine use in mg    278 \nFigure 7.4 Behavioural recovery: time to walking    279 \nFigure 7.5 Behavioural recovery: wellbeing day 1 post surgery   280 \nFigure 7.6 Behavioural recovery: fatigue day 1     281 \nFigure 7.7 Negative affect:  STAI Trait questionnaire    282 \nFigure 7.8 Negative affect: nausea and vomiting day 1    283 \nFigure 7.9 Length of stay        284 \nFigure 7.10  Risk of bias        285 \nFigure 7.11 Funnel plot pain VAS       286 \nFigure 7.12  Funnel plot morphine use (mg)     287 \nFigure 7.13 Funnel plot time to walking      288 \nFigure 7.14 Funnel plot wellbeing day 1      289 \nFigure 7.15 Funnel plot Nausea and vomiting     290 \nFigure 7.16 Funnel plot fatigue day 1      291 \nFigure 7.17 Funnel plot STAI trait       292 \nFigure 7.18 Funnel plot length of stay      293 \n \n   \n     \n\n15 \n \nList of Appendices       Page numbers \n \nAppendix 1 Sponsor authorisation      317 \nAppendix 2 Participants information sheet     318 \nReturn to work questionnaire \nAppendix 3 Return to work questionnaire     320 \nAppendix 4 Health care professional participant information sheet 324 \nAppendix 5 Invitation letter to health care professionals   326 \nAppendix 6 Questionnaire to UK Gynaecologists    327 \nAppendix 7 Questionnaires to General Practitioners   329 \nAppendix 8  Questionnaire to nursing staff     331 \nAppendix 9 Participant information sheet interviews   332 \nAppendix 10 Consent form Expectations & Experience    335 \n  Of Women who have had hysterectomy \nAppendix 11 Consent Form Recovery from hysterectomy   336  \nAppendix 12 Interview schedule pre-operation    337 \nAppendix 13 Interview schedule post operation    338 \nAppendix 14 SF12 Short form      340 \nAppendix 15 EQ 5 Questionnaire      343 \nAppendix 16 STAI questionnaire      344 \nAppendix 17 Menorrhagia Outcomes Questionnaire    348 \nAppendix 18 Systematic review data extraction form   352 \nAppendix 19 Ethics application      355 \nAppendix 20 Cochrane Protocol       398 \n\n16 \n \n \n \n \n \nChapter 1: Overview \n \nRecovery from surgery \n \nSurgery induces physiological and psychological stresses to the body which are known to \naffect organ function and recovery. Perioperative pathophysiology is multifactorial \ncontributing to postoperative morbidity, length of stay in hospital, and convalescen ce (1). \nThis thesis is the study of experiences of recovery from different routes of hysterectomy, \nthe beliefs of health care professionals around recovery from hysterectomy and the actual \nexperiences of patients who undergo a hysterectomy. \n \nHysterectomy \n \nHysterectomy is one of the most common gynaecological procedures performed in the \nnon-pregnant woman. It involves the removal of the womb (u terus) combined sometimes \nwith removal of the ovaries as well. It can be performed through an incision in the \nabdomen, vagina or by key hole surgery using a laparoscopic assisted method. The \nincision is often decided upon by the indication for the hysterec tomy, the surgical \nexpertise of the surgeon and their beliefs. Recovery from the various routes of \nhysterectomy is believed to be different anecdotally by health care professionals and \n\n17 \n \npatients, in order to understand why this may be the case, some underst anding of the \nanatomy of hysterectomy is useful. \n \n  \n\n18 \n \nAnatomy of a hysterectomy \n \nThe uterus is supported by the uterosacral ligaments and the transverse cervical ligaments \nat the level of the cervix. It is attached to the pelvic side walls by the round ligam ent and \novarian pedicle, which houses some of its blood supply from the ovarian vessels. The \nremainder of its blood supply is from the internal iliac vessels which enter via the broad \nligament either side in the form of the uterine vessels. Any type of hys terectomy involves \n1. ligating the blood supply at the ovarian and uterine vessels, 2. exposing the uterus by \nreflecting the bladder in the utero-vesical peritoneal fold with concurrent reflection of the \nureters and 3. Releasing the supports of the uterus at the round, utero -sacral and \ntransverse cervical ligaments. Regardless of the abdominal incision, the actual procedure \nfor the hysterectomy is the same for all types.  \n \nHysterectomy can be carried out via the abdominal, laparoscopic or vaginal routes. In  a \ntotal abdominal hysterectomy, the abdominal wall is opened which is believed to add to \nthe length of recovery and mobility of the patient afterwards . This is due to the fact that \nthe abdominal wall forms part of the core strength of the body which is un der strain \nduring any movement post -surgery. In a laparoscopic procedure, the abdominal incisions \nare small and do not disrupt the abdominal wall strength and function as much, leading to \nthe assumption that recovery is faster. In a vaginal hysterectomy, t here are no abdominal \nincisions, instead all incisions are in the vagina, and therefore is not under the same strain \nas the abdominal wall incisions, possibly leading to faster recovery. \n \n\n19 \n \nRecovery advice from hysterectomy \nTraditional recovery relies on adv ice given by health care professionals in the form of \nverbal and leaflets. Many units have a pre -operative service where patients are seen by \npre-operative nurses who spend time going through what to expect during recovery and \nhow to aid recovery. At BWH, the pre-operative service is run by specialist nurses who \nexplain the procedure around hysterectomy including practicalities of what to bring into \nhospital, how long to expect to stay, what to expect on the ward and what to expect \nduring recovery. This is supplemented by patient information leaflets which outline how \nto aid recovery for example by early mobilisation, rehydration and pain relief. The advice \nrelies on the experience of the nurse giving it, although it is structured around a guidance \nframework in a protocol. There are no agreed definitions of recovery time nor return to \nnormality. \nEnhancing recovery from surgery in general \n \nEnhancing recovery is a desirable outcome for patients and the health system leading to a \nnumber of studies to how to impr ove recovery. There is already evidence that a formal \nenhanced recovery (ER) programme (or ‘fast track’) for surgery improves recovery and \nreduces hospital stay. ER is now a recognised model of care advocated by the NHS \nInstitute for Innovation and Improvement (2) for the elective surgery pathway which aims \nto reduce the physiological and psychological stress responses d uring surgery to \nminimise organ dysfunction and aid faster recovery. The pathway was first described by \nKehlet in 1990 (3) in a Danish model for colorectal patients taking into account the \ndecision for surgery, surgical work up, anaesthetic, surgery post -operative care and \nadvice for the recovery period. In the UK, the ESTReP (Enhanced Surgical Treatment \n\n20 \n \nand Recovery Programm e) has transformed the way in which colorectal surgery is \ndelivered (4). The programme combines known clinical predictors of r ecovery (such as \nearly feeding after surgery, not using nasogastric tubes or surgical drains) with positive \npsychological factors such as patient education and health promotion. The ESTReP \nprogramme has led to a reduction in the average hospital stay from 9-10 days per patient \nto 6 days. The authors of the study conclude that this has helped to generate extra bed \nspace to treat more patients, and under the payment by results scheme, has generated \nmore income for their trusts as well as to help meet 18 -week targets They have shown \nthat the programme is cost efficient based on the daily cost on a general or surgical ward \nof £400, and have gaining support from the Department of Health.  \n \nFurther programmes have now been developed with a variety of components of  the ER \npathway. They have been compared in two meta -analyses, Varadhan et al’s review \nincluded 6 randomised controlled trials (RCTs) with a total of 452 patients (5). This \nreview found a significant reduction in length of hospital stay  (weighted mean difference \n[MD] -2.55, 95% CI -3.24 to -1.85) and complication rates (RR 0.53, 95% CI 0.44 -0.64) \nin the ER group if at least 4 individual elements of the pathway were implemented. The \nsecond meta -analyses by Gouvas et al looked at 11 studie s including 4 RCTS and 7 \ncontrolled clinical trials with a total of 1021 patients (6). It also found a significant \nreduction in hospital stay (weighted MD -2.47, CI -3.43—1.48) without an increase in re-\nadmission rates or mortality.  \n \n\n21 \n \nA Cochrane review of ER in gynaecological cancer (7) concluded that the re were no \nRCTs of ER in this context and The Enhanced Recovery Partnership Programme was set \nup as a partnership with the Department of Health, the National Cancer Action Team, \nNHS Improvement and the NHS Institute of Innovation and Improvement in 2009 -2011. \nThis initiative included studies in gynaecology, urology and musculo -skeletal surgery. \nThe ER pathway considers the pre-operative period which includes a risk assessment and \nopportunity to provide information and psychological preparation. The discharg e plan is \ncriteria based upon mobilisation, control of pain by oral analgesia, passing flatus and \nbeing able to eat and drink. In 2012, the the Enhanced Recovery After Surgery (ERAS) \nSociety, International Association for Surgical Metabolism and Nutrition (IASMEN) and \nEuropean Society for Clinical Nutrition and Metabolism (ESPEN)  published guidelines \nfor peri-operative care in colonic surgery (8) It is recommended that patients should be \ngiven Preadmission information, education and counselling  regarding practical advice to \naid recovery, diminish fear and anxiety and expected length of time until they return to \nnormal function. When a Cochrane review did not recommend the ERAS programme as \nthe new st andard of care due to the lack of published trials, a meta -analysis of 16 trials \nand 2376 patients was published confirming a reduction in length of stay and morbidity \nrates without an increase in readmission rates.  \nRecovery from gynaecological surgery \n \nIn 2016, Lena Wijk (11) published how enhanced recovery from gynaecology oncology \ncould be applied to benign gynaecology . Further studies looked at enhanced recovery \n\n22 \n \nafter ovarian cancer surgery with early feeding improvi ng bowel function and nutritional \nstatus (12). \nDespite these recommendations in other surgical specialities and an opinion paper from \nthe Royal College of Obstetricians and Gynaecologists UK (RCOG) there is no agreed \nnational evidence based guideline for enhanced recovery in benign gynaecology surgery, \nand in particular around long term recovery to normal function (9) (10). NICE have \npublished guidance in a 24 hour discharge programme after Caesarean Section. There are \na number of published local enhanced recovery programmes after Caesarean (13)  and the \nScottish Government guidelines (14)which publish an increase in 24 hour discharge using \ntheir programme from 5% to 33% . \nSteps for Enhanced recovery (ER) \nTraditionally ER has a number of components: \n1. Pre-operative education \n2. Carbohydrate drinks \n3. Fluid balance and warming \n4. Early feeding \n5. Removing tubes early \n6. Early mobilisation \n \nThis thesis considers the first step of pre -operative education, including whether better \ninformation and counselling with psychological preparation could alter behaviour to \nimprove recovery from hysterectomy in the long term beyond the traditional boundaries \nof ER which is discharge from hospital . Enhanced recovery programmes have been \n\n23 \n \nestablished and  shown to reduce length of stay and morbidity for benign gynaecology \nprocedures (15).  A Cochrane review of approaches to hysterectomy (16) found a shorter \nhospital stay in women who have had a vaginal rather than a laparoscopic assisted or \nabdominal hysterectomy and the National Institu te for Clinical Excellence (NICE) has \nrecommended a vaginal approach as first line (17). Regardless of this,  in the real life \npragmatic situation, hospital st atistics report that women who have undergone a vaginal \nhysterectomy, with no abdominal incisions,  have an average post -operative stay of 3.2 \ndays in England, which is longer than the laparoscopic approach and not much different \nto the stay after the abdo minal route (HES Statistics 2012 (18)) and NHS Choices advise \nbetween 1 and 4 days for a laparoscopic or vaginal hysterectomy and 5 days  for an \nabdominal hysterectomy (19).  \n \nThis may indicate that in strictly controlled experimental designs clinicians are \npotentially achieving optimum care efficiency through their beliefs about therapy and \nthrough the inadvertent physiological and psychological preparation of all patients. Thi s \ncould be in the form of stringent trial inclusion and consent procedures with increased \naccess to support mechanisms and follow up. It may be that patients’ and health care \nprofessionals’ beliefs and expectations of recovery play a more significant part in what \nactually occurs outside clinical trial settings. Aspects of this could be amenable to \npsychological intervention to improve recovery outcomes.       \n \nER programmes consider psychological interventions by involving the patient at every \nstep of their surgery from planning to recovery to provide women with all the information \n\n24 \n \nand support they require regarding treatment options, the surgery, recovery and \ndischarge.  \n \nPsychological preparation \nPsychological preparation incorporates a range of strategies  designed to influence how a \nperson feels, thinks or acts (emotions, cognitions or behaviours). The benefits of \npsychological preparation for surgery have been evaluated in a meta -analysis. It \nidentified many different types of psychological preparation, i ncluding procedural \ninformation, sensation information, behavioural instruction, hypnotic and relaxation \ntraining, psychotherapeutic interventions and cognitive behavioural approaches. They \nwere found to be beneficial for a range of outcome variables such as negative affect, pain, \nand pain medication, length of hospital stay, behavioural recovery, clinical recovery, \nphysiological indices and satisfaction. Psychological interventions consider people’s \ncognition, beliefs of control, empowerment and self -efficacy and the behaviours they \nassociate with them. \n \nControl \nThe locus of control is a psychological term referring to the extent to which individuals \nbelieve they control events that affect them. People can have a perceived internal or \nexternal locus of control.  People with external locus of control will believe s trongly in \nother people, fate and in their destiny, whereas someone with a strong internal locus of \ncontrol will believe that they have the ability to influence their own future. Information \nseeking is more common in people who have an internal locus of co ntrol. They benefit \n\n25 \n \nfrom knowing more information and are able to reduce their anxiety levels about \nforthcoming surgery, whereas the same information may increase the anxiety levels of \nsomeone with an external locus of control as they may rather not know the details (20). A \nshorter time interval to achieving a straight leg raise was found with patients who had an \ninternal locus of control after total knee surgery (21). The effect of psychological \npreparation before surgery is questionable on patients with an external health locus of \ncontrol (22). A consideration of the individual’s locus of control can be made through \noffering a choice of information to reduce anxiety and to increase their ability to cope \n(23).  \n \nCoping strategies \n \nThe patient’s coping tendency has also been studied in relation to the information patients \nneed. People can cope with situations through mainly problem focused strategies or \nemotional focused strategies. Those who use problem focused strategies make plans to \nimprove the situation and feel better when these are followed through. Emotio nal focused \nindividuals tend to alter their own cognitive interpretation of the situation rather than \nchange it, for example, ‘looking at the bright side’  (24). It may be that there is a \ncontinuum of control and coping strategies, which may also be influenced by the situation \nof undergoing surgery and by the feeling of conforming to social bias (assuming the sick \nrole of being a patient). Research is needed into whether psychological support is mor e \neffective if matched with coping styles. \n \n\n26 \n \nEmpowerment and self-efficacy \n \nIn the past, patient education followed the traditional disease based model, where the \nprovider was the expert who decided what information and how much of it the patient \nshould receive. The provider becomes the primary decision maker and problem solver. \nOutcomes of this model are the patient’s compliance with the provider’s suggestion. In an \nempowerment model, health providers assist patients in gaining knowledge, developing \nskills and identifying resources.  Empowerment enables others to take control of their \nown lives. This model recognises the psychosocial as well as the physical aspects of \nhealth and disease. Empowerment and self -efficacy are closely related constructs. Self -\nefficacy is the belief that you can effectively perform a given behaviour to produce the \ndesired outcome (24). Motivation and perseverance is dependent on the individual’s \nevaluation of their self -efficacy. If the individual does not believe they can perform \nbehaviour, their motivation will decrease. \n \nUsing psychological interventions to improve the quality of post-operative recovery. \n \nAlthough psychological interventions have been shown to improve outcomes, it would be \nimportant to establish which interventions improve which outcome. There is much \nheterogeneity among studies in their definition of a favourable recovery outcome, and \nwhat a favourable outcome might be to clinicians and patients. Recovery has many \ncomponents including measurable clinical aspects such as vital observations, norm alising \nof test parameters, the use of analgesia, return of physiological function such as passing \n\n27 \n \nurine or opening their bowels, number of days as an inpatient and mobility. Clinical \ninterventions need to be evaluated for quality as well as importance and  value to patients.  \nFrom the perspective of the patient, a favourable outcome may be more related to \nimportant aspects of their lives such as being able to sleep normally, looking after their \nfamilies, socialising, feeling emotionally back to normal or be ing able to go back to \nwork. In the past, patient education followed the traditional disease based model, where \nthe provider was the expert who decided what information and how much of it the patient \nshould receive. The provider becomes the primary decisio n maker and problem solver. \nOutcomes of this model are the patient’s compliance with the provider’s suggestion. In an \nempowerment model, health providers assist patients in gaining knowledge, developing \nskills and identifying resources.  Empowerment enable s patients to take control of their \nown lives. This model recognises the psychosocial as well as the physical aspects of \nhealth and disease. Empowerment and self -efficacy (the belief in one’s ability to succeed \nor accomplish a task) are closely related con structs which can affect behaviour . \nPsychological interventions which increase empowerment and self-efficacy could be a \ncost effective way of improving those aspects of recovery which the patients value as \nwell as traditional clinical measures. More resear ch is needed into which psychological \ninterventions improve which recovery outcomes. Through qualitative in-depth analysis of \npatient’s views and experiences, we can understand their recovery and which outcomes \nare valued by them, and how they perceive their experiences to influence recovery.  \n \nPsychological preparation has been shown to be an important factor in the patient’s \nsurgical experience. These can be affected by the beliefs of health care providers in the \n\n28 \n \nway t hey counsel and advise their patients  (25).  With an increasing drive towards a \nshorter length of stay in all specialities, efficient patient preparation is an important area.  \nIn the example of the route taken for hysterectomy, operativ e incision itself does not \nseem to account for the differences in recovery and the discrepancy between the everyday \nclinical situation and that of clinical trials. Psychological variables in the patient which \nare influenced by the beliefs and practices of health care professionals could play a part \nin accounting for these differences. The rigorous consent procedures in clinical trials and \nthe participant support facilities through access to health care professionals and \nresearchers as well as activities such as newsletters will have psychological consequences \non the patients involved, regardless of which treatment arm they are in. This could \naccount for the better outcomes seen in trials. Recovery outcomes could be improved in \nreal life situations through th e use of psychological interventions aimed at recovery \noutcomes which are valued by patients in particular, the use of well -designed information \ngiving, cognitive therapy and emotion focussed therapy to match those seen in clinical \ntrials.  \nResearch Aims: \n \n1. To examine factors which might affect return to work after a hysterectomy  from \nheavy menstrual bleeding. \n2. To examine the beliefs and practices of health care professionals with respect to \nhysterectomy through the abdominal, vaginal and laparoscopic routes.  \n3. To explore the expectations, beliefs and experiences of women who have a \nhysterectomy through the abdominal, vaginal and laparoscopic routes. \n\n29 \n \n4. To search the literature in a systematic way for psychological interventions which \nmay influence recovery after hysterectomy. \n \nThis thesis presents in each chapter, the background to each research aim, the study and \nfindings with a discussion and conclusion of each. It will then consider how each of these \nstudies has contributed to the overall understanding of recov ery from hysterectomy for \nheavy menstrual bleeding using the different surgical routes and the implications for \npatients, future research and clinical practice.  \n  \n\n30 \n \n \nChapter 1b \nMethodologies  \n \nMethodologies chosen for this study by research aims: \n \n5. To examine factors which might affect return to work after a hysterectomy. \n \nA quantitative retrospective structured questionnaire was chosen to answer these \nquestions which included closed questioning for demographic data and outcome \nmeasures. \n \n6. To examine the beliefs and practices of health care professionals with respect \nto hysterectomy through the abdominal, vaginal and laparoscopic routes.  \n \nA quantitative retrospective structured questionnaire was chosen to answer these \nquestions which included closed ques tioning for demographic data and outcome \nmeasures. \n \n \n \n \n\n31 \n \n7. To explore the expectations, beliefs and experiences of women who have a \nhysterectomy through the abdominal, vaginal and laparoscopic routes. \n \nThis part of the study included qualitative semi -structured interviews which \ncovered the expectations, beliefs and experiences of women as well as \nconsidering physical emotional, social and sexual aspects of recovery. The \ninterviews were carried out before and after the hysterectomy with each woman. \n \nIt also used validated quality of life questionnaires, anxiety and specific disease \nrelated questionnaires at various time points before and after hysterectomy, \nanalysed in a quantitative method.  \n \n8. To compare the literature on psychological interventions f or surgical \nrecovery  \nUsing systematic review of literature. \n \n \n \n  \n\n32 \n \nBackground on qualitative research methodology \n \nAs a health care professional, I am trained and familiar with the methodology of \nquantitative research and systematic review, however, I have limited experience of the \nbasis and methodology of qualitative research, and hence I feel I need to explore this \ntopic in this part of the introduction.  \n \nQualitative research aims to answer questions of ‘why and how’ through in depth \nexploration and under standing of human behaviour. Shank (26) defines qualitative \nresearch as “a form of systematic empirical inquiry into meaning”. By systematic he \nmeans “planned, ordered and pub lic”; following established methodologies. Denzin and \nLincoln  (27) suggest that qualitative research involves an interpretive and naturalistic  \napproach: “This means that qualitative researchers study things in their natural settings, \nattempting to make sense of, or to interpret, phenomena in terms of the meanings people \nbring to them”. In order to study in the naturalist setting, the researcher needs to enter that \nsetting. In this way, qualitative research is different from quantitative research, where the \nresearcher attempts to study a phenomenon from a position outside the research setting so \nthat the researcher does not bring any effect such as bias to the setting (figure 1). \n \nQualitative research has a wide range of approaches and methodologies such as grounded \ntheory, phenomenology, ethnography, narrative research and case study, but they \ndescribe all types having a focus on natural settings, an interest in meanings, perspectives \nand understandings, an emphasis on the process and involve inducing meaning (28). For \n\n33 \n \nexample, quantitative research may look at demographics such as socio -economic \nbackground and the prevalence of smoking, but qualitative research would explore what \ninfluences certain groups to smoke. \n \nIn qualitative research few assumptions as possible are made beforehand and it is about \ngenerating possible hypotheses, unlike quantitative research which starts with a \nhypothesis to test. An example is inductive methodology generally seeking to generate or \ninduce a theory from the data, theory is then said to be ‘grounded’ in that data as in \ngrounded theory  (29).Qualitative research places importance on situations whic h \ninfluence behaviour, and the context in which the behaviour is being studied, with \nvarious layers of study and interpretation which can be lengthy to discover deeper \nmeaning that participants attach to behaviour, how they interpret situations and their \nperspectives. For example, a study by Measor and Woods  (30) to attempt to understand \nhow to  dissolve gender boundaries at a secondary school by introducing a common  \ncurriculum found that boys used cakes as weapons and sewing machines as trains, while \ngirls complained about nasty smells and unisex goggles in physical science. It was by \nobserving the behaviours of the girls and boys in the natural setting of the classr ooms \nwhereby the researcher was able to explore what happened and the meaning each gender \ngave to the subjects on the curriculum; gaining an understanding of the barriers which \nmay be experienced in dissolving gender boundaries. In order to gain deeper mea ning, \nthe researcher needs to gain a certain rapport with the subjects, and needs to consider \ntheir own influence on the subjects’ behaviour. Researchers should also consider the \n\n34 \n \neffects of time and sample across time as the same activity or item could mea n different \nthings at different times (28).  \n \nQualitative research is sometimes criticised for not being generalizable although there are \nexamples of where it has been used and debated to determine health care and educational \npolicy (31). For example, Hargreaves (1967) and Lacey (1970) used mainly qualitative \nmethods to study a secondary modern and grammar school respectively and the data they \ngathered generated the  theory of differentiation and polarisation, used in educational \npolicy. They suggested that where pupils were differentiated by ability, then a \npolarisation of attitudes into pro - and anti -school would occur among them. Some \nqualitative research does not aim to produce a theory but to understand the quality of \nsocial life, including the emotions and complex social interactions which accompany it. \n \n  \n\n35 \n \nFigure 1: Schematic difference between qualitative and quantitative research \nmethodology. \n \n \n \n  \nNatural setting \n \n \nPhenomenon \nResearcher \nPhenomenon \n Researcher \nResearch setting \n \nQualitative research \n \nQuantitative research \n \n\n36 \n \nMethods of qualitative research \n \n \nMany methods are used in qualitative research such as observation, diaries, interviews \nand documentary analysis (32, 33). \n \nIn observation, the researcher aims to be an unobtrusive observer to the natural situation \nwhere the researcher adopts a role in th e natural setting, such as a member in a group, or \na non-participant observer where the researcher watches the natural situation and tries not \nto disturb the scene, such as in ethnography (34, 35) .  \n \nInterviews can be formal or more casual conversations to explore the participant and their \nresponses (33, 36, 37). The best format in order to minimise the effect of the researcher is \nthe unstructured interview where the researcher has some general ideas or topics but the \nflow of the interview is dictated by the subject in the  natural course of discussion. The \nresearcher tries to appear to be natural rather than someone with the role of research and \nattention is paid to where the interview happens, the seating arrangements, how the \ninterviewer dresses and the manner of approach  in order to keep the setting as natural as \npossible. The researcher is careful not to appear to be leading along the topic areas, but \nuses skills and techniques to explore clarity and depth to allow the participant to lead the \ninterview in a non -structured way in order to explore where the participant wants to take \nthe conversation. A disadvantage of the unstructured interview is that it may not cover all \naspects which the researcher is interested in (33). \n\n37 \n \n \nA structured interview is useful when the study is more focussed where the researcher \ndecides the structure of the interview with pre-determined broad topic questions requiring \nan in depth response from the participant. Semi -structured interviews use some structure \nbut questions which have scope for open -ended answers. Semi -structured interviews are \nuseful to compare responses to themes from different participants or groups (33, 37). \n \nWhen qualitative research is compared to quantitative research, it is sometimes criticised \nas lacking vigour in validity, interpretation and bias by the researcher and not being \nreproducible or generalizable to other situations (38). There are techniques which need to \nbe considered in order to increase the validity of qualitative research (39), i.e. to ensure \nthat the interpretation of find ings is real by recognising the researcher’s impact on the \nparticipant and the natural situation. Such techniques include respondent validation and \ntriangulation. Respondent validation is a technique where the interpretation of findings is \ngiven to the par ticipants to judge whether it is an accurate understanding and portrayal \nafter the study is complete (40). Method triangulation uses multiple methods to study an \nissue to increase accuracy and depth, such as combining  structured interviews with \nobservation or questionnaires. Time triangulation studies the issue at different time \npoints, for example before during and after the event. Triangulation of persons might \ninvolve consulting with a range of people involved in th e issue who may have differing \nroles where their accounts can then be studied to look for differences. In this study, \nvalidity will be attempted using triangulation of method by using semi - structured \n\n38 \n \ninterviews and validated questionnaires, time by interv iewing at different time points and \nperson by interviewing a number of women in the three groups of route of hysterectomy. \n \n \n  \n\n39 \n \nChapter 2 Return to work: a quantitative analysis. \n \nIntroduction  \nHeavy menstrual bleeding (HMB) is an important cause of ill health in women. Surgical \ntreatment of HMB often follows failed or ineffective medical therapy and the definitive \ntreatment is hysterectomy. This is a major surgical procedure with significant physical \nand emotional complications as well as economic cost. Resumption of work activities \nafter gynaecological surgery takes much longer than expected, irrespective of the surgical \ntechnique used and the severity of the surgery (41-44). Return to work is perceived by \npatients and increasingly by the health care industry as a highly important outcome and \nrecovery promotion ideas after surgery are not new. There is documented evidence that \nlong periods of sickness absence can result in detrimental personal consequences for the \nindividual in work disability, social exclusion, poorer general health, increased risk of \nmental health problems and higher mortality (45). An Individual’s personal consequence \nof delayed resumption of normal activities has an impact on the health service resulting in \nmore physician consultations, medical treatment and higher hospital admission rates. \nLonger absences are associated with a reduced probability of eventual return to work and \nsubsequent economic and social deprivation (45, 46).  Sickness absence is a major public \nhealth and economic problem. In 2003, 176 million working days were lost through \nsickness absence, the cost of which to the economy is enormous. Each absent employee \ncost their employer £760 per year on average in 2010 through a combination of direct \ncosts in sick pay, lost output and provision of cover. Across the economy as a whole, the \n\n40 \n \ndirect costs alone amount to more than £17bn a year and after non-work related injury \npost-operative recovery time is the second most common cause of absence (47).  \n \nInterventions aimed at reducing the post-operative recovery time to resumption of normal \nactivities have a huge potential benefit to individual patients, the health service, Society \nand the economy. Return to work is a complex concept, influenced not only by the type \nof surgical procedure but also by a multitude of other variables such as age, education \nlevel, income level and type of occupation (23;25) as well as the attitudes and advice \ngiven by health care practitioners (25;26). There are reports of immediate ambulation \nafter herniorrhaphy to aid recovery since the 1960’s (30) and many since such as studies \nto investigate return to work rates and factors that influence it in patients undergoing \nsurgical procedures like inguinal hernia repair, coronary artery bypass graft and renal \ntransplant (22-24). There is now evidence that a formal enhanced recovery programme \nfor surgery improves recovery and reduces hospital stay (18) and the ESTReP (Enhanced \nSurgical Treatment and Recovery Programme) has transformed the way in which \ncolorectal surgery is delivered in the UK (4). Their programme combines known clinical \npredictors of recovery (such as early feeding after surgery, not using nasogastric tubes or \nsurgical drains) with positive psychological factors such as patient education and health \npromotion. The ESTReP programme has led to a reduction in the average hospital stay \nfrom 9-10 days per patient to 6 days. The authors of the study conclude that this has \nhelped to generate extra bed space to treat more patients, and under the payment by \nresults scheme, has generated more income for their NHS Trusts as well as to help meet \n18-week targets (19). They have shown that the programme is cost efficient based on the \ndaily cost on a general or surgical ward of £400, and have gained support from the \n\n41 \n \nDepartment of Health. The ENHANCE surgery programme is now a national initiative \nfrom the NHS Institute of Innovation and Improvement and focuses on patients playing \nan active role in their recovery (8).  \nImproving post-operative recovery after a hysterectomy is important to the NHS as it is \none of the commonest surgical gynaecological procedures performed; around 40,000 are \ncarried out in the NHS every year (37). Most of these are done on women of working age \nbetween 40-50 years (37).  Therefore the disease burden on the NHS is high, as is the \ncost to the economy and society during the post-operative convalescence period.  \n \nThis study is to identify the baseline return to normal data for women who have had a \nhysterectomy in our local population at Birmingham Women’s Hospital, and to find any \nfactors which may have influenced their return to work.  \n \n \nAims \nThis study aimed to establish the baseline data for time of return to work after a \nhysterectomy and to find any variables such as type of employment and operating \nconsultant which may affect return to work rates following a hysterectomy in our local \npopulation at Birmingham Women’s Hospital. In particular, data for women who had a \nhysterectomy for heavy menstrual bleeding was studied. This questionnaire only looked \nat return to work, not return to normality. \n \n \n\n42 \n \n \nObjectives \nPrimary research question:For women who have had a hysterectomy for heavy \nmenstrual bleeding, how is time of return to work affected by: \n Type of employment organisation (public or private) \n Type of sick pay (usual, reduced, statutory sick pay, incapacity benefit, none) \n Employment status (full, part time or self-employed) \nResponsible consultantSecondary research questions \n How is time of return to work related to the patient’s perception of whether they \nreturned at the right time, too early or too late?  \n \n Is the patient’s perception of their time of return to work influenced by the \nconsultant who operated on them? \n \nMethods \nDesign \nEthical approval (appendix 1) was gained and a patient information leaflet was sent to all \nparticipants (appendix 2). A retrospective structured questionnaire study (appendix 3) \nwhich was developed using the standard Department of Work and Pensions questions and \nvariables for sickness pay and employment status. In particular, we were interested to see \nif there was an association with whether there was further loss of income if women were \nself-employed or if they did not have any sickness pay cover. The questionnaire was \npiloted on 3 women in a benign gynaecology clinic waiting room to ensure construct \n\n43 \n \nvalidity. There were no standard questionnaires known of which we could utilise to \nanswer the research questions for this section.  \n \nStudy sample \nThis was a study of women who had a hysterectomy at the Birmingham Women’s \nHospital over a 12 month period from January 2008-2009. A total of 150 women were \nidentified as having had a hysterectomy using clinical coding systems during this time \nperiod for total abdominal hysterectomy, vaginal hysterectomy, laparoscopic assisted \nhysterectomy and subtotal hysterectomy.  The participant information letter (appendix 2), \nand questionnaire (appendix 3) was posted to the home addresses of all women along \nwith an invitation letter (appendix 3). Responses were then stratified and analysed for \nwomen who had a hysterectomy for heavy menstrual bleeding in order to reduce \nconfounders in recovery such as carcinoma; which is known to have more prolonged \nrecovery due to the disease process. Other benign conditions such as endometriosis may \nhave differences in recovery as well associated with the increased pain and surgical \ncomplexity associated with the disease per se. \n \nProcedure \nThe questionnaire was mailed to women at their home address which was identified from \nhospital databases. A stamped addressed envelope was included for return post. A \nreminder letter and questionnaire was sent around 3 weeks later.  \n \n \n\n44 \n \nAnalysis \nData from completed questionnaires was analysed using IMB SPSS v16 © by MS.Data \nwas analysed by descriptive statistics of frequency and means. Data distributions were \nvisually examined for normality using histograms. Scatter plots were drawn to explore  \npatterns between time of return to work and type of incapacity benefit, type of \nemployment contract, public or private sector employment and consultant gynaecologist \nunder whose care the surgery was performed. Differences in mean time back to work \nwith the type of employing organisation (private or public) were tested using an \nindependent-samples T-Test. The relationships between time of return to work and \nemployment status (full, part time or self-employed) and type of sick pay were explored \nby analysis of variance (ANOVA). If significant differences were found between groups, \npost hoc testing and tests of multiple comparison were performed. \n \nEthical considerations \nEthical approval was gained from Black Country Research Ethics committee \n(09/H1202/66) (Appendix 17) and sponsorship from UoB (Appendix 1). \n \nResults \nA response rate of 53% was achieved (80/150).  Of the respondents, 15 women did work \nand only 1 did not return to work after her hysterectomy (table 2.1). Of the women who \ndid work, 16 women worked in a private organisation (11 full time, 3 part time, 2 self-\nemployed) and 40 worked in a public organisation (21 full time, 19 part time). During \ntheir convalescence, the total number of women who received incapacity benefit as their \nmain source of income was 2, statutory sick pay (SSP) was 12, a reduced income from \n\n45 \n \ntheir employer was 3 and their usual pay was 35. One woman did not receive any income \nand 2 women did not answer this question.  \n \nResults for data on women who had a hysterectomy for heavy menstrual bleeding \n(Table 2.1) \nData was split to include only those women who had a hysterectomy for heavy menstrual \nbleeding. There were a total of 63 women in this group of whom 55 returned to work. Of \nthose who did not return to work, 1 woman had retired, 3 who were unemployed and 4 \nwho did not answer this question. Women in this group were in full time employment in \n42.5% of cases, part time in 24% and self-employed in 1.5%. The mean time for return to \nnormality was 11.6 weeks (SD 4.84, table 2.1). Most of these women felt that they had \nreturned to work at the right time (49%) with 15% feeling they had returned too early and \nonly 1.8% feeling they could have returned earlier than they did. For this group of \nwomen, 43% received their usual pay while they were on sick leave, 16% received \nstatutory sick pay only, 4% received reduced pay from their employer, and 1.8% received \nincapacity benefit.  \n \ni) Return to work and organisation type \nTable 2.2 shows the mean time of return to work according to whether the patient worked \nfor a private (n=16) or public (n=40) organisation. An ANOVA did not show a \nsignificant difference between mean time of return to work and public organisation and \nprivate organisation F 0.165 p= 0.686. \n \n\n46 \n \nii) Return to work and type of sick pay \nMost women received their usual pay during their recovery, but a lower proportion of \nwomen received any category of sick pay if they worked for a private organisation (table \n2.3).  An ANOVA was conducted to explore the impact of type of sick pay received on \nwhen patients returned to work (RTW) after a hysterectomy measured in weeks. Type of \nsick pay was categorised as usual pay, reduced pay, statutory sick pay (SSP), incapacity \nbenefit and no pay (table 2.4). There was no statistically significant difference at the \np<0.05 level in the RTW time for the type of sick pay. F (2 50) = 0.187, P=0.48. \n \niii) Return to work and employment status \nAn ANOVA was conducted to explore the impact of employment status on when patients \nreturned to work (RTW) after a hysterectomy, measured in weeks. Employment status \nwas categorised as full time, part time and self-employed. There was no statistically \nsignificant difference in the RTW time for the type of sick pay. \nF (2 52) = 0.76, P=0.59 \n \nAs none of the above variables had a significant effect on RTW, no further statistical tests \n(such as multiple comparison and post hoc tests) were carried out.  \n \niv)  Mean time of return to work and operating consultant \nThe mean time that patients went back to work according to the consultant who operated \non them is shown in figure 2.1 and table 2.5. \n\n47 \n \nAn ANOVA was conducted to explore the impact of consultant on when patients \nreturned to work (RTW) after a hysterectomy measured in weeks. There was no \nstatistically significant difference at the p<0.05 level in the RTW time for the type of sick \npay F (2=1.087), P=0.38. \n \n \n \n  \n\n48 \n \nFigure 2.1: Box plot of return to work time by operating consultant \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n  \nConsultant N \nA 7 \nB 7 \nC 1 \nD 5 \nE 4 \nF 18 \nG 2 \nH 1 \nI 2 \nJ 2 \nK 6 \nTotal 55 \n\n49 \n \nThe influence of operating consultant on patient perception of time of return to work. \nFigure 2.2 shows patient perception of return to work, actual mean time of return to work \nand the consultant who operated on them. For most consultants, patients felt they \nreturned to work about the right time or too early. There was no pattern for any particular \nconsultant suggesting that in this cohort, there was no obvious influence of the operating \nconsultant on the patient’s perception of time to return to work. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n\n50 \n \n \n \nFigure 2.2: Perception of return to work, actual mean time of return to work and \noperating consultant. \n  \nMean time of  \nreturn to work \n(weeks) \nPatient perception \nConsultant \n\n51 \n \n \nv) Patient perception of return to work and actual mean time of return. \n \nThere were no differences in the meantime return to work and whether the patient \nperceived their return time to be about right, too early or too late (figure 2.3).  \n \n  \n\n52 \n \nFigure 2.3: Patient perception of return to work and actual mean time of return to \nwork.  \n \n \n \n \n \n \n \n \n \n \n \n  \n27 \n8 \n1 \n19 \nRight Early Late No answer\nPatient perception of time of return \nto work \n\n53 \n \nDiscussion \n \nReturn to work is a complex concept influenced by not only the disease and type of \nsurgery, but by socioeconomic factors and attitudes of patients and health care workers. It \nis encouraging from this survey that most women return back to normal after a \nhysterectomy. This study does not show any differences in when women return to work \nin relation to the type of incapacity benefit they receive, the type of employment contract \nthey have or whether they work in the private or public sector. However, the numbers in \nthe study are currently too small to be able to detect a difference if it exists, especially for \nthe self-employed versus employed group. There were no real differences in time of \nreturn to work and the consultant under whose care the hysterectomy was performed. \nThis may be due to a difference in the type of hysterectomy they had (laparoscopic, \nvaginal or abdominal) and a difference in the advice about recovery given by each \nconsultant. A larger sample size in a future study will help to confirm whether this \ndifference is statistically significant. Return to work after different routes of hysterectomy \nwas not measured in this survey but other surveys of laparoscopic surgery have shown a \npositive association with laparoscopic approaches (49). There is no published data to \ncompare the results from our study at BWH to other hospitals for return to work.  \n \n \nOther studies have demonstrated factors which are associated with return to work and \nhave been compared in a literature review for cancer survivors (50). Positive associations \nincluded positive reactions of work colleagues and patient reaction to the disease and \ntreatment. Negative associations with return to work included a lack of discussion with \nhealth care professionals. Counselling and giving patients realistic expectations pre-\noperatively and during recovery are therefore important in nurturing a positive attitude \nfor return to work. This review did not find any association with return to work and \nincome or education. There will be specific factors in cancer survivors which cannot be \nextrapolated to surgery for benign conditions, but pre-operative patient preparation has \nbeen shown to be important in other conditions such as laparoscopic cholecystectomy  \n(51), inguinal hernia repair (44) and coronary artery bypass graft (52). These studies did \n\n54 \n \nfind a difference in return to work with age, education level, income and type of \noccupation.  \n \n\n55 \n \nTable 2.1: Return to work after hysterectomy for heavy menstrual bleeding. \n \nNumber of women returned to work  87% (55/63) \nReasons for not returning \n    Retired  1 \n    Unemployed 3 \n    No answer 4 \nFull time employment    42.5% (27/63) \nPart time employment    24% (15/63) \nSelf-employed     1.5% (1/63) \n \nMean time of return to work   11.6 weeks (SD  4.84) \nOpinion of return to work \n    Right time 49% (27/55) \n    Too early 15% (8/55) \n    Too late 1.8% (1/55) \n    No answer 35% (19/55) \nType of pay while off sick \n    Usual  43% (24/55) \n    SSP  16% (9/55) \n    Reduced 4% (2/55) \n    Incapacity  \n    Benefit  1.8% (1/55)\n\n56 \n \n Table 2.2: Mean time back to work according to the type of organisation. \n \nType of  \norganisation \nNumber Mean time back to \nwork \n(weeks) \nSD time back to \nwork \n(weeks) \nPrivate 16 11.14 5.53 \nPublic 40 11.76 4.65 \n \n \n \nTable 2.3: Type of sick pay according to employment in a public or private \norganisation. \n \n Total \nNumber \nIncapacity \n \n(%) \nNo \npay \n(%) \nReduced \npay  \n(%) \nSSP  \n \n \n(%) \nUsual \n \n(%) \nNot \nmentioned \n(%) \nPublic \norganisation \n40 0 0 2 \n(10%) \n10 \n(25%) \n27 \n(67.5%) \n1 \n(2.5%) \nPrivate \norganisation \n16 2  \n(12.5%) \n1 \n(6%) \n1 \n(6%) \n2 \n(12.5%) \n8 \n(50%) \n2 \n(12.5%) \n \n\n57 \n \nTable 2.4: Mean time back to work according to type of sick pay. \n \nType of sick pay Number Mean time back to \nwork \n(weeks) \nSD Mean time back \nto work (weeks). \nIncapacity benefit 2 16 11 \nNo pay 1 8  \nReduced pay 3 13 2 \nSSP 12 12 4 \nUsual pay 35 11 5 \nNot mentioned 3 6 3 \n \nTable 2.5: Mean time of return to work after a hysterectomy with Consultant. \n \nConsultant Number Mean time back to \nwork (weeks) \nSD time back to \nwork (weeks) \nA 6 9 7 \nB 1 4  \nC 30 8 7 \nD 4 8 7 \nE 18 12 7 \nF 2 7 1 \nG 2 6 8 \nH 6 4 6 \n \n\n58 \n \nChapter 3 \nHealth care professionals’ beliefs about recovery after hysterectomy: A quantitative \ncross-sectional study. \n \nIntroduction \n \nDoctor-patient communication and physicians’ beliefs about efficacy of surgery are \nknown to be important factors when both patients and doctors make treatment decisions \nfor elective surgical procedures (55, 56). Physician factor has been implicated as a source \nof practice variation (57, 58) which could represent a set of beliefs which have a powerful \neffect on the behaviour of patients (59). The UK Department of Work and Pensions \n(DWP) has produced guidance for some surgical procedures but published evidence \nshows that there is a lack of awareness of them (41). Patients give high importance to the \ninformation given to them by health care professionals over other sources and it \ninfluences behaviours such as when to return to normal activity. In addition, shared \nclinical decision making has been shown to improve patient outcomes such as satisfaction \nand improved functional status (60, 61) . However shared clinical decision -making is \nmore difficult than it appears due to divergent perspectives relating to beliefs about health \nand illness, expectations of medical care, treatment priorities and ways in which \ninformation is interpreted  (62, 63). As patient behaviour is influenced by the information \ngiven to them by health care professionals, and there are variations in their beliefs and \nadvice, there may be a resultant dif ference in patients’ behaviour. Hence study of health \ncare professional beliefs could help us to understand what they think of patient recovery \nexperiences. \n\n59 \n \nGuidance for health care professionals in post-operative recovery has been shown to \nreduce illness related work absenteeism by several weeks compared to unstructured \nstandard advice (48, 64-70). Well defined postoperative recommendations have been \nshown to reduce sick leave by several weeks in comparison to standard care given \nwithout any structural convalescence recommendations (18, 71-75). In section 1.8 of \nNICE guidelines for Heavy Menstrual Bleeding (48), the following recommendations are \nmade: \n  1.8.2 Women offered hysterectomy should have a full discussion of the implication of the \nsurgery before a decision is made. The discussion should include: sexual feelings, fertility \nimpact, bladder function, need for further treatment, treatment complications, the \nwoman's expectations, alternative surgery and psychological impact. [2007] \n1.8.5 Individual assessment is essential when deciding the route of hysterectomy. The \nfollowing factors need to be taken into account:  \n presence of other gynaecological conditions or disease  \n uterine size  \n presence and size of uterine fibroids  \n mobility and descent of the uterus  \n size and shape of the vagina \n history of previous surgery. [2007] \n1.8.6 Taking into account the need for individual assessment, the route of hysterectomy \nshould be considered in the following order: first line vaginal; second line abdominal. \n[2007] \n \nHowever detailed recommendations on the resumption of activities are not alwa ys \nprovided by medical specialists as a result of the lack of recognised guidelines on the \n\n60 \n \ngradual resumption of activities and because of a lack of knowledge about the physical \ndemands of the patient’s job (45, 71, 76). We know there is variation between the advice \ngiven by different health care professionals on convalescence from illness which is not \nevidence based or specific to the type of surgery (77-84)  and this will lead to confusion, \ncomplications (85) and longer absenteeism for patients. Long periods of sick leave are \nknown to result in work disability, poorer health, an increased risk of mental health \ndisease and mortality (85, 86) Therefore it follows that structured guidance on recovery \nfrom specific types of surgery based on evidence and patient experience will provide \nconsistent advice which may lead to better patient satisfaction and expectations and \nshorter illness related absenteeism.  \n \nIn this study we will examine the beliefs of health care practitioners upon which their \nadvice to patients is likely based. The advice given to women on recovery after \nhysterectomy is anecdotal and historical, based on the experience of health care \nprofessionals with other patients or on their beliefs.  There is substantial variation in the \nconvalescence recommendations given by gynaecologists, general practitioners and \noccupational physicians (20, 45, 73, 75, 87 -89), however we do not know which \nhealthcare professionals patients are more likely to be influenced by . In one study  (45), \n433 Danish gynaecologists were surveyed about their convalescence recommendations \nafter a vaginal repair procedure for prolapse. Post -operative stay ranged from 1 to 7 days \nand the recommended sick leave was 2 to 12 weeks with a median of 6 weeks for women \nwith heavy lifting work. The recommended time for r ecommencement of sexual \nintercourse was 0 to 12 weeks with a median of 4 weeks. The recommended range of \n\n61 \n \ntime for non -strenuous activity was 0 to 24 weeks. These differences could not be \nexplained by demographic differences between gynaecologists.   Studie s have looked at \nthe educational and informational needs of hysterectomy patients (73, 74, 90) and the \nquality and management of written information given to patients undergoing \nhysterectomy was evaluated as poor quality and unsuited to patients’ needs in NICE \nguidance 2007 (48). These guidelines also addressed treatment options, indications for \nsurgery and type of surgery, but not return to normality . In a consensus of surgical \nexperts, a reference guide of 4 to 6 weeks after a total abdominal hysterectomy and 2 to 4 \nweeks after a vaginal hysterectomy has been proposed for recovery (91). More recently \nan expert multidisciplinary group in Holland made recommendations of 3 -4 weeks for \nlaparoscopic hysterectomy, 4 weeks for vaginal hysterectomy and 6 weeks for an \nabdominal hysterectomy (92) after a modified Delphi Study of 5 gynaecologists, 2 \ngeneral practitioners, 5 occupational physicians and a representative sample of 63 \nmedical doctor. \nAim: \nTo explore the beliefs and current practices of UK gynaecologists, South Birmingham \nPCT general practitioners and local gynaecology nurses  in counselling patients before \nand after hysterectomy.  \nThe following questions were addressed: \n What proportion of health care professionals are aware of the NICE guidelines for \nHeavy Menstrual Bleeding  \n What are the current practices of different health care professionals? \n\n62 \n \n Health care professional opinions on what influences the practices and beliefs of \ndifferent health care professionals? \n What advice do different he alth care professionals give to women after a \nhysterectomy through the abdominal, vaginal and laparoscopic routes? \n Is there a difference in the above questions for Gynaecologists, General \nPractitioners and gynaecology nurses? \n What are the beliefs and practices for UK Gynaecologists in the different regions? \n \nStudy design. \nA cross sectional structured questionnaire study for each health care professional group \n(UK Gynaecologists, South Birmingham PCT General Practitioners, Gynaecology \nnursing staff Birmingham Women’s Hospital). \n \n\n63 \n \nMethods \nStudy sample \nThere were three sample groups to this study: UK Gynaecologists, South Birmingham \nPrimary Care Trust General Practitioners (SBPCT GPs) and Gynaecology Nursing staff \nat Birmingham Women’s’ Hospital (BWH). Contact details of UK gynaecologists were \nsourced from the Royal College of Obstetricians and Gynaecologists database, SBPCT \nGP details were sourced from SBPCT databases and practice managers and details for \nBWH Nursing staff was obtained from the Gynaecology Dire ctorate at the hospital . \nBWH nurses were chosen as there were no databases available for UK or regional \ngynaecology nurses which we could access. An information sheet and invitation letter \nwas sent to all participants (appendix 4,5). \n \nMeasures (appendices 6-8). \n \nThe questionnaires were developed using standard measures from SF36 questionnaire as \nwell as to answer the objectives. The questionnaire was divided into three sections asking \nquestions about the health care professional, their usual practice and about their usual \ncounselling to patients. All the questionnaires asked about awareness of National \nGuidelines for the management of Heavy Menstrual B leeding (48), whether the health \ncare professional performs or looks after women who have had a hysterectomy by the \nabdominal, vaginal or laparoscopic routes, and what would influence the routine practice \nof the professional. The counselling section asked how the health care professional would \ncounsel patients about recovery. This included inpatient stay, length of time they would \n\n64 \n \nadvise care would be needed for at home, and when certain physical activities could be \nperformed. These physical activities were taken from the physical functioning subscale of \nthe SF36. SF -36 is a multi -purpose, generic, non -disease targeted health survey which \nmeasures functional health and wellbeing. The SF36 has been shown to be both reliable \nand valid in psychometric evaluation (93, 94). \nThe questionnaires were piloted on 3 hea lth care professionals and research colleagues \nfrom each group to test for understanding. They were adapted for each group to take into \naccount their role in the recovery process, although the bulk of the questionnaire was the \nsame. Items which varied for example was to ask general practitioners about the common \ncomplications symptoms they may see such as constipation as this is unlikely to have \npresented to hospital and therefore gynaecology nurses and gynaecologists may not have \nas much of an idea about i ts prevalence. The SF36 questions for recovery were the same \nin all three questionnaires. Gynaecologists were asked if their practice of choice of \nsurgery route and follow up appointment is based mostly on local, National or personal \nexperience. This quest ion was not relevant for nurses or general practitioners as they \nwould not be making those decisions. \n \nProcedure  \nEach questionnaire was accompanied with an explanation of the study and its use towards \na Doctorate of Medicine (MD) thesis (appendix  9) and invitation letter emailed to \nparticipate in the study (appendix 5) with. An email of returned completed questionnaire \nwas taken as participant consent. Questionnaires were sent by electronic -mail using a \nSurvey Monkey link on an Outlook email (appendix 6-8). \n\n65 \n \n \nEthical considerations. \nEthical approval was gained from Black Country Research Ethics committee \n(09/H1202/66). Research and Development approval was gained from Birmingham \nWomen’s Hospital Foundation Trust and South Birmingham PCT. Approval of the \nquestionnaires and study was also gained from the Royal College of Obstetricians and \nGynaecologists. \n \nAnalysis \nDescriptive analysis via surveymonkey.co.uk was used to gain an understanding of \ncurrent practices and beliefs.  \nResults \nUK Gynaecologists \nThere were a total of 2600 members and fellows on the RCOG database sent to us. Of \nthese, 1090 were consultants who currently practiced in gynaecology. Questionnaires \nwere emailed to these 1090 with a single reminder. There were 120 emails which were \nundeliverable d ue to incorrect email addresses and an overall response rate of 39% \n(378/970) was achieved.  \n \nSouth Birmingham PCT General Practitioners \nA total of 291questionnaires were mailed out to GP practices with a single reminder. \nUnfortunately only 1 GP replied an d therefore this data was not analysed  despite \nreminders. \n\n66 \n \n \nNursing staff at Birmingham Women’s Hospital \nA total number of 40 questionnaires were sent with a response rate of 43% (18/40) after 1 \nreminder.  \n \nUK Gynaecologists \nA total of 378 questionnaires were returned. Figure 3.1 shows the regional distribution of \nresponses. There is good representation from all regions of the UK and Northern Ireland.  \n \nMost respondents were in a senior position with 71% of the respondents in a consultant, \nstaff grade or post certificate of completion of training (CCT) grade.  \n \nThere was a spread in time of experience in their grade from 41% being in their grade for \nover 10 years and 23% between 1 to 2 years.  \n \nThe vast majority of gynaecologis ts performed abdominal (99%) and vaginal (93%) \nhysterectomies with only 35% reporting that they perform laparoscopic hysterectomies \n(figure 3.2).  \n \nWhen asking about their practice, 97% of gynaecologists reported that they are aware of \nthe NICE Guidelines on Heavy Menstrual Bleeding, but only 22% reported that they \nwould follow NICE recommendations in surgical route of hysterectomy if there were no \nother clinical indication. \n\n67 \n \n \nMost (78%) gynaecologists reported that they would decide on hysterectomy route \naccording to their personal confidence in performing the procedure as opposed to NICE. \nMost UK gynaecologists offer a follow up appointment after hysterectomy (60%). The \ndecision for follow up is based on personal belief/experience for 55%, unit policy for \n41% and on evidence for only 4%.  \n \n \n \n\n68 \n \nRecovery advice \n \nInpatient days (table 3.1) \nThere was a large spread in the recovery advice after a hysterectomy given by UK \ngynaecologists. Most (46%,) of gynaecologists advised 3 inpatient days routinely after an \nabdominal hysterectomy, but 15% advised 2 days, 28% advised 4 days and 10% advised \n5 to 7 days. One gynaecologist advised less than 1 inpatient day routinely and 1 advised \nmore than 7 days. After a vaginal hysterectomy, 40% routinely advised 2 inpatient days \nbut 37% advised 4 days. There was one gynaecologist who advised less than day, 16% \nadvised 1 day only, 4% advised 4 days and 2% advised 5 to 7 days. Routine advice on \ninpatient days after a laparoscopic hysterectomy was 2 days in 41% of gynaecologists \nand 2 days in 40%. There were 8% who routinely advised less than 1 inpatient day, 10% \nwho advised 3 days and 1% who advised 5 to seven days.  \n \n\n69 \n \nTable 3.1:  \nNumber of inpatient days gynaecologists would routinely advise after different types of \nhysterectomy \n \nType of \nhysterectomy \nNumber of days advised routinely for inpatient stay  \n(% and frequency of response) \n Less \nthan 1 \n1 2 \n  \n3 4 5-7 More \nthan 7 \nAbdominal  0.5% \n(1) \n0 15.2% \n(30) \n46% \n(91) \n28.3% \n(56) \n9.6% \n(19) \n0.5% \n(1) \nVaginal  0.5% \n(1) \n16.2% \n(32) \n39.9% \n(79) \n37.4% \n(74) \n4% \n(8) \n2% \n(4) \n0 \nLaparoscopic 8.1% \n(16) \n41.4% \n(82) \n39.4% \n(78) \n10.1% \n(20) \n0 1% \n(2) \n0 \n \n \n \n\n70 \n \nNumber of weeks for care at home (table 3.2). \nAfter an abdominal hysterectomy, 33% of UK gynaecologists would advise patients that \nthey need 5 -6 weeks of care at home. Again there was wide variation in advice ranging \nfrom 1.5% advising only 1 week of care and 5% advising 11 to12 weeks of care. For a \nvaginal hysterectomy, 21% would advise 1 to 2 weeks of care at home but almost as \nmany (19%) would advise 3 to 4 weeks of care. This advice ranged from 6% advising 1 \nweek and 3% advising 11 to 12 weeks of care. After a laparoscopic hysterectomy, 29% \nadvised 1 to 2 weeks of care at home. The range was 13% advising only 1 week of care \nand 1.5% advising 11 to 12 weeks.  \n \n\n71 \n \nTable 3.2:  \nAdvice about number of weeks patients will need care at home after different types of \nhysterectomy. \n \nType  Routine advice for number of weeks patients will need care at home \n(% and frequency of response) \n 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-\n9 \n9-10 10-\n11 \n11-\n12 \n>1\n2 \nAbdominal 1.5% \n(3) \n10.3\n% \n(20) \n12.9\n% \n(25) \n16.5\n% \n(32) \n3.1% \n(6) \n33% \n(64) \n9.3\n% \n(18) \n6.7\n% \n(13) \n1\n% \n(2 \n0.5\n% \n(1) \n0 5.2\n% \n(10) \n0 \nVaginal 6.2% \n(12) \n20.6\n% \n(40) \n12.4\n% \n(24) \n18.6\n% \n(36) \n11.3\n% \n(22) \n17.5\n% \n(34) \n5.7\n% \n(11) \n4.6\n% \n(9) \n0 0.5\n% \n(1) \n0 2.6\n% \n(5) \n0 \nLap 13.4% \n26 \n28.9\n% \n(56) \n16% \n(31) \n17.5\n% \n(34) \n8.8% \n(17) \n7.7% \n(15) \n4.1\n% \n(8) \n2.1\n% \n(4) \n0 0 1.5\n% \n(3) \n0  \n \n\n72 \n \nAdvice regarding physical recovery after different types of hysterectomy \n \nAbdominal hysterectomy (table 3.3) \nAfter an abdominal hysterectomy 21% of UK gynaecologists would advise 5 -6 weeks \npost operation before vigorous activity such as running, lifting heavy objects and \nparticipating in st renuous sports. The range was 1% advising 4 weeks and 6% advising \nmore than 16 weeks. For moderate activities such as moving a table, pushing a vacuum \ncleaner, bowling and playing golf, 25% advised 5 to 6 weeks after an abdominal \nhysterectomy and 23% advis ed 6 to 7 weeks. The range was 0.5% advising 1 week and \n0.5% advising more than 16 weeks. Advice was varied for lifting or carrying groceries \nwith 28% advising 4 weeks with a range of 1% advising 1 week and 0.5% advising more \nthan 16 weeks. For climbing se veral flights of stairs, 24% advised 4 weeks with a range \nof 1% advising 1 week and 1% advising more than 16 weeks. There was more consensus \non the advice for climbing one flight of stairs with 52% advising 1 week; however the \n0.5% reported advising 14-16 weeks. For bending, kneeling and stooping, 38% advised 1 \nweek with a range up to 0.5% advising more than 16 weeks. The advice for walking more \nthan a mile was 26% advising 4 weeks with a range of 1.5% advising 1 week and 0.5% \nadvising more than 16 weeks, w hereas the advice for walking several hundred yards was \n21% advising 1 week, 27% advising 2 weeks and 23% advising 4 weeks. The range for \nadvice for walking several hundred yards was up to 0.5% again advising over 16 weeks \nfor this activity. There was better consensus for the advice for walking one hundred yards \nwith 45.5% advising 1 week (up to 1% advising 12-14 weeks) and for bathing or dressing \nwhere 82% advised 1 week (up to 0.5% advising 10-12 weeks). \n\n73 \n \nTable 3.3: Advice after an abdominal hysterectomy for physical recovery \nActivity Number of weeks  \n 1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-14 14-\n16 \n>16 \nVigorous\n*1 \n0 0 0.5% \n1 \n1% \n2 \n15.7\n% \n31 \n21.2\n% \n42 \n8.6\n% \n17 \n3.5\n% \n7 \n3.5\n% \n7 \n27.3\n% \n54 \n12.1\n% \n24 \n0.5\n% \n1 \n6.1\n% \n12 \nModerate\n*2 \n0.5% \n1 \n2% \n4 \n7.1% \n14 \n18.7\n% \n37 \n24.7\n% \n49 \n23.2\n% \n46 \n6.1\n% \n12 \n7.1\n% \n14 \n4% \n8 \n4% \n8 \n1.5% \n3 \n0.5\n% \n1 \n0.5\n% \n1 \nLifting or \nCarrying \ngroceries \n1% \n2 \n4.5% \n9 \n10.6\n% \n21 \n27.8\n% \n55 \n22.7\n% \n45 \n18.2\n% \n36 \n5.1\n% \n10 \n3% \n6 \n1% \n2 \n3.5% \n7 \n1% \n2 \n1% \n2 \n0.5\n% \n1 \nClimbing \nseveral \nflights of \nstairs \n9.1% \n18 \n18.7\n% \n37 \n14.1\n% \n28 \n24.2\n% \n48 \n15.2\n% \n30 \n10.6\n% \n21 \n1.5\n% \n3 \n0.5\n% \n1 \n0 2.5% \n5 \n1% \n2 \n1.5\n% \n3 \n1% \n2 \nClimbing \none flight \nof stairs \n52% \n103 \n28.8\n% \n57 \n6.1% \n12 \n3% \n6 \n1.5% \n3 \n0.5% \n1 \n0.5\n% \n1 \n0 \n \n0.5\n% \n1 \n1% \n2 \n0 \n \n0.5\n% \n1 \n0.0 \nBending, \nkneeling, \nstooping \n37.9\n% \n75 \n32.3\n% \n64 \n5.6% \n11 \n13.6\n% \n27 \n5.1% \n10 \n3% \n6 \n1% \n2 \n0 0 1% \n2 \n0 0 0.5\n% \n1 \nWalking \nmore than \n1 mile \n1.5% \n3 \n16.2\n% \n32 \n11.1\n% \n22 \n26.3\n% \n52 \n17.7\n% \n35 \n15.2\n% \n30 \n3% \n6 \n2% \n4 \n2% \n4 \n3% \n6 \n1% \n2 \n0.5\n% \n1 \n0.5\n% \n1 \nWalking \nseveral \nhundred \nyards \n21.2\n% \n42 \n26.8\n% \n53 \n12.1\n% \n24 \n23.2\n% \n46 \n9.6% \n19 \n3% \n6 \n0.5\n% \n1 \n1.5\n% \n3 \n0 1% \n2 \n0 0.5\n% \n1 \n0.5\n% \n1 \nWalking \n1 hundred \nyard \n45.5\n% \n90 \n28.3\n% \n56 \n12.1\n% \n24 \n7.1% \n14 \n4% \n8 \n0.5% \n1 \n0.5\n% \n1 \n0 0 1% \n2 \n1% \n2 \n0 0 \nBathing/ \ndressing \nyourself \n81.8\n% \n162 \n13.1\n% \n26 \n2.5% \n5 \n1.5% \n3 \n0 0 0.5\n% \n1 \n0 0 0.5% \n1 \n0 0 0 \n*1 Running, lifting heavy objects, strenuous sports  *2 Moving a table, pushing a \nvacuum cleaner, bowling or playing golf. \n \n\n74 \n \nVaginal hysterectomy (table 3.4) \nAfter a vaginal hysterectomy 20% of UK gynaecologists would advise 5 -6 weeks post \noperation and 20% would advise 6 -7 weeks before vigorous activity suc h as running, \nlifting heavy objects and participating in strenuous sports. The range was 1% advising 2 \nweeks and 4.5% advising more than 16 weeks. For moderate activities such as moving a \ntable, pushing a vacuum cleaner, bowling and playing golf, 25% advis ed 5 to 6 weeks \nand 21% advised 4 weeks. The range was 1.5% advising 1 week and 0.5% advising more \nthan 16 weeks. Advice was varied for lifting or carrying groceries with 30%% advising 4 \nweeks with a range of 4.5% advising 1 week and 0.5% advising more tha n 16 weeks. For \nclimbing several flights of stairs, 24% advised 4 weeks with a range of 19%% advising 1 \nweek and 0.5% advising more than 16 weeks. There was more consensus on the advice \nfor climbing one flight of stairs with 67% advising 1 week; however the 0.5% reported \nadvising 14-16 weeks. For bending, kneeling and stooping, 58% advised 1 week with a \nrange up to 2.5% advising 10 to 12 weeks. The advice for walking more than a mile was \n28% advising 4 weeks with a range of 12% advising 1 week and 0.5% advi sing more \nthan 16 weeks, whereas the advice for walking several hundred yards was 34% advising \n1 week and 25% advising 2 weeks. The range for advice for walking several hundred \nyards was up to 0.5% again advising over 16 weeks for this activity. There was better \nconsensus for the advice for walking one hundred yards with 64% advising 1 week (up to \n0.5% advising 10-12 weeks) and for bathing or dressing where 89% advised 1 week (up \nto 0.5% advising 9-10 weeks). \n \n\n75 \n \nTable 3.4: Advice after a vaginal hysterectomy for physical recovery \n*1 Running, lifting heavy objects, strenuous sports *2 Moving a table, pushing a vacuum cleaner, bowling \nor playing golf \nActivity Number of weeks  \n 1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-14 14-\n16 \n>16 \nVigorous*1 0 15 \n2 \n1.5% \n3 \n10.1% \n20 \n20.2% \n40 \n20.2% \n40 \n8.6% \n17 \n5.1% \n10 \n3.5% \n7 \n18.7% \n37 \n5.6% \n11 \n1% \n2 \n4.5% \n9 \nModerate*2 1.5% \n3 \n10.6% \n21 \n11.1% \n22 \n20.7% \n41 \n24.7% \n49 \n15.7% \n31 \n5.1% \n10 \n4% \n8 \n2.5% \n5 \n2% \n4 \n1% \n2 \n0.5% \n1 \n0.5% \n1 \nLifting or \nCarrying \ngroceries \n4.5% \n9 \n13.6% \n27 \n9.6% \n19 \n30.3% \n60 \n14.1% \n28 \n16.2% \n32 \n4.5% \n9 \n1% \n2 \n0.5% \n1 \n2% \n4 \n1% \n2 \n0.5% \n1 \n0.5% \n1 \nClimbing \nseveral \nflights of \nstairs \n19.2% \n38 \n22.2% \n44 \n11.1% \n22 \n23.7% \n47 \n11.6% \n23 \n6.1% \n12 \n0.5% \n1 \n0.5% \n1 \n0 2.5% \n5 \n0.5% \n1 \n1.5% \n3 \n0.5% \n1 \nClimbing \none flight \nof stairs \n67.2% \n133 \n17.7% \n35 \n4.5% \n9 \n4.5% \n9 \n2% \n4 \n1.5% \n3 \n0.5% \n1 \n0.5% \n1 \n0 1% \n2 \n0 0.5% \n1 \n0 \nBending, \nkneeling, \nstooping \n57.6% \n114 \n22.2% \n44 \n3% \n6 \n9.1% \n18 \n4% \n8 \n1% \n2 \n0.5% \n1 \n0 0 2.5% \n5 \n0 0 0 \nWalking \nmore than \n1 mile \n12.1% \n24 \n18.7% \n37 \n11.6% \n23 \n28.3% \n56 \n12.1% \n24 \n8.6% \n17 \n3.5% \n7 \n1% \n2 \n0 2.5% \n5 \n1% \n2 \n0 0.5% \n1 \nWalking \nseveral \nhundred \nyards \n34.3% \n68 \n25.3% \n50 \n9.6% \n19 \n20.7% \n41 \n5.1% \n10 \n1.5% \n3 \n0.5% \n1 \n0 1% \n2 \n0 0.5% \n1 \n0 0 \nWalking 1 \nhundred \nyards \n64.1% \n127 \n18.2% \n36 \n7.1% \n14 \n4.5% \n9 \n3% \n6 \n1% \n2 \n0.5% \n1 \n0 0 0.5% \n1 \n0 0 0 \nBathing/ \ndressing \nyourself \n89.4% \n177 \n8.6% \n17 \n0.5% \n1 \n0.5% \n1 \n0 0 0.5% \n1 \n0 0 0.5% \n1 \n0 0 0 \n \n \n\n76 \n \nLaparoscopic hysterectomy (table 3.5) \nAfter a laparoscopic hysterectomy 21% of UK gynaecologists would advise 4 weeks post \noperation, 17%% would advise5 to 6 weeks and 17% 6 -7 weeks before vigorous activity \nsuch as running, lift ing heavy objects and participating in strenuous sports. The range \nwas 2% advising 1 week and 2.5% advising more than 16 weeks. For moderate activities \nsuch as moving a table, pushing a vacuum cleaner, bowling and playing golf, 25% \nadvised 4 weeks. The ran ge was 5.6% advising 1 week and 1% advising more than 16 \nweeks. Advice was varied for lifting or carrying groceries with 29% advising 4 weeks \nwith a range of 11% advising 1 week and 1% advising more than 16 weeks. For climbing \nseveral flights of stairs, 27 % advised 1 week and 27% advised 2 weeks. However, 1% \nadvised more than 16 weeks. There was better consensus on the advice for climbing one \nflight of stairs with 73% advising 1 week; however the 1.5% reported advising more than \n16 weeks. For bending, kneel ing and stooping, 63% advised 1 week with a range up to \n1% advising more than 16 weeks. The advice for walking more than a mile was 25% \nadvising 4 weeks, 21% advising 1 week and 23% 2 weeks. Again 1% reported advising \nmore than 16 weeks. The advice for wal king several hundred yards was 42% advising 1 \nweek with a range up to 1.5% again advising over 16 weeks for this activity. Again there \nwas better consensus for the advice for walking one hundred yards with 70% advising 1 \nweek (up to 1% advising over 16 wee ks) and for bathing or dressing where 91% advised \n1 week (up to 1% advising over 16 weeks). \n\n77 \n \nTable 3.5: Advice after a laparoscopic hysterectomy for physical recovery \nActivity Number of weeks  \n 1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-\n14 \n14-\n16 \n>16 \nVigorous*1 2% \n4 \n3.5% \n7 \n7.1% \n14 \n21.2% \n42 \n16.7% \n33 \n16.7% \n33 \n9.6% \n19 \n4.5% \n9 \n2.5% \n5 \n12.6% \n25 \n0 1% \n2 \n2.5% \n5 \nModerate*2 5.6% \n11 \n21.2% \n42 \n11.6% \n23 \n24.7% \n49 \n15.2% \n30 \n13.1% \n26 \n1.5% \n3 \n1.5% \n3 \n0.5% \n2 \n4% \n2 \n0 0 1% \n2 \nLifting or \nCarrying \ngroceries \n11.1% \n22 \n22.2% \n44 \n12.1% \n24 \n28.8% \n57 \n9.6% \n19 \n8.1% \n16 \n2% \n4 \n2% \n4 \n0.5% \n1 \n2% \n4 \n0 0.5% \n1 \n0.5% \n1 \nClimbing \nseveral \nflights of \nstairs \n26.8% \n53 \n26.8% \n53 \n12.6% \n25 \n20.2% \n40 \n5.6% \n11 \n2% \n4 \n0 0.5% \n1 \n0 3.5% \n7 \n0 1% \n2 \n1% \n2 \nClimbing \none flight \nof stairs \n73.2% \n145 \n15.7% \n31 \n3.5% \n7 \n2% \n4 \n1.5% \n3 \n0.5% \n1 \n0 0 0 1.5% \n3 \n0 0.5% \n1 \n1.5% \n3 \nBending, \nkneeling, \nstooping \n65.2% \n129 \n19.7% \n39 \n3% \n6 \n5.1% \n10 \n2.5% \n5 \n0.5% \n1 \n1% \n2 \n0 0.5% \n1 \n1.5% \n2 \n0 0 \n \n1% \n2 \nWalking \nmore than \n1 mile \n20.7% \n41 \n22.7% \n45 \n13.6% \n27 \n25.3% \n50 \n8.1% \n16 \n4% \n8 \n0.5% \n1 \n0.5% \n1 \n2.5% \n3 \n1.5% \n3 \n0 0 1% \n2 \nWalking \nseveral \nhundred \nyards \n41.9% \n83 \n27.8% \n55 \n12.6% \n25 \n10.6% \n21 \n2% \n4 \n1% \n2 \n0 1% \n2 \n1% \n2 \n0.5% \n1 \n0 0 1.5% \n3 \nWalking 1 \nhundred \nyard \n70.2% \n139 \n15.7% \n31 \n6.6% \n13 \n2% \n4 \n1.5% \n3 \n0.5% \n1 \n0.5% \n1 \n0.5% \n1 \n1% \n2 \n0.5% \n1 \n0 0 1% \n2 \nBathing/ \ndressing \nyourself \n90.9% \n180 \n3.5% \n7 \n1% \n2 \n1.5% \n3 \n0 0.5% \n1 \n0.5% \n1 \n0 0.5% \n1 \n0.5% \n1 \n0 0 1% \n2 \n*1 Running, lifting heavy objects, strenuous sports  *2 Moving a table, pushing a \nvacuum cleaner, bowling or playing golf. \n\n78 \n \nVariations in advice \nWe were not able to demonstrate regional variations in whether gynaecologists choose \nroute of hysterectomy according to NICE guidance or personal confidence (figure 3.3), or \naccording to specialist grade or years of experience in that grade (figure 3.4). A follow up \nappointment seemed to be made routinely more often in London and least in the North \nEast and North West (figure 3.5). Consultants seemed to be less likely to make a routine \nfollow up appointment (71%) and trainees in years 6-7 appeared to be most likely to offer \nthem (figure 3.6). Consultants mainly followed personal belief in this (75%), although \n48% of consultants reported their choice as unit policy (figure 3.7). A lower proportion of \ngynaecologists made a routine follow up appointment if they were more experienced in \ntheir grade (44%), and of these, 44% followed personal belief and only 23% reported \nfollowing evidence (figure 3.8). These differences may be as a result of variations in local \nhealth care set ups and commissioning agreements.  \n \n\n79 \n \nFigure 3.1:  \nRegional distribution of responses (Ireland is Northern Ireland) \nNumber of responses \n\n80 \n \nFigure 3.2:  \nProportion of gynaecologists who perform types of hysterectomy \nDo you perform the following types of \nhysterectomy ? \ny…\nn…\n\n81 \n \nFigure 3.3:  \nRegional variation in decision for route of hysterectomy \n \n \n\n\n82 \n \nFigure 3.4:  \nExperience level and decision for route of hysterectomy \n \n \n\n\n83 \n \nFigure 3.5:  \nRegional variations in offering a routine follow up appointment \n \n\n\n84 \n \nFigure 3.6:  \nVariations in follow up appointment and grade \n \n \n \n \n \nFollow up \nappointment \nrequested \n\n85 \n \nFigure 3.7:  \nRegional variations in reasons to offer routine follow up appointment \n \n\n\n86 \n \nFigure 3.8:  \nVariations in decision making for offering a follow up appointment and experience in \ngrade \n \n\n\n87 \n \nResults Gynaecology nurses Birmingham Women’s Hospital \n \nThere were 18 responses out of 40 after a single reminder (43%). The mean number of \nyears of experience was 11.88 years (3 -30). Statistical comparisons were not made \nbetween the UK gynaecologists and BWH nurses due to the small number of responses \nfrom nurses. \nIn-patient days after each type of hysterectomy (table 3.6). \nAfter a total abdominal hysterectomy, two thirds of nurses would advise a stay of 4 to 6 \ndays, with the remaining one third advising 2 to 3 days. After a vaginal hysterectomy, \nthere was more consensus with 94.5% advising 2 to 3 days. After a laparoscopic \nhysterectomy, only 28% of nurses would advise a I day stay in hospital with the \nremainder advising 2 to 3 days.  \n \n\n88 \n \nTable 3.6:  \nHow would you routinely counsel your patients regarding numbers of postoperative days \nstay in hospital? \n \nNumber \nof days % \n(number \nof \nresponses) \nNumber \nof days % \n(number \nof \nresponses)  \nNumber \nof days % \n(number \nof \nresponses)  \nNumber \nof days % \n(number \nof \nresponses)  \n \n \n0-1 2-3 4-6 7-12  \nAbdominal \nhysterectomy \n0 \n39% \n (7)  \n61%  \n(11) \n0 \n \nVaginal \nhysterectomy \n0 \n94.6%  \n(17) \n4.5%  \n(1) \n0 \n \nLaparoscopic \nhysterectomy \n28% \n(5) \n72% \n(13) \n0 0 \n \n \n \n\n89 \n \nNumber of weeks of care at home (table 3.7) \n \nThe majority of nurses (79%) advised between 2 to 6 weeks care at after an abdominal \nhysterectomy, this was also similar after a vaginal hysterectomy where 89%  also advised \n2 to 6 weeks. After a laparoscopic hysterectomy, most nurses (79%) advised 0 to 3 weeks \nof care at home. \n \n\n90 \n \nTable 3.7:  \nHow many weeks of care at home would you advice? \nRoute \nhysterectomy \n \n0-1 \n%  \n(number of \nresponses) \nWeeks \n2-3 \n%  \n(number \nof \nresponses) \n \n4-6 \n%  \n(number \nof \nresponses) \n \n7-12 \n%  \n(number \nof \nresponses) \n \nAbdominal \nhysterectomy \n4.5% \n(1) \n \n39% \n(7) \n \n44% \n(8) \n \n11% \n(2) \n \n \nVaginal \nhysterectomy \n11% \n(2) \n50% \n(9) \n39% \n(7) \n \n0 \n \n \nLaparoscopic \nhysterectomy \n \n39% \n(7) \n44% \n(8) \n17% \n(3) \n0 \n \n \n \n\n91 \n \nAdvice after an abdominal hysterectomy for physical recovery. \nAll nurses felt that vigorous activity was only advised after 6 weeks and most felt that \nthis was the same for moderate activity (94%) and lifting (65.5%). The majority of nurses \nwould advise climbing one flight of stairs (83%), bending, kneeling and stooping (61%) \nwalking a hundred yards (83%) and bathing and dressing (94%) after 1 week. Half of all \nnurses would advise walking several hundred yards after 1 week with only 17% advising \nto wait more than 2 weeks, whereas 90% of nurses would advise waiting more than 2 \nweeks to walk more than 1 mile. A third of nurses advised climbing several flights of \nstairs after 1 completed week, but a third advised to wait until after 6 completed weeks \n(table 3.8).  \n  \n\n92 \n \nTable 3.8:  \nNumber of weeks for advice after abdominal hysterectomy for physical recovery \nActivity Weeks (% responses) \n 1 \n \n2 \n \n3 4 5-6 6-7 8-9 12-14 >16 Don’t \nknow \nVigorous*1 0 0 0 0 0 50% \n9 \n11% \n2 \n22% \n4 \n4.5% \n1 \n11% \n2 \nModerate*2 0 0 0 4.5% \n1 \n0 83% \n15 \n0 0 4.5% \n1 \n4.5% \n1 \nLifting or \nCarrying \ngroceries \n0 0 4.5% \n1 \n22% \n4 \n0 61% \n11 \n0 0 0 4.5% \n1 \nClimbing \nseveral \nflights of \nstairs \n33% \n6 \n22% \n4 \n0 11% \n2 \n4.5% \n1 \n11% \n2 \n0 4.5% \n1 \n0 17% \n3 \nClimbing \none flight of \nstairs \n83% \n15 \n11% \n2 \n0 0 0 0 0 0 0 4.5% \n1 \nBending, \nkneeling, \nstooping \n61% \n11 \n11% \n2 \n0 11% \n2 \n0 11% \n2 \n0 0 0 4.5% \n1 \nWalking \nmore than 1 \nmile \n4.5% \n1 \n4.5% \n1 \n22% \n4 \n33% \n6 \n0 17% \n3 \n0 0 4.5% \n1 \n11% \n2 \nWalking \nseveral \nhundred \nyards \n50% \n9 \n66% \n6 \n0 0 0 0 0 0 0 17% \n3 \nWalking 1 \nhundred yard \n83% \n15 \n4.5% \n1 \n4.5% \n1 \n0 0 0 0 0 0 4.5% \n1 \nBathing/ \ndressing \nyourself \n94% \n17 \n0 0 0 0 0 0 0 0 4.5% \n1 \n\n93 \n \n \n \nAdvice after a vaginal hysterectomy: physical recovery (table 3.9) \nAfter a vaginal hysterectomy, most nurses advised waiting until after 6 weeks before \nvigorous activity (89%), and 66% advised lifting only after 4 weeks. For climbing stairs, \n89% advised being able to climb one flight and 39% advised climbing several fligh ts in a \nweek. The majority of nurses advised bending (67%), walking 1 hundred yards (83%) \nand bathing and dressing (94%) in 1 week.  \n \n\n94 \n \nTable 3.9: Number of weeks for advice after vaginal hysterectomy: physical recovery. \nActivity Weeks (% number of responses) \n 1 2 3 4 6-7 8-9 12-\n14 \nMore \n16 \nDon’t \nknow \nVigorous*1 0 0 4.5% \n1 \n4,5% \n1 \n50% \n9 \n4.5% \n1 \n17% \n3 \n4.5% \n1 \n11% \n2 \nModerate*2 0 0 0 28% \n5 \n61% \n11 \n0 0 4.5% \n1 \n4.5% \n1 \nLifting or \nCarrying \ngroceries \n0 11% \n2 \n4.5% \n1 \n4.5% \n1 \n55% \n10 \n0 0 0 4.5% \n1 \nClimbing \nseveral \nflights of \nstairs \n39% \n7 \n28% \n5 \n17% \n3 \n4.5% \n1 \n11% \n2 \n0 4.5% \n1 \n0 17% \n3 \nClimbing \none flight \nof stairs \n89% \n16 \n4.5% \n1 \n0 0 0 0 0 0 4.5% \n1 \nBending, \nkneeling, \nstooping \n67% \n12 \n4.5% \n1 \n0 22% \n4 \n0 0 0 0 4.5% \n1 \nWalking \nmore than \n1 mile \n11% \n2 \n17% \n3 \n11% \n2 \n28% \n5 \n17% \n3 \n0 0 4.5% \n1 \n11% \n2 \nWalking \nseveral \nhundred \nyards \n50% \n9 \n33% \n6 \n0 0 0 0 0 0 17% \n3 \nWalking 1 \nhundred \nyard \n83% \n15 \n4.5% \n1 \n4.5% \n1 \n0 0 0 0 0 4.5% \n1 \nBathing/ \ndressing \nyourself \n94% \n17 \n0 0 0 0 0 0 0 4.5% \n1 \n \n\n95 \n \n \n \nAdvice after laparoscopic hysterectomy: physical recovery (table 3.10) \n \nNo nurses advised waiting after 7 weeks for any of the physical recovery activities. \nThirty nine percent felt that vigorous activity and 44% felt that moderate activity could be \nadvised by 2 weeks. The majority felt that climbing a flight of stairs (94%), bending \n(81.5%), walking several hundred yards (77%), walking 1 hundred yards (94%) and \nbathing and dressing (94%) could be advised by 1 week.  \n \n \n\n96 \n \nTable 3.10 Number of weeks for advice after laparoscopic hysterectomy: physical \nrecovery. \nActivity Weeks (% number of responses) \n Less \n1 \n1 2 3 4 5-6 6-7 Don’t \nknow \nVigorous*1 0 11% \n2 \n28% \n5 \n0 11% \n2 \n4.5% \n1 \n33% \n6 \n4.5% \n1 \nModerate*2 0 22% \n4 \n22% \n4 \n0 22% \n4 \n0 28% \n5 \n4.5% \n1 \nLifting or \nCarrying \ngroceries \n0 22% \n4 \n28% \n5 \n4.5% \n1 \n17% \n3 \n0 22% \n4 \n4.5% \n1 \nClimbing \nseveral \nflights of \nstairs \n0 50% \n9 \n33% \n6 \n0 0 0 0 17% \n3 \nClimbing \none flight \nof stairs \n0 94% \n17 \n0 0 0 0 0 4.5% \n1 \nBending, \nkneeling, \nstooping \n4.5% \n1 \n77% \n14 \n4.5% \n1 \n4.5% \n1 \n4.5% \n1 \n0 0 4.5% \n1 \nWalking \nmore than \n1 mile \n0 28% \n5 \n33% \n6 \n0 11% \n2 \n0 11% \n2 \n11% \n2 \nWalking \nseveral \nhundred \nyards \n0 77% \n14 \n4.5% \n1 \n0 0 0 0 17% \n3 \nWalking 1 \nhundred \nyard \n0 94% \n17 \n0 0 0 0 0 4.5% \n1 \nBathing/ \ndressing \nyourself \n0 94% \n17 \n0 0 0 0 0 4.5% \n1 \n\n97 \n \nDiscussion \nThis survey represents the practice and beliefs of 378 gynaecologists representing all \nregions in the UK and a small number of gynaecology nurses in one unit. The main \nfindings from this study are that there is great variance between the advice UK \ngynaecologists and nurses would give after all types of hysterectomy. There is better \nconsensus for activities which are appropriate within the first week such as walking a few \nhundred yards, bathing and dressing and climbing one flight of stairs. This may be due to \nthe fact that all these activities are usually achieved before discharge from hospital and so \ngynaecologists and nurses are familiar with these milestones. Longer term recovery \nadvice is surprisingly varied, suggesting that UK gynaecologists and nurses are less \nfamiliar or confident about this. There seems to be a difference in the type of advice \ngiven between the three different routes of hysterectomy such as vigorous activity. Most \nUK gynaecologists would advise 4 weeks after a laparoscopic hysterectomy, 5 to 6 weeks \nafter a vaginal and 10 to 12 weeks after an abdominal hysterectomy. Advice for other \nactivities such as moderate activities was more similar (most recommending 5 to 6 weeks \nfor abdominal and vaginal and 4 weeks for laparoscopic) and no diff erence in the advice \nto walk more than a mile between route of hysterectomy (4 weeks for all routes). The \nadvice given by gynaecology nurses is similar for all types of hysterectomy route for \nimmediate postoperative activities, but is lower for longer term  recovery activities for the \nlaparoscopic route. There is surprisingly less difference in longer term recovery advice \nafter an abdominal or vaginal hysterectomy for heavy menstrual bleeding. Limitations of \nthis study include differences in the sample demog raphics for gynaecologists and nurses. \nIt would have been useful to have been able to compare responses between these groups. \n\n98 \n \nA better study design would have been to have UK gynaecology nurses; which could \nhave been via a survey to gynaecology units in th e UK. Another limitation is that \ngynaecology nurses were not asked if they follow NICE guidelines in their approach to \ncounselling, again making it difficult to then compare or draw meaningful conclusions.  \n \nThe results from this survey differ to one carri ed out in the Netherlands (95) with UK \ngynaecologists advising longer convalescence in all categories of activities. In the \nNetherland survey, a Delphi technique was used to come to a consensus of opinion from \na total of 12 experts (5 gynaecologists, 2 GPs and 5 occupational physicians). In a Delphi \ntechnique, the survey options are reduced according to the most popular responses and \nthe survey is re -issued a number of times repeating this step at each issue. In this way, \nparticipants are forced to choose and prioritise between the reduced opti ons until a \nconsensus is reached. The UK survey is a one off survey with all options available. \nTherefore, the difference in methodology of survey may explain the differences.  In the \nNetherlands survey, advice for recovery was shorter in all categories an d for all routes of \nhysterectomy. For light work, the UK opinion was 4 to 7 weeks (55% of cases) for \nlaparoscopic hysterectomy whereas the Netherland consensus was 1 week, for moderate \nactivity UK was 4 weeks (25%) versus 2 weeks and for heavy activities U K was 4 weeks \n(29%) versus 3 weeks. For abdominal hysterectomy, UK opinion on light activities was 4 \nweeks (28%) versus 2 weeks in Netherlands, for moderate activities it was 5 to 7 weeks \n(53%) against 3 to 4 weeks and for heavy activities it was 5 to 6 we eks (21%). For \nvaginal hysterectomy, the UK opinion on light activities was 4 weeks (30%) compared to \n2 weeks, for moderate activities it was 4 to 6 weeks (46%) compared to 3 weeks and for \n\n99 \n \nheavy activities it was 5 to 7 weeks as compared to 4 weeks for the  Netherlands \nconsensus.  The difference in results may be explained by the differences in methodology \nand slightly different examples of heavy, moderate and light activities. It may be that a \nDelphi study on our UK gynaecologists would find a different con sensus of opinion due \nto the methodology of a Delphi where multiple surveys are sent around to participants \nbased on the results of the previous survey. In this way, the participants of the survey \nwould be presented with fewer options in each survey round and are then asked to choose \ntheir most appropriate response for the focussed options (so in a way are forced to choose \nbetween options that they may not have originally considered). However, the larger \nnumber of gynaecologists in our survey would suggest that this survey is more \nrepresentative of gynaecologist opinion and practice and patients may be influenced by \ndiffering advice. If recovery, especially long term is influenced mainly by health care \nprofessionals, then conflicting advice to patients is li kely to cause confusion and \nfrustration. It may also have an impact on the economy if patients are advised to stay off \nwork for longer than they need to or conversely, be contributing to problems if patients \nare advised to return to work too soon. It seems  that the published advantage of faster \nrecovery from laparoscopic or vaginal routes is not conveyed to UK patients, and hence \nmay be reflected in longer and similar actual recovery times for all routes. NICE \nguidance advice using a vaginal approach as fir st line, then abdominal as second line \ntaking into account the need for individual assessment (59). Although there is National \nNICE Guidance in recommendations for the route for hysterectomy, most UK \ngynaecologists use their own experience and confidence t o decide on the surgery despite \nknowing of the evidence, and do not follow the pattern of guidance set out by NICE. The \n\n100 \n \nreason for this may be due to the quality of the evidence upon which the \nrecommendations in guidelines have been made. If it is poor qua lity or based on \nconsensus opinion, some health care practitioners may choose to follow their own \nexperience and beliefs. This finding is in keeping with the published literature for \ndifficulties in implementing research findings.   \n \nThis survey also gives  information on the current hysterectomy practice in the UK at the \ntime of the survey, with only 35% performing laparoscopic hysterectomies. Conversely, a \nsimilar and high proportion (99 and 93%) of UK gynaecologists perform abdominal and \nvaginal hysterectomies.  \nThere is also a culture of offering a routine follow up appointment after surgery (60%), \nwhich seems to be derived from personal belief or experience (55%) as well as unit \npolicy (41%). This is interesting in a climate of efficiency with commissioners tryi ng to \nreduce follow up rates in secondary and tertiary centres. It may be that NHS Trusts and \nindividual gynaecologists will be asked to reduce their post-operative follow up rates and \nit is likely that Trusts will not get remunerated for unnecessary follo w up appointments. \nIn my opinion, unless there are specific concerns, most post-operative follow ups can be \nmanaged in primary care as long as there has been good communication from the hospital \nto the GP. At the post-operative hospital visit, the majority  of women will have \nrecovered, but will have had to take time out of their schedules to travel to hospital and \nwait to be seen to be told they have recovered. The post-operative visit is an opportunity \nto answer patient questions and review any complicatio ns. However, we should aim to \ncommunicate with our GP colleagues so that this follow up is not necessary. If there are \n\n101 \n \nspecific concerns, then those patients should be re -referred. Complications requiring re -\npresentation to the hospital will still be monit ored on hospital statistics, but it seems \ninefficient to see patients in a clinic to gain information on minor complications e.g. \nurinary tract infections. Other more innovative ways of checking on patient progress \nshould be found such as telephone consult ations by nursing staff at recovery time points \nwhich are agreed to be important for each type of surgery. This is an area where Trusts \ncan increase their efficiency with relative ease without compromising the quality of care. \n \nA limitation to this study i s the lack of responses from GPs which leaves open the \nquestion of what GP beliefs are, whether they will give appropriate or consistent advice. \nIt may be that GPs are too busy in responding to research questionnaires, which raises the \nquestion of whether they would have the time or resources to arrange follow up visits \nafter surgery. Unfortunately, I was not able to get any feedback from GPs so I was not \nable to ask why they did not respond to the survey, it may be that they were not interested \nin the surv ey, in research or it may have been that the methodology of emailing the \nsurvey was flawed. At the time of the survey email, the local GPs were going through a \ntransition in email addresses from individual practices to NHS.net accounts.  It is \ntherefore likely that a number of emails did not reach the GPs and I did not receive any \nresponse to indicate that there was a change in email address. A similar issue occurred \nwhen our trust changed to NHS.net where a number of emails were lost.  I came to know \nafter t he completion of the study that there had been a technical issue with GP email \naddresses and this cross over and this may have affected the email survey.  Similar to the \nDutch Delphi study, other health care professionals such as physiotherapists are not \n\n102 \n \nusually involved in the recovery process for hysterectomy and therefore were not part of \nthis survey.  \n \nConclusion \nUK gynaecologists and gynaecology nurses at Birmingham Women’s hospital give \nvariable advice on recovery from all route of hysterectomy. There  is more consensus in \nopinion for activities which would be expected to be accomplished while still an \ninpatient. It is reassuring that there are no differences in opinion according to different \nregions, but there is variation by experience and grade, whic h is what we expected to see. \nFurthermore, there was variation by personal belief as opposed to by national or local \npolicy.  As patients are greatly influenced by the advice given by health care \nprofessionals, particularly by doctors (50, 51) it is important to provide consistent advice \nbased on evidence and actual patient experience.  \n  \n\n103 \n \nChapter 4: Experiences of women who have a hysterectomy; a qualitative interview \nstudy \n \nIntroduction \n \nThe experiences which women go through during and after a hysterectom y have been \ndiscussed for many years. In December 1982, an article in the Guardian: Every Woman’s \nRight to Know (Perry C) stated: \n \n‘Having a hysterectomy is an emotional as well as a physical operation, it is to do with \nbeing a women, it is to do with conc eption and sex; the children you’ve had or won’t be \nable to have’.  \n \nBetter counselling and preparation for hysterectomy can improve the way women cope \nand recover from the surgery. The hysterectomy often comes at a time in their lives when \nthey are also f acing other personal crises such as going through the menopause, children \ngrowing up and changes in the roles they perceive themselves in. A post hysterectomy \nsyndrome has been described where depression is the primary component, although there \nis a wide range of reported incidence for the syndrome of 4 -70% (96, 97) but overall the \nestimate of depression is 2 to 4 times higher than the general po pulation, peaks at 2 years \npost-surgery and lasts for 2 to 3 times longer than in age matched controls who have had \nother surgeries. \n \n\n104 \n \n \nWe know that information patients are given has an effect on their experience (76) and \nthat patient expectations influences patient satisfaction of medical treatment  (64). \nDissatisfied patients are less likely to comply with medical advice, default from follow up \nappointments and show less improvement in symptoms than satisf ied patients (65). \nPatients seek information from various sources including the internet, where a search for \nthe term hysterectomy presents 7,160,000 links including a variety of we b pages, chat \nrooms, patient’s forums and patient support groups. One such patient website is \nHysterosisters Online (http://www.hysterosisters.com), which describes itself as a social \nsupport site for women who are undergoing the experience of a hysterecto my. This \nwebsite published the results of a survey in which they found that patients sought \ninformation and advice more than emotional support or self-esteem (p<0.01) (98).  \nDespite the huge array of published literature there is concern regarding the provision of \ninformation for women undergoing treatment for heavy menstrual bleeding, particularly \nin the recovery phase (48, 99, 100) and women and their partners still express wishes for \nmore information (101). There have been specific questions regarding the reliability and \naccuracy of information on the internet and its effect on the relationship between the \npatient and health care professional (79, 80).  \nAt Birmingham women’s Hospital, women are prepared for hysterectomy by trained pre-\noperative nurses during a pre-operative appointment. At this appointment, the nurse talks \nabout the hysterectomy and provides written information in the form of leaflets. The \ndetails cover what will happen on the day, when to arrive and wher e, what to pack and \nbring in with them as well as fasting information. Recovery information includes \n\n105 \n \ndiscussion and leaflets about pain, movement and self -help such as how to get out of bed \neasier and breathing techniques to ease pain. Recovery advice once  discharged includes \nsymptoms to look out for in case of complications, driving advice and general advice on \nhow long the recovery might take. There is also advice about the effect of surgery on \nsexual function and when it is safe to resume sexual intercourse. If the patient asks for \nmore detailed advice about any aspect in particular, the nurse gives individualised \ninformation based on their own experience. The patient is encouraged to bring the leaflets \ninto hospital with them as a reference guide. This p rocess is the same for both benign and \nnon-benign disease. There is not published literature on how this pocess varies from  \n \nMost published studies of patient experience and belief ask retrospective questions about \nclinical outcomes from hysterectomy such as effectiveness and safety; or look at a single \ntime point s in the patient journey  such as length of stay, and satisfaction at time of \nquestionnaire (102, 103) . Some studies acknowledge these limitations and recommend \nlonger follow up periods for recovery outcomes (104). A more recent published study has \nlooked at 3 and 12 month recovery from hysterectomy; however it focused on chronic \npain only and did not consider other recovery outcomes or experiences. A literature \nreview of qualitative studies for enhanced recovery high lighted how patients required \nadditional support to be motivated in recovery during times of symptoms such as pain, \nnausea and weakness. This study concluded that patients still required more consistency \nin information pre and post -operatively in order to feel confident about symptom \nmanagement (107). In this qualitative study, we have followed women through fr om the \npre-operative period to three months after the hysterectomy in order to gain a longitudinal \n\n106 \n \nunderstanding of the women’s experiences of hysterectomy by the vaginal, laparoscopic \nand abdominal routes. \nWe know that recovery is affected by the underlyi ng pathology of the specific disease \nprocess as well as co -morbidity. In breast cancer, a study reported on the experiences for \nyoung women taking into consideration their unique situation of cancer diagnosis at early \nage (108), and similarly for recovery 6 months after colorectal cancer surgery (109). \nThese studies showed how individuals required specific support in their recovery because \nof their diagnosis. In ord er to reduce the differences in experiences due to underlying \nvariation from disease process, this study is limited to recovery from hysterectomy for \nheavy menstrual bleeding in order to reduce the confounding effect of disease process on \nrecovery such as cancer.  \nAim: \nTo explore in depth the beliefs, longitudinal experiences and expectations of women who \nhave a hysterectomy for heavy menstrual bleeding through the vaginal, abdominal and \nlaparoscopic routes.  \n \nStudy design \nA longitudinal semi-structured interview study of women who are having a hysterectomy \nat the Birmingham Women’s Hospital through the abdominal, vaginal or laparoscopic \nroutes.  \n \n \n \n\n107 \n \nMethods \nSample \nWe recruited women who were on the waiting list to have a hys terectomy for heavy \nmenstrual bleeding by the abdominal, vaginal or laparoscopic routes at Birmingham \nWomen’s Hospital. An estimated target sample of ten women from each hysterectomy \ngroup was set. We did not delineate between whether women were planned to  or had \ntheir ovaries removed as the study was mainly looking at route of surgery. A total number \nof 26 women were finally recruited which represented 10 from the abdominal route, 7 \nfrom the vaginal route and 9 from the laparoscopic route. Recruitment was stopped at this \nstage as no new themes were emerging from the interviews. All women were identified \nfrom Birmingham Women’s Hospital elective waiting list databases and they were \ninvited to join the study during their pre-operation visit to the hospital, which was usually \nbetween 1 and 4 weeks before surgery where consent for the study was taken after an \nexplanation of the study with the participant information leaflet (appendix 9). \n \n  \n\n108 \n \nMeasures \nSemi-structured interview topic guides were drawn up for the pr e-surgery interview and \nthe post-surgery one (appendices 10,11). They were tested in interviews to 3 lay people \nand patient volunteers to ensure that they were coherent.  \n \nProcedure \nParticipants were telephoned to arrange convenient times for the interview s. Some \nparticipants opted to have the interview at home, whilst others came to the Birmingham \nWomen’s Hospital. If the interview was at the hospital, a private room without \ndisturbance was arranged each time. If the researcher went to a participant’s home  for the \ninterview, the details of the venue were left with the research secretary who was included \nin the ethical application. The researcher telephoned on arrival and departure from the \ninterview venue for safety. The researcher informed participants tha t she would be \ncarrying identification, and produced this at each interview. Before the start of the \ninterview, the consent was again confirmed. The consent form included options for doing \nand recording the interview, completing questionnaires and the part icipant’s General \nPractitioner being informed of their participation in the study (appendix 10 and 11). Once \nthe participant agreed to continue, the microphone was tested and each interview was \ncarried out as set out in the interview topic guide. Interview s were transcribed by the \nresearch team secretary and checked by Dr M Shehmar by reading the transcripts while \nlistening to the interviews. Interviewers were undertaken pre -surgery and at around 3 \nmonths post-surgery. Interviews before surgery focussed on preparation for recovery and \n\n109 \n \nexpectations of recovery at 1 week, 1 month, 2 months and 3 months post -surgery. \nInterviews post-surgery focused on actual experiences.  \n \n  \n\n110 \n \nAnalysis \n \nInterviews were analysed by thematic analysis (33) in order to gain an understanding of \nthe common themes which emerged from the study , which is a more feasible method \nrather than reporting each experience comment made . As the themes were identified \nthrough interrogation of the interview transcript by the researcher retrospectively and not \nin the natural setting of the recovery (i.e. not alongside the patients in their recovery \nenvironments), the validated methodology of thematic analysis was chosen to meet the \naims of the study rather than other methods described in chapter 1b . The methodology of \nthematic analysis used a framework as described below was followed: \n \nSteps of thematic analysis (84). \nStep 1: Familiarization of the data \nThe in terviews were read and listened to multiple times to become familiar with their \ncontent. \nStep 2: Thematic analysis \nCommon themes were identified in the interviews and were labelled as codes (table 4.1).  \nStep 3: Indexing \nAll interviews were then read again in detail and the codes were applied to each line of \nthe interview transcript manually.  \nStep 4: Charting \nCharts of summaries of the data arranged by codes were made to see across themes and \nthe whole data set. Summaries were then referenced back to the whole data set.  \n\n111 \n \nStep 5: Mapping and interpretation. \nWhere possible, inferences were made by looking at relationships between the codes by \nusing diagrams and tables.  \n  \n\n112 \n \nTable 4.1 Codes of analysis \nT subtheme Code \nTheme Subtheme Code \nPreparation  1 \n Practical preparation 1.1 \n Emotional preparation 1.2 \n Physical preparation 1.3 \n Experiential preparation 1.4 \n Informational preparation 1.5 \n Social preparation 1.6 \n Cognitive preparation 1.7 \n Sexual preparation 1.8 \nDecision making  2 \n Type of hysterectomy 2.1 \nExpectations  3 \n Hospital stay 3.1 \n Recovery 3.2 \n Influences 3.3 \n Support 3.4 \nRecovery   4 \n 1 week 4.1 \n Emotional  4.1.1 \n Physical  4.1.2 \n Behavioural 4.1.3 \n Social 4.1.4 \n Sexual 4.1.5 \n 4 weeks 4.2 \n Emotional  4.2.1 \n Physical  4.2.2 \n Behavioural 4.2.3 \n Social 4.2.4 \n Sexual 4.2.5 \n 8 weeks 4.3 \n Emotional  4.3.1 \n Physical  4.3.2 \n Behavioural 4.3.3 \n Social 4.3.4 \n Sexual 4.3.4 \n 12 weeks 4.4 \n Emotional  4.4.1 \n Physical  4.4.2 \n Behavioural 4.4.3 \n Social 4.4.4 \n Sexual 4.4.5 \n   \n\n113 \n \n \n \nTheme \n \nSubtheme \n \nCode \nThoughts of surgery  5 \n Negative 5.1 \n Positive 5.2 \nOthers attitude  6 \n Partner 6.1 \n Children 6.2 \n Family 6.3 \n Friends 6.4 \nEffects  7 \n Of surgery 7.1 \n Illness 7.2 \n   Experiences  8 \n Of surgery 8.1 \n of hospital stay 8.2 \nRecovery   9 \n 1 week 9.1 \n Emotional  9.1.1 \n Physical  9.1.2 \n Behavioural 9.1.2 \n Social 9.1.3 \n Sexual 9.1.4 \n 4 weeks 9.2 \n Emotional  9.2.1 \n Physical  9.2.2 \n Behavioural 9.2.3 \n Social 9.2.4 \n Sexual 9.2.5 \n 8 weeks 9.3 \n Emotional  9.3.1 \n Physical  9.3.2 \n Behavioural 9.3.3 \n Social 9.3.4 \n Sexual 9.3.5 \n 12 weeks 9.4 \n Emotional  9.4.1 \n Physical  9.4.2 \n Behavioural 9.4.3 \n Social 9.4.4 \n Sexual 9.4.5 \nExperiences vs. \nexpectations \n 10 \n As expected 10.1 \n Positive 10.2 \n Negative 10.3 \n\n114 \n \nResults \nSample characteristics \nAll participants were women who had a hysterectomy for heavy menstrual bleeding as a \nprimary diagnosis. They underwent a total abdominal hysterectomy vaginal hysterectomy \nor laparoscopic hysterectomy . The pa rticipants had a range of occupations involving \nvarying degrees of physical activity including stocking heavy items as a bar worker, \nteacher, housing officer, carer, nurse, retired and house wife.  \n \nQualitative interview thematic analysis. \n \nPart I Preparation Pre-surgery \nInformation \n \nAll groups talked about the variety of information available as books, leaflets and on the \ninternet. They all felt that there was a large amount of information and that it was \ndifficult to sift  through to find what was useful. They talked about how some of the \ninformation made them worry, including videos on you tube showing the whole \nprocedure from start to finish, and sites where they felt it was easy to try and self -\ndiagnose to their own detr iment. Some participants talked about buying the wrong books \nand some about trying to distract themselves from the information. There was no \ndifference in the three routes of surgery and the laparoscopic hysterectomy (LH)  \nhysterectomy group were no less concerned. \n \n \n\n115 \n \n \n \nTAH group \n IB06- Bought a book, ‘And I think I will bin it. It’s not my sort of book. But it tells you \nweek one what you can do, week two, week three you know right up to week 6. Em, and \nit’s just you can’t do anything, according to this book.  But obviously it depends on how \nyou are.’ \nIB18- ‘I try not to think about IT’ – preparing going into hospital. \n \nLH group \nIB16 ‘There is so much help on the internet now for people to self-diagnose a bit which is \na bit of a worry for the doctors I suppose cos you talk yourself into having lots of things \ncan’t you? But em I think I used to be a nurse anyway and I was pretty clear headed \nwhere I was looking. I knew exactly what my symptoms were’. \n \nIB22 was having mixed feelings – ‘It’s I’ve been on the intern et and I kind of read about \nsome of the complications and so on. …and not that I am not confident in the doctors and \neverything,  but in the back of your mind wondering you know is this going to happen to \nme… You know the fact that you can you can have pro bably injury to the bladder …not \nthat I’ve known anyone that has experienced anything like that but it’s just sometimes you \nstumble over information, that do you more harm than good to be honest’. \nIB22- ‘Sometimes you stumble on things on the internet that do you more harm than good \nto be honest.’ IB22 – Had not intended to go on the internet but her husband asked \n\n116 \n \nsomething ‘and I thought I will try and get some information to explain….and I saw this \nvideo on you tube, you know, and it kind of shows you from  start to finish what they \nbasically do and it just looks terrifying to be honest’. \nIB22 – A nurse watched a video on YouTube on start to finish of surgery ‘I felt better \nseeing it to be honest.’ \n \nVH group \nIB09 ‘And having the two kids they keep me busy so  I’ve just been trying to find things to \ntake my mind off it’. \nIB14- Internet , use long words. ‘ then I thought no I’m not gonna look at this anymore \nbecause I am going to frighten myself…..because unless you are a medical person some \nof the terminology and expressions used could be a little worrying.’ \n \n  \n\n117 \n \nPractical preparation \n \nA number of participants outlined the practical preparation they had made before their \nsurgery which included child and pet care arrangements, tying up loose ends such as \npaying bills, completing housework in case they could not do it for a while after surgery \nand arranging for help with cooking and shopping. This did not differ in the three routes \nof surgery, and there were examples of this theme in all routes and the responsibil ities \nthis age group of women have. \n \nTAH group \n \nIB005 – ‘I’ve got so many animals and that, that I have had to arrange for like \nneighbours who are gonna be coming in and you know, it’s just like, probably because \nI’ve got so many, I’ve gotta arrange for them to be fed’.  \n \nIB005 – ‘I live with my husband so he’ll be doing all the day to day things like cooking \nand things like that.’ \n \nIB01- ‘I have been doing all my windows and changing me curtains and everything \nbecause I know I’m not gonna be able to do it.’ \n \n \n \n\n118 \n \n \n \nLH group \n \nIB13 – ‘There is people who have offered to come in and help with the kids. And people \nhave offered to come in and do my housework and stuff…I’ve got a good network around \nme’.  \n \nIB21- plans to look after granddaughter ‘My other daughter i s coming to stay here, and \nem, she is going to get her on the bus, get her dressed you know certain things like that’. \n \nIB07 ‘I have made arrangements with school, em because of me not driving or anything, \nthey will come and collect him and fetch him back for me…Because there is no plans for \nsingle parents with the government to help out with transport’.  \n \nIB16 ‘My sister is a nurse and she has offered to take some time off work to look after me \nfor the first few days anyway…or to help out with the shopping and bits and pieces’. \n \n IB22 ‘husband is taking 2 weeks off work’.  \n \nIB14 (VH) ‘I have organised that my husband will do the housework and my sister in \nlaw’.  \n\n119 \n \nIB14- ‘I have tried to get on top of everything. I have washed all the clothes, washed all \nthe bedding, seen to me curtains.’ \n  \n\n120 \n \nPhysical preparation \n \nIn the abdominal and laparoscopic hysterectomy group, there were examples where \nparticipants had talked about trying to improve their fitness before surgery. However, this \nwas not the case with the vagi nal hysterectomy group, in fact one participant described \nhow due to her problems she had stopped her fitness regime of dancing as she thought it \nwas making it worse and would wait until after surgery to resume. \n \nIB16 (TAH) ‘I had physiotherapy every coupl e of weeks and I had an exercise plan as \nwell. He has been building up my core muscles’ . Walking and getting fit, tried to lose \nweight to help with recovery. \n \nIB06 (LH) – Walking to get fit  ‘I’ve tried to lose a bit of weight.’ \n \nEmotional preparation \n \nBoth the abdominal and laparoscopic group talked about how the surgery had affected \ntheir emotions. Some participants had not thought about their emotions and whether they \nwould change and some were quite concerned about how they would emotionally cope \nwith the surgery. One participant talked about the fear of losing her job if she was going \nto need much time off after her surgery and the financial effect. Some participants saw \nthe hysterectomy as a positive influence on their emotions and that it would lead t o a \nreduction in the stressors in their life. \n\n121 \n \n \n \nIB004 (TAH) ‘I don’t think men understand do they. It’s part of you at the end of the day \nthat you are having to give up.’ \nIB004 ‘His attitude to it is well I’ll pick you up and drop you off and I’ve gotta  g o to \nwork meself like, you know.’ \nIB004 ‘He’s frightened as well as I am am but they don’t show it. Do they. And, em, I’m \nhoping after everythings done I can get me life back in order because it has been an \nemotional up and down roundabouts circle’ \nIB004 – Fear of effect on lifestyle, although her sisters’ have had a hysterectomy, \nconcerned that her life is busier and that she still goes to work when they do not ‘And it’s \njust sort of grabbed my life and held it. You know, I’ve had 10 months off work where I \ncouldn’t cope with that’. \nFear of sickness – IB004 ‘I just basically thought, you know I’m gonna lose ma job’. \nFinancial strain – IB004 ‘As obviously it affects your money..so, now he is doing extra \ndays overtime. He is working 6 days a week.’ \n \nIB16 (LH) ‘Emotionally, I haven’t really thought about it ..I am just, well it’s part of life, \nyou know you’ve had children…and with the pain I have had over the last year with the \namount of problems..I am just looking to see this hopefully resolve….then I  can get back \non track’. \n \n\n122 \n \nWorried about complications – IB22(LH) ‘…the fact that some people get depressed and \neverything you know. I am just hoping that doesn’t come my way, cos you know, that’s \nprobably something I wouldn’t be able to deal with’. \n \n \n \nSexual preparation \n \nSome women were concerned about how removal of their ovaries would affect their \nemotions and the consequences.  \n \nIB07 ‘I’m having my ovaries out I should imagine all them strange. A bit like the baby \nblues…And that’s horrible….Mood swings….Yeah and that’s worrying me really because \nyou shout at your kids don’t you. They suffer’. \n \nIB005 – ‘They (hormones)  are probably going to be a bit all over the place, like. You \nknow, probably weepy and things like this and probably irritable’.  \n \nCognitive preparation \n \nThere were not many participants who spoke about preparing for the loss of their fertility \nhowever, there were examples of both apprehension about losing their fertility and \nphilosophical views where a participant saw it as a natural life cycle event.  \n\n123 \n \n \nIB007 (TAH) ‘I think it really hits home. … it is and you can’t even think about having \nany more children’.  \nLH ‘Well its part of life, you know you’ve had children. I am 49 tomorrow. I am not \ngonna have any more children em and with the pain I have had over the year I will be \njust so happy if it it does resolve the problems that I’ve got my life because I used to be \nvery fit and active .’ \n \nSome participants did talk about whether they had prepared themselves and their partners \nfor any changes in their sexual lives after the surgery. It seemed that most women would \nask their doctors for advice on when it would be safe to continue with their sexual lives, \nand they felt they needed review first before being confident to resume.  \n \nIB22 ‘I understan d that I can’t be sexually active until maybe up to 6 weeks or so. I \nhaven’t even spoken to him to be honest. I probably told him at one point that you know \ndefinitely I will be unable to do anything like that until you know been seen or reviewed \nby my doctors’. \n \nIB24 ‘I’m just trying to think what it’s going to be like, is everything going to be normal \nin you know your private life, is everything going to be perfect again?….I spoke to him he \nsaid just speak to the doctor’. \n \n\n124 \n \nOne participant assumed it would  mark the end of her sexual life, IB10 - ‘Well I won’t \nhave any sex drive.’  \n \n \nOne participant did talk about how she had actively asked the question from the pre -\noperative nurse, who explained to the participant’s satisfaction.  \n \nIB007 – ‘I asked her (pre -operative nurse) ..you know what happens actually to the sex, \nsexual side and she explained it all to me. So I know what to expect when it comes down \nto that. And I said well its not gonna be any different from what it already is really for \nme’. (Said she had lost her libido years ago). \n \nIt was interesting how many women were reluctant to speak about their sexual \npreparedness and the most usual answer was that it was not going to make any difference \nor that it was not a concern to them. \n \nA couple of partici pants talked about how they had booked activities to look forward to \nwhich they believed would aid their recovery by having something to aim towards, such \nas a 40th birthday party, holidays, booking cinema tickets (IB16), Christmas and Easter \ncelebrations. \n \n\n125 \n \nSome participants talked about getting mentally prepared for the surgery through positive \nattitudes or by rationalising and justifying the surgery to bring about an improvement in \ntheir lives afterwards. \n \nIB13 ‘Gotta have it done, that’s it isn’t it. So carry on the way I was, which is not making \nme any happier or have it out and we will see’. \nIB21 (LH) ‘Mentally I’m gonna be fab because I am not gonna have a period anymore \nand that’s it, it’s a big thing in my life. I can’t go swimming. You know. Can’t g o out and \nabout’.  \n \n \n \n  \n\n126 \n \nDecision making \nParticipants talked about how they had tried other options to manage their heavy \nmenstrual bleeding before and how they had finally come to the decision of surgery. \nThere was a theme of surgery being seen as a last resort with delays due to their situation  \nexcluding surgery as an option at the time. Participants talked about wanting an option \nwhich gave them a definitive end to their problems.  \n \nIB16 had an ablation before – ‘I know that em the NHS does like you to try lots of \ndifferent options first before  you go for a major operation…but because I’m a single \nparent…em really I would have hoped for the hysterectomy earlier really…and really it \nhas taken so long you know it’s a big impact on our lives at the moment..the fact that I \nam not at work’. \n \nIB18- ‘I’ve been having heavy periods..I’ve had em since I was15..And I had the bilation \n(ablation) 2 years ago. And that didn’t work’.  \n \nIB07 ‘I know I’ve got to do it but because I am on the Prostat (Prostap) injections I \nhaven’t had a period now for 3 months, and my iron levels are 14.3, and I feel really \ngood, like I used to feel’. \nIB07 ‘I hadn’t gone for it before now. I’ve had other things, I’ve had the Mirena coil \nwhich didn’t work. I’ve had tablets and goodness know what else. I havn’t gone for it \nbefore now because of the situation with somebody looking after the children..so really I \nsuppose I put myself on the back burner’. \n\n127 \n \n \nIB005 – Had the Mirena but had side effect – ‘And once I had it fitted, I started getting \nreally bad dizzy spells…to the point where I would be at work and get this floating feeling \nin my head and I’d have to hold on to something’.  \n \nIB010- ‘I just feel I’ve suffered for 20 years and I feel like the, the people I’ve spoken to \nhave all said it was the best thing they ever did’.  \nIB09 ‘I have also had the coil fitted and had various tablets to try and stem the bleeding. \nAnd I know there is a procedure where you can burn the lining of the womb, but to me I \nhave had enough done that has let me down because the hospital has done everything \nthat they thought was right to try and stop it and help. I just think my body needs \nsomething final to say that’s it no more’.  \n \nIB16 – Had a failed ablation ‘I don’t think it worked very well for me. I had a lot of pain \nafter it and I was hoping that it would resolve and it didn’t ever resolve.’ \n \nParticipants understood that a hysterectomy via any route was major surgery and that \nthey had considered the decision in this light. \n \nIB06 ‘It’s the only guarantee, em because I was offered the ablation …but the c onsultant \nsaid it was about 30% successful..and I didn’t want to go through that and find that it \nhadn’t worked. And then of course you go back on the waiting list for everything….I \n\n128 \n \nknow it’s a major decision and it’s a major operation, but I don’t wanna h ave to go back \nin 12 months and try something else’. \n \nSometimes, the decision was influenced by other co -existing problems such as prolapse \nor ovarian cysts, completion of their family and those affected had an understanding of \nthe rationale and there was evidence of joint decision making with the gynaecologist. \n \n Associated breast cancer in family with HRT after hysterectomy - IB01- ‘before when \nthey first told me I was going to have the hysterectomy I didn’t want to know. I refused \npoint blank I wasn’t go nna have because I’ve got my aunty who had it done, my mother \nhad it done and obviously they both got breast cancer and that was my main issue’. \n…The HRT tablets and that was one of my biggest worries actually’. \n \nThere was no difference with the route of s urgery in the reasons given for choosing \nsurgery, and all groups talked about the effect of heavy bleeding on their quality of life \nand how they saw surgery as a way to improve this. \n \nIB01- ‘Because if I arrange to go out with my friends….and I came on. Fu ll stop I can’t \ngo.’ \n \nIB 013 ‘ I mean I was out shopping one day, came back and just got covered in blood. \nIt’s not nice when you have got children here…the reason they decided it was the best \nsolution was, because I had been sterilised 4 years ago’. \n\n129 \n \n \nIB21- ‘And because I am a carer for my grand -daughter, I need to be on top form really. \nSo the only option is to have a hysterectomy….I am on iron tablets, I am on the pill at my \nage em I am on tablets to stop the flow and but I have had a thrombosis so all th ose \ntablets are just not right for  me’.  \n \nIB06 ‘Em, its just a necessary evil so to speak. You know my periods have been bad for \nso long that I just wanna stop the bleeding’.  \n \nChoice of surgical route \nIn some instances, the participants talked about how the route was determined by their \ndoctors and some of them although they had an understanding of why that route was \nadvised found it was different from what they had hoped for. For the laparoscopic route, \nthe main understanding for this choice seemed to be smaller scars and better recovery. \n \nIB010- ‘I was hoping that I wouldn’t have to be cut across the stomach…But (consultant \nname) has said it was too big to do that.’ \n \n IB24 ‘Then it won’t leave a lot of scars cos as I said before, if your body would be \nnormal, I don’t like lots of cutting on your body. So that, he said the keyhole is just a little \nhole’. \n \n\n130 \n \nIB06- ‘Well em that wasn’t my choice, that was the surgeon’s. So hopefully if there are \nno complications with the keyhole, less invasive, quicker recov ery’. Recovery time – \nsingle woman dependant on her car and needing to be able to drive quickly to be able to \nget out of the house’.  \n \nSingle parent -IB07 ‘Because there is no way I would have gone through with an 8 week \nrecovery thing..because I just coul dn’t…there’s no leeway, you know school they’ve just \ngotta be there’.  \n \nIB21 ‘The doctor suggested it’. She thought ‘Yes great Quick recovery rather than a \nbigger recovery…you know with the scar across there then it takes you more time to \nrecover. Whereas two little ones I am hoping that I will be up and about quicker.’ \n \nIB16 ‘I’m having which one is it now..the laparoscopic hysterectomy. But em, until they \nlook inside they don’t know what they are gonna do…but if they can’t do the procedure \nthen they will do the abdominal hysterectomy….I am not too happy about having lots of \nscars on my tummy but there is no other way round it, so you know. And I do heal up \npretty quickly…and it’s not like I go round showing my tummy all the time…so it’s not \ntoo bad’. \n \nOnly a few women talked about how they had actively thought about the route they \nwanted and why.  \n \n\n131 \n \nIB06 ‘Thought a lot and looked online for route ‘But I think I went a bit too far, You \nknow. Because does it really matter what they are gonna do to me under ana esthetic. I \nknow they are gonna remove my womb which is the whole point of it.’ \n \nIb16 ‘I’m not too happy about having lots of scars on my tummy but there is no other way \nround it.’ \n \nOne participant had changed her mind on the route once reading the informa tion leaflet, \nand was concerned with her recovery. Furthermore, she was influenced by her mother’s \nexperiences. \n \nIB09 After pre op  ‘Em I signed the consent form for a vaginal hysterectomy but I have \nread the leaflet…And I’m swayed off that now so I want t he abdominal hysterectomy so I \nsee there is a few questions round that and if I can still change’ \nWhen asked why: IB09 ‘Em, oh sounds a bit, I am funny about anything coming out like \nthat end…. Em and I know I am gonna be sore if I have the abdominal, sort  of on my \nstomach line and yes I will be sore down there but I think I will be more sore if I have it \nout of there and I don’t like being uncomfortable down there.’ \nIB09 ‘I don’ t like being swollen in my vagina area. And that makes me more \napprehensive and stressed and I don’t know if that will lengthen the recovery time…And \nmy mon had a hysterectomy (abdominal) ..so I’ve seen how people recover from \nthat….And looking at the two, I think you go with what you know really’. \n \n\n132 \n \nRemoval of ovaries \nAlthough the number of women who had their ovaries removed was not considered in \nthis study, nor was it balanced in the sample of women interviewed, s ome participants \ntalked about their understanding and questions around the decision as to whether their \novaries would be removed as well as the hysterectomy. \n \n IB13 – ‘I understand that if I keep my ovaries I will go through the change normally and \nif I don’t then I will have to go on HRT’.  \n \nIB007 Did not know where her eggs would go if the ovaries were left in place once  the \nwomb was removed ‘and then I learnt that you still have the oestrogen hormone ….and \nthat you need that for your bones and whatever. And that, you see I didn’t know that’. \n \nIB16 ‘The only thing that I am unsure about is the HRT whether I will need that . I mean \nthat’s a bit confusing. Because one of my doctors has told me that even if you do need \nHRT that sometimes it is best for maybe a homeopathic type which is like plant \noestrogens. ..Cos it’s not clear at the moment 100% what’s gonna actually be done on the \nday’ [removal of ovaries]. \n \nOne participant talked about how she was finding it difficult to make the decision herself \nand had looked for advice and wanted someone to tell her what she should do. \n \n\n133 \n \nIB07 –‘ I was unable to go to the evening thing (information evening), but I did speak in \ndepth with one of the people there at the hospital….I was trying to ask the doctors and \nnurses and nobody would actually say yeah I think you should have this done or no you  \nshould have that done. It’s all my decision but…I just felt that I didn’t have enough \ninformation. …but there again the more information I found the more that I felt …at the \nend of the day again we are coming down to an individuality. …And I haven’t got t he \nmedical knowledge to say well okay I need my ovaries or I don’t need my ovaries, that’s \nwhat I wanted someone to tell me’. \n  \n\n134 \n \nInfluences \n \nParticipants were influenced in their expectations by people around them who had had \nprevious experience of a hyster ectomy. Participants were concerned that from what other \npeople had said, that they would not be able to do much after surgery, and they were \ninclined to believe the advice they had been given in order to learn from them and avoid \ndelays in recovery. \n \nIB14- People told her things ‘That I won’t be able to do much at all. They have said that \nyou will have to sit quiet and just toddle round the house a bit…..And I shall be happy to \ndo what they say because I want to be right.’ \nIB16 ‘..my sister’s had a hystere ctomy, my mum…my auntie and I’ve listened to all their \nexperience. My best friend as well and em they are all back at work. You know they are \nall back to their normal selves’.   \nIB22 ‘Information that I have shared with friends…you know nothing too negativ e but \njust that they have been quite fatigued and tired, off work for long periods of time, but \noverall they basically said you know that they made the best decision. But you know I \nknow each individual is different so I am just kind of wondering what is g oing to happen \nin my situation’.  \nIB21- sister had the same – expects recovery of 6 weeks ‘rather than 12 weeks’. \n \n\n135 \n \nThis participant was due for a VH but took advice from her mother who had had a TAH \nbut she did not expect that her recovery was going to be any different due to the route so \nwas inclined to listen to the advice.  \n \nIB09 ‘Just what I won’t be able to do really and how long I won’t be able to do them for. \nBut she has been really supportive and encouraging.’ \n \nA participant who was expecting a LH talked about the advice she had received again \nfrom women who had had a TAH.  \n \nIB22 – ‘you know they have been quite fatigued and tired, off work for long periods of \ntime.’  \n \nAgain, she did not expect any difference due  to fact that her surgery was planned for a \ndifferent route. \n \nOne participant did talk about how she was surprised at the experiences of others and that \nshe expected her recovery to be better. \n \n IB06 ‘They said at work get your friends to make you a sandwi ch before they leave you \nand I’m thinking I will be able to make a sandwich. Surely I will be able to make a \nsandwich. I don’t think I will have my arms cut off.’ \n \n\n136 \n \nSome participants were influenced by their previous experiences of other types of surgery \nthey had and were worried about the hysterectomy being a larger procedure. In particular, \nthey spoke about how they would cope with recovery in their different circumstances \nfrom their pervious surgery. \n \nIB005 ‘Well, when I broke my leg, things like, you kno w when you are straining to do \nsomething or you are finding it a little bit hard and just in that sort of way. I think you \nknow yourself.’ \n \nIB010 – ‘Em quite worried in one respect. I’ve had lots of surgery before….So there is a \npart of me that knows what’s coming. Em but it’s the, this is a little bit more serious than \nwhat I’ve had done before and it’s the after effects I’m more concerned about. Having my \nchildren to cope with. And how long it’s going to be before I’m back to normal so to \nspeak. Like with my husband working away’. \n \nPrevious major surgery – IB21 ‘And as long as they give me injection for being sick \nafter…I will be fine.’ \n \n \n  \n\n137 \n \nPart II Expectations Pre Surgery \n \nExpectations about length of hospital stay \n \nParticipants all talked about confusion  in their expectations of how long they would stay \nin hospital. They attributed this mainly down to conflicting information they had received \nfrom various health care professionals, including discrepancies between their consultants \nand the pre-operative nurses. \n \n IB06 laparoscopic- ‘He [consultant] said to me if you choose a hysterectomy you will  be  \nin hospital for one night, within a couple of weeks you should be feeling more of less back \nto normal, then when I saw him in July and I said is it just one night, and he was like \nmaybe  two or three, and then at the pre -op the nurse said usually 3 to 5 nights it might \nyou know be longer…So now it’s almost gone from sort of like 24 hours, which I could \ncope with, to sort of 3 nights minimum which is like oh my God, to maybe 5 may be \nlonger’.  \n \nOther participants in the laparoscopic group expected to stay in between 3 and 5 nights as \nwell.  \n \nIB24 ‘3-4 nights’  \n \nIB22 – ‘Hospital stay 3 to 4 days’ \n\n138 \n \n \nIB21 – ‘I am in Tuesday and hoping to come out Friday’.  \n \nIB16 ‘I suppose they said the average is 4 and I think …I would be a bit worried if I was \nonly staying for 2.’ \n \nIB13 ‘Em originally they said 2 -4 days, now they are saying 3 -5… Because they were \nnot aware of the problems with my bladder and the problems with my discs.’ \n \nIn the vaginal hysterectomy group, most participants expected a stay of 3 to 5 days.  \n \nIB09- Mum had TAH ‘I mean mom had hers on Friday and came home on the \nMonday….I mean I have read the leaflets and the leaflets say 3-5 days’. \n \nOne participant talked about how if she needed to stay longer than she expected, it would \nbe in her best interests. She felt that if she was in hospital then at least she was in the \nsafest place and that if they kept her in she probably needed the time in, but would like to \ncome out as soon as possible. \n \nIB005 ‘Well obviously I’d rather be out than in hospital, than lets, so if I was ok on the \nSunday I would rather come out.  The sooner the better’.  \n \n \n\n139 \n \nExpectations of recovery \n \nPain was something that participants associated as a marker of their recovery. They \ntalked about how pain would concern them and stop them from doing things they might \nfeel they could. \n \nIB07 ‘But if you get more pain….then obviously something’s a bit wrong so you have to \nget advice’. \n \nThere was no difference in the expectations of participants in the activities they would \nhave to refrain from regardless of the route of surgery they were having.  \n \nIB005 (TAH) – ‘I suppose I’m going to have to stop myself from you know just like \nbending down, picking things up and you know changing the cat litters, just things that I \ndo every single day.’  \n \nIB14 (VH) ‘I can’t go picking my grandson up.’ \n \nIB14- ‘I’m going to be staying upstairs for the first few weeks. I am going to stay out of \nthe way.’ \n \n\n140 \n \nIB24 ‘There’s an old saying that once God made your body perfect and then once the \ndoctor get inside you, you are not normal again cos that cut will always be there….It’s an \nold saying from my parents…You know if it’s gonna heal properly you know’. \n \nIB010- ‘I’m not looking forward to staying in.. Because I can never sleep.’ \n \nIB01-‘I think you can heal better at home’. \n \nDriving 3 weeks from pre-op nurse \n \n \nIB06 (LH)– Driving 3 weeks- at pre-op, patient thinks it will be 6 (from family member \nwho had CS).  \n \nIB16 (LH) ‘Well I am hoping maybe after 6 weeks I will feel well enough to think about \ngoing back to work.’ \n \n  \n\n141 \n \nThoughts about recovery \n \nAll groups regardless of route of surgery had similar concerns about their recovery. This \nstemmed sometimes from the experience of other people they knew; \n \n IB005 (TAH) – ‘three of my closest friends have had hysterectomies……all of them have \nactually said the one thing that is the worst for all of them, is the terrible terrible \nconstipation after. And that’s what they said they found the hardest. I mean some of them \nsaid they went home from hospital they would be there all night crying. Trying just to go \nto the toilet because they felt bloated and that inside’.  \n \nRecovery expectations were associated more with the indiv idual, there were participants \nwho were keen for a fast recovery and those who felt that they would not want to rush \nthemselves.  \n \nIB16 (TAH) ‘I am hoping that I can manage to do the general household stuff pretty \nquickly…Em, you know manage to go back to work. You know as soon as possible..Well I \nam hoping maybe after 6 weeks I will feel well enough to think about going back to \nwork’. \n \nSome participants were quite negative about their immediate recovery and the effect it \nwould have on their lives and respo nsibilities, again this trend was seen across all \nsurgical routes; \n\n142 \n \n \n IB07 (TAH)  ‘I live on the other side and he goes to school (son) and most of the people \nlive by school. It’s definitely a car drive away…So you have got to walk to the bus stop, \nwait for buses and I couldn’t do that in the beginning anyway’. \n \nIB09 (VH) ‘You won’t be able to walk…I probably would’t even get to the end of my \nroad’.  \n \nIB06 (LH) ‘It’s almost as if things will never be the same again but 6 weeks in reality is \nnothing’. It just seems, oh well I can walk 4 miles any day I like now. But I am not gonna \nbe able to do that next week. And, you know, I am gonna struggle to get out of bed and I \ndon’t wanna be, you know gonna have to be dependent on people and have lots of people \naround me that I am not really looking forward to’.  \n \nIn this part of the study, most women spoke about physical and behavioural recovery \nrather than emotional or sexual. These areas were addressed with prompt questions later. \n \n  \n\n143 \n \nOne week after surgery \n \n In gener al, regardless of route of surgery, participants expected to not be able to lift \nheavy things, do the vacuuming, bend or stretch. A number of participants had \nexpectations but were mindful again that there is individual variation and that their \nrecovery may be different. They spoke about listening to their bodies. \n \nTAH Group \n \nIB18 – ‘I know I won’t be ironing’ ‘Em just think its down to your body really and you \nlisten to your own body.’ ‘I won’t know until I you know probably experience pain or \nwhatever…That I’m not supposed to be doing what I am supposed to be doing’. \n \nIB008- ‘Em one of the things I suppose I think I won’t be able to do is probably wear \nnormal clothes for a while. Eh, I have got a few loose things that I have not thrown out’.  \n \nIB01- ‘Just me normal things, like cleaning up and vacuuming and you know.’ \nIB01- ‘Like I say it all depends on that person…you know and I think me myself, I am a \nstronger person. I am not gonna think I’ve had that operation like oh I can’t do this. I am \nstill gonna get up and try.’ \n \nIn the LH group, there did not appear to be any difference in recovery expectations from \nthe TAH group and were mostly around lifting, vacuuming and driving. \n\n144 \n \n \nIB16 ‘Maybe just walk up to the shops which is 10 minutes’ walk from my house’.  \n \nIB22 – ‘I won’t be able to push them (kids) in the chair (pushchair) or lift them out of the \nbath.’ \n \nIB13 ‘I know I’ve got to sleep and eat properly.’ \n \nVH Group \n \nIn this group, there were some specific concerns around pain when sitting down, and \nopening their bowels. They expected more pain with both of these activities due to the \npositioning of their vaginal scar.  \n \nIB14 ‘sitting down in the bath might be a bit awkward.  And the toilet. Just going to the \ntoilet because I remember when I had the children I was quite stitched up after I had the \nchildren. I am just hoping my bowels and all that, it’s a terrible thing to talk about , but \nyeah I don’t look forward to down there.’ \n \n  \n\n145 \n \nOne month post-surgery \n \nAt one month, there was again little difference in the  expectations of participants \naccording to their route of surgery. In the TAH group, participants felt they could partake \nin light exercise only, lying down exercises, no driving, no sexual intercourse and no \nheavy lifting still such as children. Again, th ere was reference to listening to your own \nbody and individual variation. \n  \nIB005 ‘doing the normal things then…Just like going back out socialising and just doing \nthe normal things, like putting the washing on and things like that. I won’t be vacuuming \nor anything like that’.  \n \nIB005 ‘Just take it at my own pace and sort of, I think you can tell if you are over doing it \nwith your own body’.  \n \nIB10- ‘Em-, well I won’t be back at the gym.’ \n \nIB18- No heavy lifting ‘Will have to do light jobs like working on the wards’ – works in \ntheatres. ‘They reckon I might be at work after 6 weeks’.  \n \nOne participant was optimistic and felt that they should be almost back to normal in the \nTAH group. \n \n\n146 \n \nIB01- ‘I should be hoping by then things would be getting back to normal then. I would \nbe expecting to be getting, not 100% but at least 85% back to normal.’ \n \nIn the LH group, there were participants who felt that they may be driving by 1 month but \non the whole, their expectations were similar to the TAH group. Again, they expe cted not \nto be able to do strenuous exercise, vacuuming and listening to their bodies. \n \nIB21- ‘I’m gonna see how I go and then perhaps in a month I might be driving.’ \n \nIB06 ‘I hope after a month I will be able to do almost everything…Maybe not vacuuming \nbut maybe.’ \n \nIB16 ‘I don’t think I’ll be taking any strenuous exercise.’ ‘Just general things around the \nhouse.’ \n \nIB22 – ‘No driving’  \n \nIB13 ‘Well hopefully I will be able to do the majority of things apart from like real \nphysical exercise.’ \n \nOne participant talked about how she was not expecting to be back at work because of the \nadvice her doctor had given her. None of the group talked about being back at work by 1 \nmonth. \n\n147 \n \n \n IB06 – ‘The consultant said we sign you off for 6 weeks straight away’. \n \nThere were s imilar expectations around sexual recovery regardless of route of surgery, \nand this seemed to be due to what they had been told; \n \nIB22 (LAH) ‘I understand that I can’t be sexually active until maybe up to 6 weeks or \nso.’ \n \nIB10 (TAH) ‘The sex possibly not as it says on the thing. …on the leaflets that potentially \nit is 6 weeks.’ \n \n IB09 (VH) Sexual  ‘And like after childbirth as well, you have to refrain from sexual \nintercourse for 6 to 8 weeks anyway so  it’s just the same to me’. \n \nThe VH group had similar expectations at 1 month around driving, strenuous activity, \nheavy lifting.  \n \nIB09 ‘Possible drive, depending on whether you can get the seatbelt round you with my \ninsurance’. IB09 Has a night out paid for ‘Well. I have paid for it in the hope that I’ll go.  \nIts gonna give me something to, to work for’. \n \n\n148 \n \nIB14 –‘Would not be expecting to do vacuuming, going out shopping and driving, picking \nup grandson, gardening and dancing, driving – 6 weeks. ‘Yeh I’m worried about the \nmuscles. I am not sure what happens about your muscles so I will have to ask about that.’ \n \nExpectation of recovery two months post-surgery \n  \nAt this time period, there were differences in the expectations of recovery in the different \nsurgical route participants, but this was more marked in the VH group. The TAH and LH \ntalked about how they should be expecting to get back to normal and start thi nking about \nexercise again, vacuuming, pushing children’s prams, shopping and sexual intercourse. \nThe VH group were expecting to be careful around lifting and strenuous housework still \nat this stage.  \n \nTAH group \n \n IB07’ As long as I can do a bit of Christm as shopping and make sure that, coz he (son) \nstill believes in Santa so I’ve still gotta hide the presents so whether I out them in the attic \nthis year I don’t know’. \n \nIB10-‘I would hope 2 months after that the only limitations I would have would be at the  \ngym. And I would expect that everything else would be back to normal.’ \n \nIB01- ‘I’m hoping by the 6 weeks I will be flying round the block.’ \n \n\n149 \n \nThere was still reference to not pushing it and taking account of your body’s signals. \n \nIB18- ‘More or less the same but not pushing it’ \n \nLH Group \n \nIB21 ‘I should be as fit as a fiddle’. \n \nIB06 ‘Expecting to do everything and will be completely back to normal’.  \n \nIB16 ‘Em hopefully I will be back to normal.’  \n \nIB013 ‘Intercourse obviously cos they reckon 6-8 weeks for that. …obviously a lot of it is \ncommon sense isn’t it. Your body tells you how you are feeling’. \n \nIn the LH group, there were differences in expectations about whether they would be \ngoing back to work and these appeared to be related to their activity type at work. \n \nIB16 – ‘work 6 weeks’ (office worker). \n \nIB22 ‘Active but not necessarily back to normal.  No vacuuming, thinking about going \nback to work (nurse). \n \n\n150 \n \nVH group \nIB09 ‘Heavy lifting might hurt, can’t do some house work  ‘But I hope to be able to at \nleast walk to the school and pick my kids up.’ \nIB14- ‘No heavy shopping or picking up grandson. ‘I may be able to take him to \nplayschool’.  \n \n  \n\n151 \n \nRecovery expectations three months post-surgery  \n \nAll groups felt that they would be back to normal by 3 months. Th e LH group were more \noptimistic and used more positive words such as ‘great’ and ‘distant memory’ and being \nback at work, whereas the TAH group were talking about starting to feel normal. \n \nTAH group \n \nIB10 – ‘thinks should be able to do everything’. \n \nIB18- ‘By 6 months I will be more or less doing everything’. \n \n IB005 ‘Actually in my own mind I think I will be off about 3 months (from work)’. \n \nLH group \n \nIB21- ‘Oh I’ll be great’. \n \nIB06 – ‘Oh God, it’ll be a distant memory’.  \n \nIB16 – ‘Can do everything’. \n \nIB22- ‘Hopes to be back at work then’. \n\n152 \n \n \nIB13 ‘I should be fine.’ \n \nAgain, the VH group were more cautious in their recovery expectation at 3 months.  \n \nIB09 ‘I would like to be doing everything….work is my only grey area….But that’s \nsomething obviously my doctor and hospital would discuss with me.’ \n \nIB14- ‘I was hoping I would get to a bit of normal. Exercise, I will probably have to ask \nabout that.’ Didn’t think she would be completely back to normal’.   \n \n  \n\n153 \n \nExpectations of sexual recovery \n \nAll groups regardless of their route of surgery felt that there would be a positive change \nin their sexual functioning. There was some apprehension about sexual feelings and how \nto approach the subject with their partners. \n \nIB16 ‘Well I’d like to be but at the moment , no, well it would be too painful…Well I am \nhoping that my body feels better afterwards, so you know I am not worried about it but I \nam hoping I am optimistic that maybe I will get back to being a normal human being that \ncan take up any activities’. \n \nIB21- ‘Oh (it will be) a lot better. Because we are not at the moment…We haven’t for \nabout 18 months. Because every time we get in the mood it just happens. You know…I \nbleed you know and I am in pain.’ \nIB22 ‘You’ve asked me about how I, how I feel you know, I am going to approach things \nsexually, but I was wondering, I mean some people probably have reduced feelings \nafterwards, and for some it makes no difference. But you know that’s probably something \nI probably need to sit down with my husband and talk about.  I am just wondering you \nknow it, how it will affect me personally.’ \n \n  \n\n154 \n \nThoughts about surgery \nPositive \n \nPositive cognition was framed around trust in doctors, going through the stress of surgery \nin order to gain a solution to their problems and even a bet ter quality of life than they \nhave had (pain for gain), focussing on a good outcome and the positive experiences of \nothers. This was similar across all surgical routes. \n \nTAH group \n \nIB16 ‘Well I know I trust the doctors here and I know they are gonna do the ir best. \nThey’ve got the best available medication…so I know I’m gonna be in the best hands \nreally…you know that I’m gonna be on the mend’. \n \n IB22 ‘Well I’m quite nervous to be honest. Just in case something should go wrong but I \nhave gotten to the point w here I am quite happy that I have made the decision, you know \nbetween my gynaecologist and myself. You know based on the problems that I have been \nhaving in the past’. \n \nIB01 ‘I’m just thinking to myself now hopefully all the problems will go away…You know \nthe periods, the heavy periods, the pain, just hoping it all, I hope it’s worthwhile \nactually.’ \n \n\n155 \n \nVH Group \n \nIB01- ‘Everybody’s told me who I  know who’s had an hysterectomy, it’s the best thing \nthey ever did, even the woman at the bus stop said to me today,  she was telling me it was \nthe best thing that ever happened to her.’ \n \nIB14 – Hoping to get back to dancing ‘I found that awkward , planning holidays’. \n \nLH group \n \nIB006 – ‘So once that’s gone (bleeding) you know, I will be able to go if people are \nsaying oh do you wanna walk up mount Everest at the weekend I will be oh yeah \ncourse…I haven’t gotta worry where the toilets are.’ \n \nIB21 ‘Em, quite looking forward to it actually. It’s gonna change my life hopefully’. \n \nThe LH group talked about how they were stil l comfortable about their decision despite \nthe risks associated with surgery; \nIB21- Positive despite risks - ‘it can perforate your bowel or whatever but I am kind of \nnot bothered about that. You know I mean I just need this hysterectomy.’ \n \n\n156 \n \nIB22 – ‘Well I’m quite nervous to be honest. Just in case something should go wrong but \nI have gotten to the point where I am quite happy that I have made the decision, you \nknow between my gynaecologist and myself.’ \n \nNegative thoughts \n \nParticipants who talked about negati ve cognition were those who had a poor experience \npreviously of surgery, mostly associated with anaesthetic or complications; \n \nIB16 (TAH) ‘It’s just that I have had a few operations in the past and I know what it’s \nlike when you come round and you don’t fe el too good and you know the amount of time \nthat it does take to recover sometimes.’ \n \nIB14 (VH) Anaesthetic, pain after. ‘Because when you are put out….I mean you don’t \nknow whether you talk in your sleep or something or what. So I am a bit apprehensive \nbecause people say that you feel sick.’ \n \nIB13 (TAH) ‘My last operation they burst the discs in my back and damaged my \nbladder…so obviously there are some of my concerns…Being catheterised after the \noperation. They said it could be anything up to 72 hours. I am worried about that cos my \nbladder doesn’t, I don’t know when my bladder is full. The operation itself doesn’t worry \nme. Em, apart from when my sister had a laparoscopy, she nearly died…..she got \nsepticaemia in it….I have friends who have been in. Like w omen who have had \n\n157 \n \nhysterectomies and you know, so I’ve seen that not all of them go the same, so what will \nbe will be’. \n \nThere were also participants who were afraid because they had not experienced surgery \nor a hospital stay before;  \n \nIB06 (LH) ‘Petrified, I’ve never been in hospital before. ..I’m scared that I’m gonna \nwake up in pain. …and the whole hospital situation is very much out of my comfort \nzone….and because I’ve lived on my own for a while, I am used to doing everything for \nmyself’. \n \n IB21(LH) ‘I am dreading it..Being in hospital. The thought of just being in hospital \nterrifies me…But the MRSA things like that you know…….but the operation no. Not at \nall, I’ll be in and I’ll be out’. \n \nThere were anxieties around being able to carry out their usual roles and responsibilities \nsuch as child care and housework, as well as lose their independence and rely on others; \n \nIB07 (TAH) (single mother)  ‘ I am anxious, em not just because of the surgery but \nbecause my son has got to go and stay somewhere for a wee k and I’m not gonna see \nhim…coz I’ve no family in the vicinity…so it’s just extra extra pressure I suppose. …He \nis off school that week it fell really well actually, so he will be in Manchester with my \nbrother’. \n\n158 \n \n \n IB010 (LH) Leaving children - ‘And the fact  that they are gonna go and stay with my \nparents on Thursday and I’ve got to say goodbye to them and I get emotional and that \nand I’ve never really felt like that.’ \n \nIB24 (TAH) ‘My independence is gonna go..In like cos I won’t, for a while I won’t be \nable to tidy up, I won’t be able to cook, I won’t be you know to do like, somebody is \ngonna have to take over everything and it bothers me’. \n \nIB01(LH)– ‘I just thought I’m gonna be bed ridden and that’s what I didn’t wanna do \nthat’.  I spoke to the nurse…she sa ys that I would be able to walk to the little corner \nshop’.  \n \nIB06 (LH) ‘Scared to death…I’m scared that I’m gonna wake up in pain…That I’m not \ngonna be able to cope very well with the pain and with the whole hospital situation is \nvery much out of my comfort zone. Coz it’s completely unknown.’ \n \nOnly one participant talked about the fear of sexual recovery and what it will be like \nafterwards; \n \nIB01 (LH) ‘I’m worried about all the dos and don’ts you can do. But my main issue was \nem sex. That was my main worry  and but obviously I spoke to somebody (the pre -op \n\n159 \n \nnurse) about that….and I was quite happy with what they told me about it. You know. \nThat it’s just as normal as it could be.’ \n \nAgain, there were similar negative thoughts about surgery and surgical recovery across \nall surgical route groups. \n \nLoss of fertility \n \nThere were a few women who talked about the effect of surgery on their fertility and how \nthis had made them feel;  \n \nIB13 I’ll cry my eyes out, but you know, like I say I don’t want no more chil dren so that’s \nnot gonna be, it’s not like as if em Iv’e been just told I’ve gotta have this and no choice in \nthe matter’. \n \nIB24 ‘My partner hasn’t got any kids…I feel really emotional that I have a kid and he \nhasn’t got any. But I have to do it. So I am j ust thinking down the line. Where we go from \nhere, cos he is gonna want kids. But he doesn’t want any you know. I don’t know how he \nis gonna react. He said he is fine..but you never know later on’. \n \n IB07 (LH) ‘I’m too old now to have any more children…But..I don’t know really. It’s..It \nseems a bit sad the thought of it’.  \n \n\n160 \n \nSome women were philosophical or had decided that they did not want children and so \ndid not mind losing their uterus. \n \n IB06 (LH) ‘I’ve not had children so I’ve not had any sort of major interference with my \nbody. You know I’ve not had any other illnesses. So I suppose when you have a child you \nknow a bit about what maybe is to come. I mean I know most women in my situation \nwould be like oh gosh I can’t have any children…And here I am saying I’m afraid of the \npain. It’s like oh well if I had wanted a baby I would have had one years ago or \nwhatever…I just want an end to this bleeding’. \n  \n\n161 \n \nPart III Post-surgery experiences \n \n1. Post-surgery attitude of others \nSome women spoke about the attitudes of family members and the effect of surgery and \nhospital stay on them. \n \nIB17- ‘Told the kids that I was gonna be going into hospital for a couple of days but I \nwould be back which scared my son a lit tle bit. Cos he is sort of 7, so he was a bit \nconcerned about me going in but I promised him that I would be fine, that I would be \nback, you can come and see me I won’t be long’.  \n \nThis participant had been quite tearful before surgery about whether her hu sband would \nunderstand and how he would react to her recovery needs after surgery. She went on to \ntalk about her experience of how this was after surgery:  \n \nIB02 – ‘He was leaving me half a kettle of water, so I could just tip it and make me own \ncups of tea…I says I’ll get by. He’d do me a sandwich you know, ready for me tea, make \nsure I was fed before he went to work.’ \n \n  \n\n162 \n \nEffects of surgery and illness \nParticipants who talked about the effects of surgery were positive and spoke about how it \nhad solved their problems and improved their quality of life; \n \nIB05 (TAH) ‘I feel like I know what it’s like to be in your 80s or something, to be a really \nold person, and it’s sort of been reversed and I am just really happy.’ \n \nIB17 (TAH) ‘I had to sort of limit what I could do cos of how bad my periods were. Now \nI can do whatever I want it’s gonna make no difference whatsoever.’ \n \nIB21 (LH) ‘Quality of life much better now, can do much more ‘Gardening, going out, I \nused to have to take a bag with me with pads and a new set of trousers or skirt. I am \nlooking forward to my holiday…last year was horrendous. I had a period from the time I \nwent to the time I came home. You know and it was just, I couldn’t do nothing. I felt dirty \nand you know even though I was showering every  day, well about 3 times a day, it was \njust horrendous. But this time I am looking forward to it.’ \n \n IB06 (LH) ‘I’ve got 3 little dashes on me belly. They’re nothink. You know, they’re \nnothink and to have you know such a major thing removed.’ \n \nIB 13 (LH) ‘I had gone from this tired, bleeding person to like this happy sparkly person. \nSo like totally changed me straight away.’ \n \n\n163 \n \nExperiences of hospital and surgery \nHere there were differences between the three surgical routes, in particular a lower length \nof stay in the LH group.  \n \nIB05 (TAH) ‘I had it done on Tuesday late afternoon, Thursday morning they let me go \nhome.  . So I just went back and had the stitches out 5 days later and then just been \ngetting better and better. ‘‘I was thinking I would be in for about 5 days’. ‘It was right to \ngo (home when she did), and I knew then I could have gone straight back in if there was \nany problems’. \n \nIB17 (TAH) 2 days ‘I thought I was gonna be in there until Monday (extra 4 days) to be \nhonest’.  \n \nIB8 (TAH) ‘I was in on Wednesday and came out Friday.. I was very pleased to come \nout...it was exactly right for me’. \n \nIB21 (LH) ‘Tuesday to Friday, 1 day longer than expected because she had a cold’. \n \nIB06 (LH) ‘You know I wasn’t in hospital lon g. I was only in one night…And I was out, \nwhich I was delighted about cos I was really scarred about my hospital stay.’ \n \nIB06 (LH) ‘I bought two nighties for my hospital experience and I should have left the \ntags on and taken them back.’ \n\n164 \n \n \nOne participant i n the LH group (IB22) had a prolonged stay which was not associated \nwith any complications of 3 days, which was similar to the TAH group. \n \nActual recovery experience \nThe actual recovery experience and mile stones were more associated with the individual, \ntheir circumstances and complications rather than the surgical route. \n \nTAH Group \n \nIB05 ‘after 3 weeks it was like a bit of bleeding again and I thought oh no, you feel like \nyour insides are falling out…but I just went to the GP and got some antibiotics. Cleared \nup then and just so relieved and so happy to have it done.’ \n \n IB05 – ‘It’s slow because  you feel really good and then you probably overdo it a bit, I \ndon’t know just walking round, it’s like the weight kind of collects just at your stomach \nand you get this numb, your stomach goes numb. At first you feel as if it’s some kind of a \nspace hopper or something you know, sort of you know from the inside. But that just gets \nless and less.’ \n \nIB08- ‘I was out and about 2 days afterwards…I started my exercise regime …on \nSaturday which was the day after I came out of hospital I walked round the garden. A nd \non Sunday I did 10 minutes’ walk.’ \n\n165 \n \nIBO8- Mother was ill and had to go on the train to Gloucester herself around 2.5 weeks – \n‘I did feel extremely tired afterwards and my stomach felt, did feel swollen and bloated’. \nShe didn’t feel she was doing herself any harm – ‘I just thought, I would get warnings if I \nwas doing myself some harm and I didn’t feel that. I just felt very tired from that.’ \nIBO8- At 8 weeks doing everything – ‘I think I hovered after about 6 weeks.’ \n \nIB05 – ‘So now there is very little I couldn’t do’. (3 months). \n \nVH Group \n \nIB03 ‘Very tired the first couple of weeks…Extremely, I was sleeping 16 hours a day. \nDon’t know if that’s normal or not. …..Em, had a bit of an infection. Three no two lots of \nantibiotics’. \nIB03 ‘And I just remember my throat was so sore, so dry, but obviously from that \nbreathing pipe.’ ‘I didn’t like the catheter’.  \n \nIB02 ‘In fact my biggest problem was remembering that I’ve had something done and I \nmustn’t lift heavy weights.’ ‘But once I had the drip off and the oxyge n off and all those \ntubes out and I just trotted off to the bathroom as I wanted, I was fine.’ \n \nIB03 Pain – ‘Fine, I didn’t even take paracetomol. I did as a matter of routine the first \ncouple of days, but after that.’ \n \n\n166 \n \nLH Group \n \nIB22 ‘It’s been really good’.  \n \nIB22 ‘After the first week or so, I wasn’t in a lot of pain and I kept taking my painkillers, \nso I didn’t have much problem at all, and I was able to go up and down the stairs.’ \n \nIB22- ‘I went back to work after what 10 weeks’. \n \nIB06 ‘And I never felt ill in myself. I was tender and uncomfortable at times but it wasn’t \nreally anything to complain about. You know I’ve felt worse when I‘ve had the flu.’ \nIB06 ‘Well I didn’t really lift anything for weeks and when I first vacuumed after about 6 \nweeks cos I  had to, em it took my breath away.’ \nIB06 – pushed herself with walking a bit further every day but then felt tender ‘And then \nI’d just lie down. I mean it soon got better and then I was angry with myself thinking you \nhave had major surgery.’ \n \nMost participants did not drive until after 6 weeks, regardless of surgical route, however, \nthere were two participants who drove much sooner. One had a TAH and the other had a \nLH. \n \nIB02 (TAH) - Driving for 3 weeks (interview at 8 weeks) seat belt annoying – ‘Because I \nam wearing it round the bottom half, it gets quite tight when you are driving .’ \n\n167 \n \n \nIB06 (LH) Driving after 3 weeks. Work after 8 weeks GP said ‘6 weeks is optimistic.’ \n \nExperiences versus expectations \nMost participants talked about a b etter experience of recovery as compared to their \nexpectations in all groups. This was not particularly associated with route of surgery. \n \nTAH group \n \nIB8- ‘My expectations are usually quite realistic I think.. Erm, I suppose it’s from the \ninformation I’ve gathered and em probably past history of surgery’. \n \nIB05 ‘Like just walking, for a long time….and I knew I felt that I could really do some \ndamage if I kept that up. And so I feel as I needed to lie down cos that pulling and that, \nthat’s gone on for a long  time really; which was to be expected. But I just wasn’t \nexpecting it’.  \n \nInfluences from other’s experiences were negative  \n(IB05) one woman had a hysterectomy around her 40th birthday and was depressed for \n10 years and I thought ‘oh I’m gonna feel reall y miserable and, but I didn’t I was just so \nrelieved that I had it done and so happy’.  \nThe same lady was prepared to have no sex life and was pleasantly surprised \n\n168 \n \n‘Perfectly alright. That was my main worry’, be depressed and have a ‘horrible scar like \na l adder going up your stomach.  And the scar you can’t even see any stitches or \nanything, it’s just brilliant’.  \n \nIB08- ‘Emotionally ‘no different to usual’ \n \nIB17 ‘Recovery was a bit faster than what I expected. I was up and about within sort of 2 \nweeks. I was pretty much back to normal within 4 weeks as opposed to 6 which they said. \nI did have an infection. But I got over that quite quickly.’ \n \nThis participant (IB17) said she had a positive attitude;  ‘Once I have decided something I \ngo for it with no ends or buts about it I will do it.’ \n \nVH group \n \nIB03 – ‘They were saying well you can’t even lift a kettle and things. Well I did….Day \none.’ How was she ‘Fine’. ……’Em after about 2 weeks I mean I went shopping.’ \nVacuuming after 2 weeks.  IB03  6 weeks off work – right for her. \n \nIB02 – ‘Much better than I expected’. ‘Because someone told me that if you have an \nanaesthetic it sometimes knocks off a few brain cells and I haven’t got many to be \nknocked off. I can’t afford to lose any and I thought perhaps I am a bit worse. But I don’t \nthink I am now.’ \n\n169 \n \nIB02 – Felt she could have gone home earlier (stayed 3 days) but it would have been \n‘unwise to….Silly to rush things’. \nLH group \n \nIB22 ‘What I was worrying about before, I don’t kn ow, it’s all gone. I think I was just \nunnecessary worries really’.  \n \nIB21 ‘It was plain sailing actually. I have heard that many rumours that you know they \ncut through to your bowel…… it can happen can’t it, you get to sign a consent form \nsaying that if an y of these symptoms happen you know it does happen. But I have had \nnothing and I am so grateful for that, you know cos it was a big concern when they go in \nblind that they can perforate something.’ \n \nIB13- Driving after 3.5 weeks ‘Better than what I thought . I was doing things more of \nless straight away. I didn’t really feel like I had had a major operation.’ \nIB13- ‘I had more pains with my previous problems than what I did with the \nhysterectomy.’ At 3.5 weeks was completely back to normal’. \n \nSome participan ts talked about being well prepared and how this has made their \nrecovery better; \n \nIB22 (LH) ‘Well I think that was why everything went smoothly, because I had you know \ngood preparation before and I had leaflet that I could go back and read information that  \n\n170 \n \nI couldn’t remember, you know, so I was well prepared, you know mentally and \notherwise.’ Thinks the method used improved her recovery. \n \nParticipants talked about listening to their own bodies in all the surgical route \ngroups; \n \nIB17 (TAH) ‘I have faith in sort of my body will let me know if I am pushing myself too \nhard. And then I would have stopped. But cos of how well I could, I just got on with it.’ \n \n IB03 (VH) Expectations – surprised because ‘I thought I would literally be bed bound as \nsuch.’ Influenced by what people told her, ‘But the one thing I did do and it always stuck \nin my  mind. Listen to your body’.  \n \nSome participants in all surgical routes had a worse recovery experience than they \nhad anticipated; \n \n \n \nTAH group \n \nIB05 – Was worried about sex life mainly – ‘perfectly alright. That was my main worry’.  \n \n\n171 \n \nIB02- ‘I was expecting to be back at work within the 12 weeks.’ Struggled with washing \nhair over a bath, described her recovery as a ‘rollercoaster’. Uncomfortable go ing up \nand down stairs. Post-operative wound infection during first week – ‘I couldn’t even put \nme drawers on. Everything was catching. It was really uncomfortable…it was all like \npulling.’ But compared it to her emergency CS 27 years ago and ‘It brought i t all back’. \nRemembers her sister helping her wash her hair over the bath then as well.  \nIB02- ‘it took me a long time to actually start sleeping on my side…Em, about 12 weeks.’ \nIB02  Did not anticipate that she would need different clothing due to pain and tenderness \n‘I’ve managed to find some very elasticated underwear…They come up to my belly button \nand there’s no seams.’  \n \nVH group \n \nIB03 ‘The only thing I was surprised but I had been warned, the amount of wind that you \nget….and the bloated feeling, it’s  horrible. I mean that it was really uncomfortable, I \nwould say it was more uncomfortable than the operation’. \nIB03 ‘So, it did get me down for a while, you know, you think oh I am not a woman, not a \nproper woman anymore, I can’t have babies.’ ‘It’s not li ke having breasts removed. \nBecause it’s not physical but mentally it did affect me for a bit. Just a couple of weeks but \nno I feel really good.’ \nIB03 – Kept ovaries and was surprised to get PMT ‘I just thought well I won’t have \nperiods I won’t get PMT.’ \n\n172 \n \nIB03 – had an infected haematoma ‘And then when I had the bleed..Em…they said they \nmay need to open me up if the bleeding didn’t stop…Which scared me again. Because I \nwasn’t mentally prepared to be opened up.’ \n \nIB06 – Wind pain was worse than expected and used a full tin of chocolates to put her \nfeet on when she was on the toilet to ease the pain. ‘I wish I’d done a swap phone \nnumbers with one of the ladies who went in on the same day to see how they were \nrecovering.’ \n \nEffect of healthcare professionals \nRegardless of surgical route, there was a strong influence of healthcare professionals in \nthe recovery experience. \n \nIB05 (TAH) ‘I felt like he had really listened to me and done what I wanted \n(surgeon)…….‘ I mean they are there, there’s a team there and you k now they were just \nbrilliant, you felt safe. ‘ \nIB02 (TAH) ‘Em, went for my 6 week check up with my doctor, just gave me a doctor’s \nnote and sent me on my way…She wasn’t eh, she didn’t examine me or nothing.’ \n \nIB06 (LH) Felt ward staff were very busy and so did not call them post operation when \nshe had a question about her bleeding. ‘the nurses didn’t seem to be particularly expert, \nbut you know there was the sister and everyone else seemed to be a student nurse.’ \n \n\n173 \n \n \nVH group  \n \nOB14- ‘But I am seeing a very good consultant, Mr X, he seems very reassuring’. \nIB14- ‘I have listened to what the consultant said and what was said in the hospital and \ntried to just focus on that really rather than on other people’s stories because you have to \nbe careful of that.’ \nIB14- ‘And if I am told by the doctors don’t do that I won’t. Because I want to, I would \nrather get better.’ \n \nIB03 ‘The anaesthetist was lovely. Because I was more afraid of not waking….But em, he \nreassured me.’ \nIB03 – Did not meet the consultant surgeon until the operating day ‘Em I mean he was \nnice enough, casual laid back sort of thing. Which is great because to me if they are too \nformal you get a bit of a barrier don’t you, you are afraid to ask questions.’ \nIB03 – ‘A night doctor. And he was really reassuring em and explained to me what had \nhappened and you have had a rough day and I went yeah. He was lovely.’ \nIB03 – When complication happened consultant ‘To me the way he explained it in plain \nEnglish and I knew what he meant…You know not like in the medical terms.’ \n \nIB02 ‘I tried to be sensible. And I think I must have succeeded because Mr X was very \npleased with me.’ \n\n174 \n \nIB02 – ‘Well you know my GP…said it is a nice little hospital you know, they will look \nafter you well and you will be alright there, that encouraged me.’ \n \n  \n\n175 \n \nWhat to tell others \nAgain, there were no particular themes linked to the surgical route and what participants \nwould tell other women who are having a hysterectomy, the advice seemed to be more \nrelated to the individual, their experience and circumstances. Advice included practical \nadvice and ways to prepare themselves. \n \nTAH group \n \nIB17  ‘be prepared for the swollen tummy and to make sure they get some clothes that \nwould fit.’ \n \nIB02 ‘There’s, there’s a lot to it, I mean if a woman is suffering you’ve got the choices.’ \n‘I don’t think you can prepare anybody mentally for it.’ Talked about how she felt it \nwould be easier to recover if you were slimmer, she felt the stitches pulled on her skin \ndue to her being ‘big’.  \n \nVH group \n \nIB03 ‘Just listen to what you are being, you know listen to them, they know what they are \ntalking about basically, they are professionals.’ \nIB02 – ‘Bring sanitary towels and a good supply of clean pants’. \n \n \n\n176 \n \n \n \nLH group \n \nIB21 ‘Get everything sorted at home….so all you’ve gotta do is when you go into hospital \nis think about yourself and think how you are gonna recover after.’ \nIB13 ‘I think mentally you’ve got to be prepared yourself. I knew that getting rid of \neverything would solve  half my problems. Well it solved them all….I think it’s down to \nthe individual.’ \n  \n\n177 \n \nDiscussion \n \nOur study shows that there are very little differences between the recovery expectations \nand experiences of women who have a hysterectomy regardless of the rout e of surgery. \nThe laparoscopic hysterectomy group showed a faster recovery period than the \nabdominal hysterectomy group and the vaginal hysterectomy group had specific concerns \naround their recovery which were associated mostly with a fear of causing damag e to the \nstitches by heavy lifting. There are published data around differences in analgesia use and \nhospital stay for laparoscopic versus vaginal hysterectomy (110), our study did not \ncompare analgesia use, however, our data did not show a clear reduction in hospital stay \nfor the laparoscopic group. \nOtherwise, they all had similar fears around the surgery, hospital stay, concerns about \ntheir responsibilities, attitudes around femininity and loss of fertility and sexual function. \nI was surprised at the depth and complexity of some of the comments, there were emotive \nand powerful words used such as ‘horrendous’ ‘dirty’, ‘grabbed my life’ , I had not \nconsidered previously to enough extent that heavy  menstrual bleeding would have such \nan impact. There was significant confusion around recovery expectations and difficulty in \ntalking about sexual feelings. It made me consider whether as a society we have done \nenough yet to reduce the taboo around talking  about sexuality and sexual emotions. As \ngynaecologists and health care providers, I feel this is somewhere we could improve on \nas well. Although this study did not aim to look at it, the role of women in this stage of \ntheir lives was highlighted. Women ha ve so many responsibilities which include looking \nafter children, wider family members as well as working for a living. The time that most \n\n178 \n \nwomen have a hysterectomy for heavy menstrual bleeding is at their prime, when these \nresponsibilities are paramount. It was evident that a number of women had struggled with \nprioritising their other responsibilities over their own health and put off treatment. \nConsidering how common heavy menstrual bleeding and hysterectomy at this age is, I do \nnot think that as a societ y we really appreciate the wider impact these medical problems \nhave on society; nor do I think after this study, we do enough to support such women in \nmy opinion.  \n \nI had not planned to compare how women felt after they had their ovaries removed versus \nconservation of ovaries, hence this data was not collected and the groups were not \nbalanced in terms of those who had or did not have ovaries removed. The interviews did \nnote some differences particularly in the expectations and feelings of emotion during \nrecovery. In addition, I had not included any details or questions around whether or not \nwomen were on hormone replacement during recovery, which again could have affected \nemotional and physical recovery. These were limitations of the study; although a number  \nof women did talk about having their ovaries removed and considering hormonal \ntreatment.  \n \nPrevious studies have reported that patients see the main advantage of a hysterectomy \nbeing no bleeding, with some women experiencing no pain or bloating after surg ery. \nHowever only 13% reporting feeling strong, healthy and fit and even less (4.8%) \nreporting no social handicaps in terms of their life, job and socially and 16% reported \nnegative attitudes towards hysterectomy including a feeling of loss and diminished \n\n179 \n \nfemininity (111, 112) . There may be some cultural differences between the attitudes \nwomen have towards hysterectomy, which we did not explore as part of this stud y. In a \nTaiwanese qualitative study, women felt that once they had completed their families, the \nuterus was ‘useless’, with five themes: release from stress, inescapable fate, positive \nsupport, hoping for peace of mind and sense of trust as reasons for cho osing the \nhysterectomy (113). Whereas, in other cultures, there was evidence of a m ore critical \napproach with consideration of the pros and cons of hysterectomy and the transition that \noccurs in self (114).  \n \nSexual function after a hysterectomy is reported to improve or remain unchanged by \nmany women (115-118), but a minority of women report a worse sexual function (118) . \nOur study found a positive effect in sexual function regardless of route of surgery, which \nconcurs with the published literature (119), again we did not take into consideration  \nwhether ovaries were removed or hormone replacement was taken. \n \nIt is unclear from the published literature how much women value sexual function after a \nhysterectomy over physical symptoms such as pain and bleeding and it may be that health \ncare professionals are still reluctant to give advice freely as part of a routine consultation \nand informed consent procedure about sexual function. Better pre -operative information \nabout what to expect regarding sexual function after a hysterectomy has been shown to \ninfluence satisfaction with hysterectomy (120). Using the Female Sexual Function Index \nand a positive and negative checklist of sexual outcomes, this study showed that pre -\noperative education about potential negative sexual outcomes was assoc iated with higher \n\n180 \n \npositive scores with hysterectomy experience. For the women who received this \ninformation or asked questions about it in our study, we found there was a more positive \nexperience after the surgery. Some women did not speak about the sensit ive issue of \nsexual expectations or felt uncomfortable when they were mentioned. It is known that \nthere is an effect of the interviewer on whether such topics are disclosed (121). The fact \nthat the interviewer here was a female and gynaecology doctor may have had an effect on \nthe responses from the women and need to be considered throughout this part of the \nstudy, both in a positive and negative way. The interviewer may have felt more \ncomfortable discussing the sensitive issue of sexual expectations and experiences, but this \nmay have been uncomfortable for some women, whereas other women may have found it \neasier to open up to a gynaecologist. The effect of the interviewer may have been even \ndeeper with women perhaps wanting to ‘say the right thing’ to a doctor. We have tried to \nreduce this risk by structuring the interview with a statement around the personal beliefs \nand experiences of each women, and that there are no ‘correct’ answers. \n \n Pre-operative education on other hysterectomy outcomes has been shown to p romote \nself-care behaviours, encourages post -operative ambulation and reduces post -operative \nanxiety and pain (122).  \nIt is likely that more targeted information which women find useful will help in the fears, \nexpectations and recovery from all types of hysterectomy. In our study, there were both \npositive and negative effects of the wide variety of information available, particularly \nfrom the internet which is not managed or signposted. Specific aids such as websites, \napps or videos, which are centred around women, and can be trusted by women should be \n\n181 \n \ndeveloped. Furthermore, we know that there is an association with pre -operative \npsychological wellbeing and positive recovery (123), which is affected by various \ntechniques including information and empowerment. Negative recovery in this study was \nassociated with a poorer pre -surgical psychological wellbeing state and minor \ncomplications post-operatively. \n \nConfounding the issue of psych ological recovery is confusion and conflicting advice \naround the recovery timescales and hospital stay with each route of surgery. We know \nthat there is variation between the beliefs of health care professionals around recovery \nand this may explain the inc onsistent messages women receive. A study of healthcare \nprofessionals and patients the in Netherlands has offered a prediction model of prolonged \nrecovery at 6 weeks which may help with counselling women about their expectations \n(124).   \n \nConclusion \nIt does not appear that the route of surgery had very much effect on the expectations nor \nthe actual recovery experience of  these patients. The only theme that was related to the \nsurgical ro ute was a lower length of stay in hospital in the LH group. Women’s \nexperiences were influenced by the information they receive, their individual perceptions \nabout the surgery and recovery, the advice from health care professionals. \n \n\n182 \n \nChapter 5: V alidated health status questionnaires to women who have had a \nhysterectomy \nAim \nTo study the quality of life before surgery, at 1 and 4 weeks after hysterectomy and at 3 \nmonths after hysterectomy in the qualitative group of participants. \nMethodology \nThree measures o f quality of life questionnaires were given to all the participants in the \nqualitative study from chapter 4 at the four time points. These questionnaires were \nsuggested by my supervisors early on in the study period. The various questionnaires \nwere chosen to ensure that there was representation of health status, quality of life and \ndisease specific measures for menorrhagia. The participants were asked to complete the \nquestionnaires in their own time and post back to the researcher in a self -addressed \nenvelope.  \n \nMeasures  \nSF12 Questionnaire (appendix 14) \nThe short form (SF) -12 questionnaire was developed from the longer, well established \nSF-36 questionnaire as a shorter, more feasible version to assess health related quality of \nlife (HRQoL). The SF -36 is one of the most widely used questionnaires for this purpose \nand it has been validated ag ainst other questionnaires such as the Nottingham Health \nProfile and the sickness impact profile for patients with coronary heart disease (125).  \nThe SF -36 was lengthy with 36 items and took a considerable amount of time to \ncomplete.  The SF12 was developed by Ware et al reducing \n\n183 \n \n \n the item number to 12, which was subsequently shown to require about one third of the \ntime of the SF -36 to complete  (126).  The SF -12 correlated with summary measures for \nthe SF-36 in a US general population observational study of chronic conditions and HR -\nQoL was shown to correlate with the SF -36 in a study of patients with coronary heart \ndisease with no dif ference in standardized response means (p<0.001) and the study \nconcluded that the SF -12 was an efficient alternative to the longer SF -36 (127). The \nscores are positively correlated with health related quality of life. \n \nEuroQuol 5D (appendix 15) \nThe EuroQuol 5D (EQ -5D) (euroquol.org) is a standardised measure of health status \nwhich is non -disease specific and can be applied to a range of health conditions and \ntreatments. It consists of a descriptive profile covering mobility, self -care, usual \nactivities, pain and discomfort and anxiety or depression, with a single index value for \nhealth status on the day of completion using a visual analogue scale  which is positi vely \ncorrelated with health status . The EQ-5D is designed to be completed by the respondent \nfor postal survey; it is designed in a way which is cognitively undemanding and takes a \nfew minutes to complete. The instructions to the respondent are contained within the \nquestionnaire. The EQ5 was developedand validated in 1990 by the EuroQol group (128). \n \nMenorrhagia Outcomes Questionnaire (Short Form) (Appendix 17) \nThe Lamping Menorrhagia Outcomes Questionnaire is a disease specific questionnaire \nfor heavy menstrual bleeding. It was developed to evaluate outcomes of hysterectomy \nand other procedures for treating menorrhagia. The questionnaire is validated (129) and \n\n184 \n \narose from a longer research questionnaire used in the North West Thames Hysterectomy \nStudy(130). It was designed to evaluate clinical, quality of life and patient satisfaction \noutcomes 3 months after the procedure by a postal survey.  \nThis questionnaire has 26 items to evaluate patient symptoms (2  items), post -surgical \ncomplications (3 items), quality of life (7 items) and patient satisfaction (5 items). As \nwell as these disease specific questions, it collects data on demographics and 1 item on \nthe patients’ global evaluation of their bleeding and or pain in the 4 weeks before surgery.  \nThe 17 items related to patient outcomes are scored to create two summary scales: \nThe Total Outcome scale (17 items) is an estimation of the patient’s overall outcome, \nincluding clinical and quality of life and satisfaction. \nThe Quality of Life/Satisfaction scale (12 items) includes items on fatigue, irritability, \ndepression, general health, improvement in symptoms, limitations in daily activities, \nsexual functioning, body image, speed of recovery, satisfaction with i nformation about \nthe operation and with the results of surgery, and willingness to recommend the operation \nto a friend with a similar problem. Scores are positively correlated. \nThe demographic and treatment related questions along with the global evaluatio n of \nsymptoms before surgery are descriptive and therefore not scored to form summary \nscores.  \nAnalysis of variance (ANOVA) was chosen as the statistical test to compare means of \nmore than 2 groups. In our case, we had 3 groups and multiple time points. Th e ANOVA \ngives an F value as its comparison of means and significance of means is tested using a P \nvalue, where significance is P> 0.05. All statistical analysis was undertaken on IBM \nSPSS v-16 © by MS.  \n\n185 \n \nHealth status questionnaire results \nEQ5 \nEQ5 scores increased 1 week after surgery and then fell with time during the recovery \nperiod, being lower at 3 months than pre-surgery (table 5.2). Quality of life on the visual \nanalogue score was lowest (low score is lower quality of life) 1 week after surgery, and \nagain improved with recovery with a high score. The mean visual analogue scale (VAS) \nscore was higher 3 months after surgery as compared to pre surgery; however this was \nnot significant (table 5.3). Table 5.2 number of women who reported problems in EQ5 \ndomains at each time point.  \n\n186 \n \nResults \nTable 5.1 shows the number of women in each route of hysterectomy group. This sample \nwas the same as the cohort who participated in the interviews in chapter 4. \n  \n\n187 \n \n \nTable 5.1 Participants \nRoute of hysterectomy Number of participants \nAbdominal 7 \nVaginal 4 \nLaparoscopic 9 \n \nTable 5.2 \nTime \nperiod \n%  (number) of women with problem   \nMobility Self-\ncare \nUsual \nactivity \nPain/discomfort Anxiety/depression  Missing \nPre-\nsurgery \n17% \n(5) \n10% \n(3) \n34% \n(10) \n31% \n(9) \n24% \n(7) \n0 \n1 week 28% \n(8) \n14% \n(4) \n52% \n(15) \n52% \n(15) \n17% \n(5) \n41% \n(12) \n4 weeks 7% \n(2) \n7% \n(2) \n24% \n(7) \n24% \n(7) \n10% \n(3) \n52% \n(15) \n12 \nweeks \n7% \n(2) \n3% \n(1) \n3% \n(1) \n10% \n(3) \n3% \n(1) \n59% \n(17) \n \n \n \n \n\n188 \n \nTable 5.3 mean EQ5 scores at each time point. \nTime point Pre surgery 1 week 4 weeks 12 weeks \nMean EQ VAS \n(SD) \n71.37 \n(25.07) \n47.67 \n(28.01) \n81.15 \n(22.28) \n84.81 \n(19.60) \n \n  \n\n189 \n \nTable 5. Analysis of variance ( Anova) for mean EQ5 VAS scores according to route of \nhysterectomy and time point \n F Value Sig \nPre-surgery 0.848 0.446 \n1 week 0.846 0.447 \n4 weeks 0.133 0.876 \n12 weeks 0.164 0.850 \n  \n\n190 \n \nSF12 Results (Fig 5.1-5.48) \nThe SF12 results are presented to compare responses to each question by the routes of \nhysterectomy at the different time points. \nSF12 was analysed by route of hysterectomy at the vario us time points. Due to the small \nnumbers of participants in each group, statistical analysis was not done. There was \nmissing data for all time points but the proportion of missing data increased with later \ntime points after surgery. \nIn the pre surgery questionnaire, there were very little differences in SF12 responses for \nthe LH and TAH groups. In SF12 question 4, less patients in the VH group reported that \nthey were limited in their accomplishments as a result of your physical health in the last 4 \nweeks and no women in the VH group reported that they had accomplished less as a \nresult of their emotional problems in question 7. The VH group reported less interference \nwith work due to pain in question 8. The VH group reported feeling cal m and peaceful \nmore of the time as well as having energy more of the time in questions 9 and 10, and \nwere the only group who reported no effect on their social functioning as a result of their \nhealth or emotional problems. \nAt 1 week after surgery, there wa s a reduction in quality of life as a result of physical \nhealth in all groups. Again, the VH group reported fewer limitations as a result of their \nemotional health than the TAH or LH groups (questions 6, 7and 9), although 3 of the 4 \nwomen in the VH group d id report feeling down in the past few weeks in question 11. \nThe VH group also reported less interference in activities as a result of pain in question 8.  \nAt 2 months after surgery, the TAH group reported more negative answers in all domains, \nincluding questions 2, 3, 4 and 5 in the physical domain and its effect on activity, as well \n\n191 \n \nas in the emotional domain for questions 6 and 7. The TAH group had a greater negative \neffect on role in questions 8, 11 and 12, and less vitality in question 10. \nAt 3 months after surgery, apart from question 2, the only group who reported any \nnegative answers to any of the domains were the TAH group, although the number of \nwomen who had negative effects on quality of life was small. \n \n \n \n \n \n \n  \n\n192 \n \nGeneral health subdomain \nFigure 5.1 \n \n \n  \n\n\n193 \n \n \nPhysical Functioning Subdomain \nFigure 5.2 \n \n \n \n \n \n \n \n \n \n \n \n\n\n194 \n \n \n \nFigure 5.3 \n\n\n195 \n \nRole Functioning (Physical) Subdomain \nFigure 5.4 \n \n \n \n \n \n \n  \n\n\n196 \n \nFigure 5.5 \n \n \n \n  \n\n\n197 \n \n \nRole Functioning (Emotional) Subdomain \nFigure 5.6 \n \n \n \n \n  \n  \n\n\n198 \n \nFigure 5.7 \n \n \n \n \n  \n\n\n199 \n \nBodily Pain Subdomain \nFigure 5.8 \n \n \n \n  \n\n\n200 \n \n \nMental Health Subdomain \nFigure 5.9 \n \n \n \n \n \n  \n  \n\n\n201 \n \nVitality Subdomain \nFigure 5.10 \n \n \n \n  \n\n\n202 \n \nMental Health Subdomain \nFigure 5.11 \n \n \n \n \n  \n  \n\n\n203 \n \nSocial Functioning Subdomain \nFigure 5.12 \n \n \n \n \n  \n  \n\n\n204 \n \nFigure 5.13 \n \n \n  \n  \n\n\n205 \n \nFigure 5.14 \n \n \n \n \n  \n\n\n206 \n \nFigure 5.15 \n \n \n \n  \n  \n\n\n207 \n \nFigure 5.16 \n \n \n \n  \n  \n\n\n208 \n \nFigure 5.17 \n \n \n  \n  \n\n\n209 \n \nFigure 5.18 \n \n  \n  \n\n\n210 \n \nFigure 5.19 \n \n \n  \n  \n\n\n211 \n \nFigure 5.20 \n \n \n  \n  \n\n\n212 \n \nFigure 5.21 \n \n \n  \n  \n\n\n213 \n \nFigure 5.22 \n \n \n  \n  \n\n\n214 \n \nFigure 5.23 \n \n \n  \n  \n\n\n215 \n \nFigure 5.24 \n \n \n  \n  \n\n\n216 \n \nFigure 5.25 \n \n \n  \n  \n\n\n217 \n \nFigure 5.26 \n \n \n \n  \n  \n\n\n218 \n \nFigure 5.27 \n \n  \n  \n\n\n219 \n \nFigure 5.28 \n \n \n \n  \n  \n\n\n220 \n \nFigure 5.29 \n \n  \n  \n\n\n221 \n \nFigure 5.30 \n \n  \n  \n\n\n222 \n \nFigure 5.31 \n \n  \n  \n\n\n223 \n \nFigure 5.32 \n \n \n  \n  \n\n\n224 \n \nFigure 5.33 \n \n \n \n \n  \n  \n\n\n225 \n \nFigure 5.34 \n \n  \n  \n\n\n226 \n \nFigure 5.35 \n \n  \n  \n\n\n227 \n \nFigure 5.36 \n \n \n  \n  \n\n\n228 \n \nFigure 5.37 \n \n \n  \n  \n\n\n229 \n \nFigure 5.38 \n \n \n  \n  \n\n\n230 \n \nFigure 5.39 \n \n \n  \n\n\n231 \n \nFigure 5.40 \n \n \n  \n \n  \n\n\n232 \n \nFigure 5.41 \n \n \n  \n  \n\n\n233 \n \nFigure 5.42 \n \n \n  \n\n\n234 \n \nFigure 5.43 \n \n \n  \n \n  \n\n\n235 \n \nFigure 5.44 \n \n \n  \n  \n\n\n236 \n \nFigure 5.45 \n \n  \n  \n\n\n237 \n \nFigure 5.46 \n \n \n  \n  \n\n\n238 \n \nFigure 5.47 \n \n \n \n \n  \n\n\n239 \n \nFigure 5.48 \n \n \n  \n\n\n240 \n \nMenorrhagia Outcomes Questionnaire (Short Form) \nThere were unfortunately more that 10% missing scores for this questionnaire. In keeping \nwith the instructions for analysis, the questionnaire results are not valid for statistical \nanalysis with more than 10% missing values.  \nI have analysed the scores onl y to learn the statistical methodology. In order to analyse \nthe menorrhagia questionnaires, the scores need to be converted around a mean of 0 \ncalled a Z score. This is then converted into a T score which is the Z score multiplied by \n10 plus 50 so that the re is a mean around 50. A standard deviation of the T score is then \n60. The T and Z scores are useful to compare means across organisations or populations \nand are the standard way of presenting this data. If the T score of a population is above \n50 then that population is above average. The results have not been taken into account for \nthis questionnaire in this study , hence are not to be used in any interpretation . Tables 5.5 \nand 5 .6 show the total outcome and quality of life/satisfaction scores in Z and sco res.  \nThere was no significant difference in the change of global quality of life score before \nand after surgery according to route of surgery (table 5.7), or in the total outcome score at \n3 months (table 5.8).   \n\n241 \n \nTable 5.5   \nTotal Outcome scale scores \nParticipant Route Mean Z score Mean T score (z \nx10) +50 \n1 TAH Missing  \n2 VH 2.235 72.35 \n3 VH Missing  \n4 TAH 1.823 68.23 \n5 TAH 1.588 65.88 \n6 LH 1.353 63.53 \n7 LH 1.176 61.76 \n8 TAH 1.118 61.18 \n9 VH Missing  \n10 TAH 1.235 62.35 \n11 LH Missing  \n12 LH 1.235 62.35 \n13 LH 1.471 64.71 \n14 VH 0.765 57.65 \n15 LH Missing  \n16 VH Missing  \n17 TAH Missing  \n18 TAH Missing  \n19 LH 1.118 61.18 \n20 LH 0.941 59.41 \n \n \n \n\n242 \n \nTable 5.6  \nQuality of Life/Satisfaction scale scores \nParticipant Route Mean Z score Mean T score (z \nx10) +50 \n1 TAH Missing  \n2 VH 2.583 75.83 \n3 VH Missing  \n4 TAH 2.583 75.83 \n5 TAH 2.083 70.83 \n6 LH 1.583 65.83 \n7 LH 1.417 64.17 \n8 TAH 1.5 65 \n9 VH Missing  \n10 TAH 1.75 67.50 \n11 LH Missing  \n12 LH 1.583 65.83 \n13 LH 2.083 70.83 \n14 VH 1.083 60.83 \n15 LH Missing  \n16 VH Missing  \n17 TAH Missing  \n18 TAH Missing  \n19 LH 1.083 60.83 \n20 LH 1.0 60 \n \n \n \n\n243 \n \nTable 5.7  \nANOVA of mean change in global evaluation of symptoms before and after surgery in \nroute of surgery categories. \n F Value Sig \nGlobal evaluation 0.500 0.622 \n \nTable 5.8 \nANOVA for mean T scores by route of surgery  \nSummary outcome F Value Sig \nTotal outcome scale 0.531 0.605 \nQuality of Life/Satisfaction \nscale \n1.227 0.338 \n \n \n  \n\n244 \n \n \nDiscussion \nThe EQ5 questionnaire showed an improvement in health statusfor all groups 3 months \nafter surgery as compared to before surgery. This is to be expected as we would expect \nthe negative affect of heavy menstruation to have been relieved by the hysterectomy, \nregardless of route.  \nFrom the SF12, the VH gro up seemed to have a better quality of life pre surgery both in \nthe physical and emotional domains. After surgery, again the VH group reported better \nquality of life particularly in the emotional domain. This may be because the ovaries are \nnot usually removed as part of a VH route, whereas they are more often removed during \nthe TAH and LH routes. We would expect that removal of the ovaries would have a \nnegative effect on emotional wellbeing due to menopausal symptoms. After surgery, the \nTAH group had a lower quality of life at both 2 and 3 months. This may have been due to \nprolonged recovery from the larger abdominal incision. However, this study did not \naccount for the reason for abdominal surgery which may have had an effect on  the SF12 \nresponses, such as co–morbidities requiring an abdominal approach like obesity, previous \nabdominal surgery or large fibroid uteri. Co -morbidities may have prolonged recovery as \nan independent factor to route of surgery.  \nWe did not find a significant difference in the total o utcome scores or global evaluation \nbefore surgery and at 3 months by the Menorrhagia Outcomes Questionnaire, however, \nthis questionnaire was limited in its analysis due to the proportion of missing values, \nmaking it an unreliable result, and for this reaso n, it has been omitted from the \nconclusions. The missing scores may have been due to the long length of this \n\n245 \n \nquestionnaire and that it was last in the questionnaire pack. By using mean Z-score rather \nthan total Z -scores, the effect of missing data items ca n be minimised, however, this is \nbased on 10% or less missing data, this study had more than 10% missing data.  \nThis study was also limited by the small numbers in each of the groups, as well as the \nmissing data from incomplete or lack of questionnaire res ponses at different time points. \nIt may have been that only those who were recovered well enough completed the \nquestionnaires, or conversely, those who were recovered had returned to normal activities \nand were too busy to complete the questionnaires. Missi ng values have been reported in \nthe literature such as the validity study for HR-QoL (127), who reported a high number of \nmissing values which was similar to an Australian study validating the SF -12 in a heart \nand stroke population of 22%. They reported a higher chance of incomplete \nquestionnaires from females, older people, those who were less  educated and those \npatients who had stayed in hospital longer or were admitted as an emergency. Moreover, \nthere was a higher rate of missing values in the health concepts role -emotional and role-\nphysical items, which was also similar for the SF -36 (131).  The instructions for the \nMenorrhagia questionnaire were for use with a much older version of SPSS. \nUnfortunately, I could not access anyone who could give me upda ted advice and the \nauthor had passed away. I therefore had a protracted analysis where I had to learn how to \nchange scores into T and Z scores using statistical methodology.  Due to the time lapse \nbetween analysing the questionnaire data and collecting the  data, there was no \nopportunity to collect the missing data from participants. In addition, the ethical approval \ndid not cover gaining missing data so long after the study (see chapter 8). In addition, \nthere were a large number of questionnaire items which  the participants may have felt \n\n246 \n \nwas onerous to complete. The Menorrhagia questionnaire was last in the pack and this \nmay be why it had the most missing values.  \nMissing data in health status and quality of life questionnaires is a known problem. The \nvalidity study for HR -QoL (127) reported a high number of missing values which was \nsimilar to an Australian study validating the SF -12 in a heart and stroke populat ion of \n22%. They reported a higher chance of incomplete questionnaires from females, older \npeople, those who were less educated and those patients who had stayed in hospital \nlonger or were admitted as an emergency. Moreover, there was a higher rate of miss ing \nvalues in the health concepts role -emotional and role -physical items, which was also \nsimilar for the SF-36 (127, 131).  \n \n \n  \n\n247 \n \nConclusion \nBy the EQ5 and SF12 questionnaires, t he VH group had least effect o n quality of life by \nheavy menstrual bleeding pre-surgery and by the surgery post-surgery, particularly in the \nemotional domain. Quality of life was reported as lowest for the TA H group at 2 and 3 \nmonths post-surgery. \n \n  \n\n248 \n \n \nChapter 6 \nAnxiety and surgery; A validated questionnaire survey to women who had a \nhysterectomy \nMechanisms that affect recovery \n \nThere are a range of mechanisms by which psychological variables could affect recov ery \nafter surgery. Variables which have been found to influence the outcome of surgery \ninclude emotional states (fear, depression, stress, a sense of hopelessness), personality \ntraits (trait anxiety, locus of control, coping), and physiological parameters (132). This \nchapter studies the anxiety levels in the women undergoing the three routes of \nhysterectomy.  \n \nAnxiety \n \nSurgery is associated with significant patient anxiety (86, 133, 134)   and behavioural \nchanges which have been shown to have an effect on recovery (135, 136). It is known \nthat the majority of pa tients who have been admitted for elective surgery experience pre -\noperative anxiety. This is greater in day case patients, particularly in women. Negative \nemotions such as anxiety can enhance pain sensations (137), There have been differing \nassociations of level of anxiety and post-operative recovery. In some studies, low as well \nas high levels of anxiety have been found to lead to worse recovery outcomes, with \nmedium levels o f anxiety being associated with the best recovery (138). Other studies \n\n249 \n \nhave found a linear relationship with low anxiety associated with a better recovery  (132).  \nAll pre-operative anxiety has been found to predict the level of post -operative pain (87). \nThe State Trait Anxiety Inventory (STAI) is a validated questionnaire to measure anxiety \nin adults. It distinguishes between the temporary condition of ‘state anxiety’ and the more \ngeneral and longstanding quality of ‘trait anxiet y’ and depression (139). Anxiety \nmeasured by the STAI in patients who had a l aparoscopy for pelvic pain correlated with \nthe length of time patients felt they were completely cured and free of complaints  \nindependently of the laparoscopy findings (140). A longitudinal study of the impact of \nanxiety and depression on pain experi ence over time after major gynaecological surgery \nfound that pre -operative anxiety was predictive of anxiety on day 2 after surgery. \nMoreover, it reported anxiety levels on day 4 in one third of patients reaching psychiatric \nproportions (141). Levels of pre-operative psychological morbidity are found to be higher \nin women who have a hysterectomy as compared to the general population (142, 143).  \n \nInitially, it was shown that there were negative associations between anxiety levels and \nendocrine changes in surgical patients (144), however in a more recent study, a \npreparatory video showing realistic asp ects of the perioperative period prior to cardiac \nsurgery did reduce blood cortisol, ACTH, prolactin and noradrenaline levels (145). \nReducing anxiety has been defined as one of the  principles of conducting a pre -\nanaesthetic consultation (146).  \n \nPersonality variables of denial, fear and aggressiveness have been shown to be associated \nwith recovery and responses to pre -operative preparations (147). For example, a high \n\n250 \n \nmortality rate has been shown in patients who were depressed before cardi ac surgery \n(148). Stress has been linked to the slower healing of wounds through \npsychoneuroimmunological mechanisms (88).  \n \n  \n\n251 \n \nThe STAI (Stait Trait Anxiety) questionnaire (appendix 16) \nThe stait trait anxiety questionnaire (STAI) is used to measure anxiety. There are three \nforms of the questionnaire, X , Y  and STAI children. The STAI X was the original \nquestionnaire to measure anxiety in adults and the current updated version is the STAI Y. \nThe STAI children is used to measure anxiety in children.  The STAI Y requires at sixth \ngrade reading level and contai ns four -point Likert scales, the scales are positively \ncorrelated with anxiety scored from 20 to 80. The higher the score, the greater the anxiety \n(139).  The questionnaire is divided into two parts, each with 20 questions. Each part \nlooks at two types of anxiety; state  (S) and trait (T) anxiety and the overall anxiety level. \nIt is estimated that 10 minutes is required for an adult to complete the questionnaire. It \nhelps researchers to distinguish between the feelings of transient anxiety from depression \n(149).  Some questions are reverse scored because they test for the absence of anxiety.  \nResponses for the S-Anxiety scale assess intensity of current feelings with answer options \nof not at all, somewhat, mo derately so and very much so. The T -Anxiety score is that of \ngeneral feelings with answer options of almost never, sometimes, often and almost \nalways. Higher scores mean more anxiety and they are used to compare anxiety trends at \nvarious time points for th e same population or to compare different populations.  STAI \ndoes not measure overall anxiety. \n \nValidity \nThe STAI has been shown to have construct validity against other assessments of anxiety, \nsuch as between Panic Disorder and right-hemisphere brain over activation (150), and the \n\n252 \n \nSTAI-trait and STAI -state correlated with the Anxiety Sensitivity Index (151) and with \nthe Conjugate Lateral Eye Movement Test  (152).  \nConcurrent validity with other scales that measure anxiety has been demonstrated with \nthe Anxiety Scale Questionnaire (ASQ) (153) and Manifest Anxiety Scales (MAS) (154).  \nReliability \nThe test -retest reliability has been demonstrated using 29 male undergraduate students \ntwo weeks before and after a stressful social analogue situation (155) . The state anxiety \nincreased but the trait remained constant. This correlated with the STAI scores of 0.54 \nand 0.40 for state and 0.86 and 0.86 for trait.  \nFeasibility \nThe STAI is inexpensive and can be used in a  multitude of scenarios including research, \npsychometric testing such as interviews and clinical scenarios. It can be administered on \nmass and has less questions than other measures of anxiety (ASQ has 40 questions and \nthe MAS has 50). Although the STAI has been adapted into 48 languages, we only used it \nfor English readers due to financial constraints of translation.  \nAim \nTo study anxiety before a hysterectomy and at 1 month and 3 months of recovery after \nsurgery. \nMethodology \nThe STAI questionnaire was given to the qualitative hysterectomy group at the interview \nbefore surgery, one week after surgery and then 3 months after surgery. The STAI was in \npaper form marked with the participant trial number and handed to the participant to \n\n253 \n \ncomplete in their own time. A self-addressed envelope was provided for the participant to \npost the completed questionnaire back.  \nThe data from the questionnaire was inputted manually into a Statistical Package for \nSocial Sciences, version 16.0 (SPSS, Inc., Chicago, Illinois, USA.) database and analysed \nfor mean STAI for the state and trait sections at each time point. Due to missing data, we \nwere not able to compare the mean STAI for participants at each time frame. Analysis \nwas done using analysis of variance (ANOVA) as the stati stical test in order to measure \nthe means of more than 2 groups or time points. The ANOVA gives a real effect \ncomparison means of the groups as a F value and the significance is tested and presented \nas a P value; where a P>0.05 is statistically significant.  \n  \n\n254 \n \nResults  \nDemographics \nThe study group comprised of the qualitative group. They were all women who were \nhaving a hysterectomy for benign gynaecology problems via the abdominal, vaginal or \nlaparoscopic routes. \nTable 6.1: Demographics \nRoute of hysterectomy Number of participants \nAbdominal 7 \nVaginal 4 \nLaparoscopic 9 \n \n \nThe mean (table 6.2) STAI -state score pre -operatively was 40 (SD 13.53) and mean \nSTAI-trait score was 41.5 (SD 11.76). At one week after surgery, the mean STAI  state \nscore was 45.6 (SD 14.9) and the mean STAI -trait was 42.7 (SD 13.0). At 3 months after \nsurgery, the mean STAI-state score had fallen to 31.1 (SD 10.7) and the mean STAI -trait \nwas 32.7 (SD 11.8).  \n  \n\n255 \n \nTable 6.2: Mean STAI scores at time points \nTime point Mean STAI-state (SD) Mean STAI-trait (SD) \nPre-surgery 40 (13.53) 41.5 (11.76) \n1 week post-surgery 45.6 (14.9) 42.7 (13.0) \n3 months post-surgery 30.1 (10.7) 32.7 (11.8) \n \nSTAI versus route at the different time points \nAnxiety levels using STAI were compared  by route of hysterectomy using a one way \nbetween groups analysis of variance (ANOVA).  Where a significant difference using a \nvalue of 0.05 was seen, multiple comparisons of means after post hoc tests using Welsh \nand Brown-Forsythe were used to identify where the difference among the groups lay. \n \nPre-operative STAI versus route of hysterectomy \nPre-operatively, there was very little difference in the state anxiety scores according to \nroute of hysterectomy. Question 6 showed a small significance towards the TAH group of \n0.375 and question 12 towards the LH group at 0.217. In the trait questions, pre -\noperatively there was more anxiety in the LH group in questions 22 at 0.17, question 28 \nat 0.301 and question 30 at 0.125. The VH had significant values for quest ions 29 at \n0.244 and question 32 at 0.182. At 1 week post operation, the state values did not show \nany trends between groups apart from the VH group, where there were no significantly \nincreased state values apart from question 1 at 0.22. Table 6.3 shows the significant stait \nvalues at 1 week post operation. \n \n\n256 \n \n \n \n \nTable 6.3: Significant ANOVA by question and route of hysterectomy for STAIT anxiety \n1 week post operation. \nQuestion number ANOVA value Route of hysterectomy \nwhere mean was higher \n1 0.22 VH \n3 0.242 LH \n4 0.062 TAH \n5 0.285 LH \n6 0.058 TAH \n7 0.418 TAH & LH \n8 0.136 LH \n9 0.023 LH \n11 0.392 LH \n12 0.484 TAH \n13 0.345 LH \n14 0.220 LH \n17 0.172 LH \n18 0.274 LH \n20 0.335 TAH \n \n\n257 \n \nAgain trait anxiety did not show any trends 1 week post operation wit h route of \nhysterectomy (table 6.4) apart from the VH group, who again did not show increased \nanxiety in any questions to a significant value. \n  \n\n258 \n \nTable 6.4: Significant ANOVA by question and route of hysterectomy for trait anxiety 1 \nweek post operation. \nQuestion number ANOVA value Route of hysterectomy \nwhere mean was higher \n21 0.87 TAH \n23 0.231 TAH \n24 0.345 TAH \n25 0.482 TAH AND LAH \n26 0.454 LH \n27 0.391 LH \n28 0.260 TAH \n31 0.454 TAH \n32 0.371 LH \n33 0.417 LH \n34 0.193 LH \n35 0.294 TAH \n36 0.481 LH \n38 0.345 LH \n39 0.229 LH \n40 0.442 TAH \n \n \n\n259 \n \nAt 3 months after hysterectomy, the TAH group showed significantly more anxiety in \nboth the state and trait questions (table 6.5), particularly in question 19 (I feel steady), \nwere the significant value was 0.003. \n \nTable 6.5: Significant ANOVA by question and route of hysterectomy for state and trait \nanxiety 3 months post operation. \nQuestion number ANOVA value Route of hysterectomy \nwhere mean was higher \nSTATE ANXIETY \n3 0.166 TAH \n4 0.145 VH \n6 0.228 TAH \n8 0.225 TAH \n10 0.112 TAH \n11 0.315 TAH \n12 0.132 TAH \n14 0.132 TAH \n15 0.012 TAH \n16 0.166 TAH \n17 0.44 TAH \n18 0.228 TAH \n19 0.003 TAH \n20 0.219 TAH \n\n260 \n \n \nTRAIT ANXIETY \nQuestion number ANOVA value Route of hysterectomy \nwhere mean was higher \n22 0.010 TAH \n24 0.302 TAH \n26 0.494 TAH \n28 0.228 TAH \n29 0.020 TAH \n30 0.494 TAH \n31 0.166 TAH \n32 0.029 TAH \n33 0.382 TAH \n34 0.209 TAH \n35 0.366 TAH \n36 0.191 TAH \n37 0.59 TAH \n39 0.31 TAH \n40 0.283 TAH \n \n  \n\n261 \n \nDiscussion \n \nThe STAI is positively correlated so the higher the score the more anxiety. In this study, \nwe found that for both the state and trait sections, the mean scores fell at 3 months post -\nsurgery from the pre -operative period. The state score was higher in the w eek after \nsurgery, which is to be expected, although the background trait scores were not changed \nmuch in the week after surgery. Our study aligns with the published literature where the \nstate anxiety becomes lower as recovery from surgery is achieved  (156). \nWe saw that the total abdominal hysterectomy group had significantly higher stait and \ntrait anxiety scores 3 months after surgery than then the vaginal or laparoscopic \nhysterectomy groups. There is no simple explanation to this and it may be associated with \nthe increased morbidity associated with an incision through the abdominal wall and \nrecovery from reduced core strength as a result. This could lead to longer recovery such \nas mobility and pain relief. It may have been that women consider an abdominal route as \na more serious or bigger operation due to the visual association with a large scar on the \nabdomen. In my experience, women do worry about a large abdominal scar more than \nlaparoscopic small incisions.  \nWe know as many as 60% of patients undergoing surgery are anxious (157), and females \nand depressed patients in pain are particularly susceptible (86). Anxiety is attributed to \nuncertainty such as the thought of the unknown, severe pain, n ausea and vomiting or \nimminent death as well lack of information (86, 158) . The previous experience and \npersonality has been shown to influence the style of coping with major life events such as \nsurgery (159).  \n\n262 \n \nTrait and existential anxiety are more resistant to psychological interventions such as \ninformation giving or cognitive therapies (160), however procedure specific interventions \nhave been shown to be influenced by psychological interventions (161).  \nThere are limitations to this study because of the missing data due to which we were not \nable to follow each patient through to compare their anxiety scores at each time point. \nThe percentage of patients where there was missing data was  40% at 3 months, and for \nthis reason, no conclusions have been formed using the statistical analysis from this part \nof the data . In thi s study, we did not study personality types, which we know influence \nanxiety and coping mechanisms, however, there were not great differences in the STAI \nscores between patients which may suggest differing personality types. The small \nnumbers in this study  is an additional limiting factor, especially to compare the STAI \nscores at each time point for the differing routes of surgery.  \nFor this part of the study, we did not perform a power calculation to assess the number \nrequired to show statistical differences in the study question, as it was designed to gain an \nunderstanding of anxiety for the qualitative interview group only.  \nThe pre -operative questionnaires were not taken at a specific time point, so some \nparticipants may have had longer to wait for their  surgery and this study cannot assess \nwhether there is a difference in anxiety scores compared to how close the participant was \nto having surgery or how long they have waited on the waiting list. Waiting for surgery \nhas been shown to be a major stressor (162). The STAI scores are not adjusted for co -\nmorbidity and we did not take into account the socio-demographics of the participants, all \nof which may have influenced the scores (163).  \n \n\n263 \n \nConclusion \nThe results from this part of the study show that STAI anxiety scores are increased in the \nperiod before surgery and in the immediate post -operative period, but that they drop in \nthe recovery period after a hysterectomy. When a hysterectomy is p erformed by the \nabdominal route, the anxiety scores are higher at 3 months post-surgery as compared with \nvaginal or laparoscopic routes. \n  \n\n264 \n \n \nSystematic Review Chapter 7 \n \nPsychological Preparation for Recovery from Gynaecological Surgery \n \nBackground \nThere is  good evidence that how people think and feel before surgery affects their \nrecovery, such as anxiety and pain (164, 165) . Negative emotions enhance pain \nsensations (137), cognitions and emotions influence behaviour such as return to normal \nactivities and higher levels of stress are linked to poorer wound healing (88). Analysis of \npsychological preparation before surgery in a systematic review by Johnson in 1993 \n(166) showed that a benefit for negative affect, pain, analgesia use, length of hospital \nstay, behavioural recovery, physiological indices and patient satisfaction. Interest in \nimproving recovery from surgery has continued since this review and more so w ith the \nattempt to optimize recovery programmes for maximum efficiency and positive patient \nexperience. The economic benefits of shorter hospital stays and a quicker return to \nnormal activity and return to work and also become important outcomes to study r ather \nthan immediate post-operative outcomes alone. \nThis systematic review took place once the rest of the studies were completed to inform \nus to the types of psychological interventions which can be used to improve them. It will \nthen form part of a larger Cochrane Systematic Review on The effects of psycho logical \npreparation in all elective surgery. For this reason, I will follow the same methodology as \nsubmitted to Cochrane (167). This methodology has had input from all the authors of this \nreview, however, I have carried out the gynaecology part of the review for this higher \ndegree independently with supervision from the first author of the Cochr ane Review (Dr \n\n265 \n \nR Powell), who was also my MD supervisor. The methods section in this report has been \nderived from parts of the submitted Cochrane Protocol (167) appendix 18 with \npermission from the authors and under guidan ce from the first author Dr R Powell. This \nis to maintain consistency in this systematic review with the larger Cochrane review.  \nIn the real life pragmatic situation, hospital statistics report that women who have \nundergone a vaginal hysterectomy, with no  abdominal incisions,  have an average post -\noperative stay of 3.2 days in England (6), which is longer than the laparoscopic approach \nand not much different to the stay after the abdominal route despite evidence for a shorter \nstay for vaginal and laparoscopic routes (48) . This may indicate that in strictly controlled \nexperimental designs clinicians are potentially achieving optimum care efficiency \nthrough their beliefs about therapy and through the inadvertent psychological preparation \nof all patients. This could be in the form of stringent consent procedu res with increased \naccess to support mechanisms and follow up. It may be that patients’ and health care \nprofessionals’ beliefs and expectations of recovery play a more significant part in what \nactually occurs outside clinical trial settings. Aspects of thi s could be amenable to \npsychological intervention to improve recovery outcomes.    \nPsychological preparation incorporates a range of strategies designed to influence how a \nperson feels, thinks or acts (emotions, cognitions or behaviours). The benefits of \npsychological preparation for surgery have been evaluated in a meta -analysis (166). It \nidentified many different types of psychological preparation, including procedural \ninformation, sensation information, behavioural instruction, hypnotic and relaxation \ntraining, psychotherapeutic interventions and cognitive behavioural approaches. They \n\n266 \n \nwere found to be beneficial for a range of outcome variables such as negative affect, pain, \nand p ain medication, length of hospital stay, behavioural recovery, clinical recovery, \nphysiological indices and satisfaction. \nInformation giving \nPatients give high importance to the information given to them by health care \nprofessionals over other sources. It influences behaviours such as when to return to \nnormal activity and the degree of analgesia use (166).  However, there is much variance \nin the beliefs and practices of health care professionals in the advice they give to patients \n(132).  Information giving to patients pre -operatively can be categorised into sensory, \nprocedural and behavioural. Sensory information describes the experience for example, \nwhat it will feel like and an y other relevant sensations (e.g. taste, smell). Behavioural \ninstruction consists of telling patients what they should do to facilitate either the \nprocedure or their recovery from the procedure. For example, instructions about post -\noperative breathing exer cises to help prevent respiratory infections. Procedural \ninformation describes the process that the patient will undergo i.e.   what will happen, \nwhen it will happen and how it will happen.  As a result patients should be more aware of \nwhat to expect which will result in reduced anxiety   with reduced pain sensations \n(137).      \n Women undergoing elective gynaecology laparoscopy who were given procedural \ninformation about the su rgery had significantly less analgesic requirements and reported \na more rapid return to full health (132, 137) . In addition, stress has been linked to the \nslower healing of wounds through psychoneuroimmunological mechanisms (138) and \n\n267 \n \nreducing anxiety has been defined as one of the principles of conducting a pre-anaesthetic \nconsultation (87). Although pre -operative information is available, consideration should \nbe given to including those categories of information which improve recovery. \nRelaxation \nRelaxation techniques can be used before surgery to reduce tension and anxiety.   These \ninclude progressive muscle relaxation (where each muscle group is tensed and then \nrelaxed), simple relaxation (each muscle group is r elaxed in turn), breathing techniques \n(e.g. practice of diaphragmatic breathing) and guided imagery (e.g. imagining a pleasant, \nrelaxing environment). A mixture of relaxation training and sensory and procedural \ninformation giving was used as a pre -operative preparation for patients undergoing a \ncholecystectomy. The group who received this preparation   reported less pain and higher \nlevels of activity (87).      \n Cognitive therapy \nCognitive interventions aim to change how an individual thinks, especially about \nnegative aspects of the procedure. Information seeking is more common in people who \nhave an internal locus of control. The locus of control is a psychologi cal term referring to \nthe extent to which individuals believe they control events that affect them. People can \nhave a perceived internal or external locus of control.   People with external locus of \ncontrol will believe strongly in other people, fate and in  their destiny, whereas someone \nwith a strong internal locus of control will believe that they have the ability to influence \ntheir own future. Those with an internal locus of control benefit from knowing more \n\n268 \n \ninformation and are able to reduce their anxiet y levels about forthcoming surgery, \nwhereas the same information may increase the anxiety levels of someone with an \nexternal locus of control as they may rather not know the details (168).  A randomised \ntrial of procedural information, cognitive coping techniques and general ward \ninformation given to pa tients who had a hysterectomy showed that cognitive coping had \nthe most effect on recovery (140).  \nHypnosis \nHypnosis can be defined as when ‘one person (the subject) is guided by another (the \nhypnotist) to respond to suggestions for changes in subjective experience, alterations in \nperception, sensation, emotion, thought or behaviour’ (144). Hypnosis may be seen to act \neither as a cognitive or a relaxation intervention. There is now evidence from a meta -\nanalytical review that hypnosis positively affects immune function and may work through \npsychoneuroimmunological mechanisms (138). \nEmotion-focussed Intervention  \nEmotion-focussed intervention aims to reduce the nega tive emotions that are predictive \nof negative post-surgical outcome. The patient’s coping tendency has also been studied in \nrelation to the information patients need. People can cope with situations through mainly \nproblem focused strategies or emotion focu sed strategies. Those who use problem \nfocused strategies make plans to improve the situation and feel better when these are \nfollowed through. Emotion focused individuals tend to alter their own cognitive \n\n269 \n \ninterpretation of the situation rather than change i t, for example, ‘looking at the bright \nside’ (145).   \n  \n\n270 \n \nObjectives \nTo explore the effects of psychological preparation on recovery outcomes after a \nhysterectomy. This systematic re view will update the previous meta -analysis (167) and \nfocus on hysterectomy. \nSearch Methods \nThe search included the Cochrane Central Register of Controlled Trials \n(cantra) (The Cochrane Library, latest Issue); Medline \n(Ovid SP) (1950 to date); Embase (Ovid SP) (1982 to date); \nPsycINFO (Ovid SP) (1982 to date); Cinhal (EBSCOhost) \n(1980 to date) and Amed (Ovid SP) (1982 to date). The literature search was performed \nby MS. The following free text keywords were used: \nSearch Terms  \nHysterectomy \nEach psychological preparation term   (’psychological preparat*’, education, information, \ninstruction, cognitive interven*, ’cognitive behavio?ral therapy’, ’cognitive therapy’, \n’behavio*ral therapy’, hypnosis, relaxation, guided imagery) AND 1 \nALL psychological preparations (link with OR) AND 1 \n\n271 \n \nRecovery \n4 AND 3 \nNo limitations were applied for year of publication, study design or language and \ntranslations were obtained for articles not in English. The reference lists and citations of \nincluded papers were also searched for additional sources. The literat ure search was \ncompleted in 2010. A total of x citations were obtained (figure 1). The full text articles \nwere assessed for eligibility by their abstracts. Full text was sourced if the abstract was \nfor a randomized controlled trial.  \n  \n\n272 \n \nMethods \nSelection criteria \nAny randomised controlled trial that: \n1. uses random or quasi-random allocation and appropriate follow up; \n2. compares the positions listed under objectives. \nTypes of participants \nWomen undergoing any gynaecological surgical procedure under a general anaesthetic. \nTypes of Intervention \nOutcome measures \nPrimary outcome measures \n1. Postoperative pain \n1a. Postoperative pain intensity using the following hierarchy: \ni) the pre-specified pain outcome (if given); \nii) a visual analogue scale, from 0 to 100 (or 0 to 10); \niii) McGill Pain Questionnaire (MPQ) intensity rating, Present Pain Intensity; \niv) other MPQ ratings i) Pain Rating Index (weighted or unweighted), \n\n273 \n \nii) Number of Words Counted; \nv) other pain intensity scale. \n Secondary Outcome measures \n1. Negative affect: post intervention and postoperative \n2. Resource use \na. Length of stay, in hospital, in post anaesthesia care unit. \nb. Postsurgical analgesia use: proportion of patients requiring an \nunplanned analgesia intervention in the post anaesthesia care unit, \nwithin 24 hours, at any time in hospital, after discharge. \n3. Behavioural recovery (defined as: resumption of performance of tasks and \nactivities). \nData collection and analysis  \nData was collected straight onto Review Manager 5.1. We considered the population, \nintervention details and their timing, number of intervention groups, the control group \nintervention, adherence to intervention, attrition rate and loss to follow up. For each study \nand intervention, we collected data on the study’s primary and secondary recovery \noutcome measures. Quality of studies was assessed using the CONSORT tool looking for \ndata collection, patient enrolment and randomization techniques, sample definiti on, \n\n274 \n \nbaseline matching of groups, blinding, outcome assessment, follow up and a priori power \ncalculations. \nEach article was assessed by two assessors (MS and MD , a research fellow on Prof JKG \nteam 2009) and any uncertainty was resolved by discussion with JKG. Analysis was done \nusing Review Manager 5.1 using a confidence interval (CI) of 95% and significance P \nvalue of below 0.05. Forest plots were used to show pooled effects. \nMeasures of treatment effect   \nDichotomous data \nFor dichotomous data, we present results as summary risk ratio with 95% confidence \nintervals.  \nContinuous data \nFor continuous data, we used the mean difference if outcomes are measured in the same \nway between trials. We used the standardised mean difference to combine trials that \nmeasure the same outcome, but using different methods.  \nUnit of analysis issues   \nDealing with missing data   \nFor included studies, levels of attrition were noted. The impact of including studies with \nhigh levels of missing data in the overall assessment of treatm ent effect were explored \nusing sensitivity analysis. \n\n275 \n \nFor all outcomes analyses were carried out, as far as possible, on an intention -to-treat \nbasis, i.e. we attempted to include all participants randomised to each group in the \nanalyses. The denominator for  each outcome in each trial was the number randomised \nminus any participants whose outcomes are known to be missing. \nAssessment of heterogeneity   \nWe used the Chi² statistic to measure heterogeneity among the trials in each analysis. We \nregarded the level of heterogeneity as substantial if it was above 50%.  \nData synthesis   \nWe carried out statistical analysis using the Review Manager software ( RevMan 2008). \nWe used fixed-effect inverse variance meta-analysis for combining data where trials were \nexamining the same intervention, and the trials’ populations and methods were judged \nsufficiently similar. Where we suspected clinical or methodological heterogeneity \nbetween studies sufficient to suggest that treatment effects may have differed between \ntrials we used random-effects meta-analysis. \nPublication bias \nPublication bias was considered as per the Cochrane Handbook  section 8.4.5. This is the \nsystematic difference between reported and non -reported findings. Those studies which \nshow a significant difference between the intervention and control are more likely to have \nbeen published than non -significant findings. The Cochrane handbook refers to this type \nas bias as substantial.  \n  \n\n276 \n \nResults of search \nFigure 7.1 Process from initial search to final inclusion for psychological preparation in \ngynaecology surgery.  \n \n \n \n \n        \nArticles excluded      n= 18 \n- not psychological preparation/incorrect population  n= 13 \n- reviews/ letters/ comments/ editorials   n= 1 \n- Paper/translation unobtainable    n= 0  \n- duplications       n= 3 \n- NOT RCTs of intervention     n=3 \n \nPrimary articles included in systematic review   n= 18 \nNumber of women        n= 1240 \nPotentially relevant citations identified from electronic searches to capture \nprimary articles on psychological preparation for gynaecology surgery  \n         N 161 \n \nReferences excluded after screening titles and/ or abstracts  \n        n= 124 \n\n277 \n \nDescription of studies \nA total of 21 abstracts were eligible. One paper was written in Chinese and translated by \nTT. After reviewing the potential papers, 3  were not included in the review as they were \nnot randomized trials of psychological preparation ( Melzack 1996, Mogan 1985, Moon \n1984). The remaining 18  papers were included in the review. All included studies \ncompared psychological preparations in a randomized controlled trial. Recovery \noutcomes were assessed in all trials. \nIncluded studies \nThere were 18 studies included in this review (Table 7.1). Two of these studies had more \nthan one psycological preparation method and so were analysed as separate studies \n(Laurion GI 2003 and Laurion MU 2003, Nilsson 2001 M&T and Nilsson 2001 Music ). \nA total of 1240 women were included in the studies.  \n  \n\n278 \n \nTable 7.1 Characteristics of included studies \nStudy Participants Intervention Description of \nintervention \nOutcomes \nAndrzejowski \n1996 \n36 patients ASA grade I \nor II for TAH \nAcupressure and \nacupuncture \nAt the pericardium 6 \npoint on both wrists \nPost-\noperative \nnausea and \nvomiting \nBlock 1991 \n109 intervention group, \n100 control. Operations \non the fallopian tubes, \ntotal abdominal \nhysterectomy, vertical \nbanding gastroplasty, \ncholecystectomy, and \novarian cystectomy or \nmyomectomy from \nUniversity of Iowa \nHospital and Clinics \nTherapeutic \npositive \nsuggestions tape \n6 minutes female voice at \na deliberate rate of \nspeech. Positive \nsuggestions about \nrecovery. \nLength of \nstay, opiod \nuse, pain, \nurine, flatus, \nbowel \nfunction and \nSTAI \nCheung 2003 \n48 in intervention and \n48 in control. Chinese \nwomen who spoke \nCantonese who were \nhaving an elective \nabdominal \nhysterectomy \nInformation \nbooklet with \ncognitive \nintervention \nCognitive distraction and \nreappraisal (Lazarus \n1984) \nPost-\noperative \nanxiety, pain, \nanalgesia use, \npatient \nsatisfaction. \nDudley 2002 \n42 women having \nhysterectomy in a \nprivate clinic in \nVirginia. 19 had \nmassage, 22 controls. \nMassage therapy 30 minutes Sweedish \nmassage from a female \ntherapist \nLength of \nstay, \nanalgesia use \nEvans 1998 Total abdominal \nhysterectomy patients \nat St Thomas’ Hospital \nLondon. 19 in \nintervention group, 20 \ncontrols. \nPositive \nsuggestion tape \nPositive suggestions \nunder general anaesthetic \nPain, nausea, \ndefecation \nand \nflatulence, \nlength of \nstay, \nmobilisation \n \nHeye 2002 70 elective \nhysterectomy patients  \n35 in each arm \nFoster pain \nintervention \n24 minute videotape of a \nnurse showing breathing \nand movement skills with \nfour post -operative \nmobility activities to \nimprove self-efficacy. \nPain \nLaourion GI \n2003 \nConvenience sample of \n84 women having \ngynaecology \nlaparoscopic surgery \n \nGuided imagery Listened to Health \nJourneys for People \nUndergoing Surgery by \nNaparstek under general \nanaesthesia \n \nPost-\noperative \nnausea and \nvomiting and \npain \nLaurion MU Convenience sample of Audiotape of  Post-\n\n279 \n \n2003 84 women having \ngynaecology \nlaparoscopic surgery \n \npiano music Listened to piano music \nwith earphones under \ngeneral anaesthetic \noperative \nnausea and \nvomiting and \npain \nLobb 1984 30 women Women in \nCleburne Texas fall of \n1981 and winter 1982 \nundergoing \nhysterectomy \n \nRelaxation \ntraining and \ndesensitization \n \nPre and postoperative. \nDesensitization for \nsurgical trauma included \npost-operative stimuli \n \nLength of \npost-\noperative \nhospital stay \nMaroof 1997 50 elective \nhysterectomy patients \n \nPositive intra -\noperative \nsuggestion tape \n \nMale voice speaking in \nthe patient 's dialect 15 \nminutes via headphones \nunder GA suggesting they \nwould experience no \nsickness. \n \nEmetic \nepisodes \nNilsson 2001 \nM&T \n90 women ASA I -II \nelective hysterectomy \nMusic with \ntherapeutic \nsuggestions \n \nMusic - Relaxing and \ncalming music with sea \nwaves. Therapeutic \nsuggestions-Relaxing and \nencouraging suggestions \nin a male voice by a \nperson with extensive \nexperience in \nhypnotherapy \nPain, post-\noperative \nnausea and \nvomiting, \nbowel \nfunction, \nfatigue, \nlength of \nstay, well -\nbeing \n \nNilsson 2001 \nMusic \n90 women A SA I -II \nelective hysterectomy \nMusic alone Music - Relaxing and \ncalming music with sea \nwaves. \n \nPain, post -\noperative \nnausea \nvomiting, \nbowel \nfunction, \nfatigue, \nlength of \nstay, well -\nbeing \nOetker- Black \n2003 \n108  h ysterectomy \npatients Midwest \nTeaching Hospital \nSelf-efficacy \nenhancing \nteaching \nprogramme \nPre-operative instruction \non mobility, turning, deep \nbreathing, pain reduction \nthrough relaxation.  \nPain on VAS, \nSAI, \nambulation, \nday 1, length \nof stay \nStudy Participants Intervention Description of \nintervention \nOutcomes \nPerri 1979 26 women for elective \nvaginal hysterectomy \n \nProgressive \nmuscle \nrelaxation \n \nTwo 90 minute individual \nsessions pre -operatively \n(Bernstein and Borkovec) \nPain \nPoolsawal \n2003 \n90 patients for TAH for \ncancer Bankok \nUniversuty Hospital \nRelaxation \ntraining \nBenson's Respiratory One \nMethod Technique \nAnxiety by \nHADS \n\n280 \n \n19/11/1999-29/02/2000   \nRidgeway \n1982 \n60 St Georges Hospital \nLondon women \nadmitted for elective \nhysterectomy (10 in \neach group) \n \nInformation \nabout surgery, \nCognitive coping \ntechnique \n \nInformation - procedural \nand sensations \nCognitive coping - \nPositive control of how to \nview events \nPain, waking \nfrequency, \nnausea, \nanalgesia use, \nmood scale \n \nTaylor 1998 62 p atients having \nelective abdominal \nhysterectomy \n \nMusic Music of their choice  on \nheadphones played in last \n30 minutes of surgery and \nfirst hour post op vs \nheadphones alone. \nVAS pain \nscore, \nGraphic pain \nintensity \nscore \n \nVitale 2006 22 Elective \nhysterectomy (10 in \nexperimental group) \nReiki 3 Reiki Nursing \nInterventions 30 minutes \neach at timed intervals at \nday 1, 24hours and 48 \nhours post -operation. \nStandard Reiki hand \npositions, implemented \nfor hand placement \nconsistency and each \nhand placement was for 3 \nminutes. Reiki by expert \nReiki Practitioners \nminimum level III, \nsupervised by m aster \nReiki registered nurse. \n \n \n \n  \n\n281 \n \nData analyses results   \nA total of 1240 women were included in all studies. There were 9 studies which assessed \nthe effect of psychological preparations on pain using a visual analogue score (VAS) and \nthey did not find a statistically significant effect 0.78 (1.04, -0.52 figure 7.2). Analgesia \nrequirements by morphine dose was ass essed in 6 studies. I t did not find a  significant \npooled effect for the psychological interventions -3.31 (-5.41, -1.22 figure 7.3). Nilsson \n2001 compared time to walking, wellbeing at day 1 and  fatigue for patients who listened \nto music alone and those w ho listened to music with therapeutic solution as compared to \nno intervention and did not find any statistically significant difference -0.20 (-5.85, 5.46 \nfigure 7.4),    -0.55 ( -1.01, -0.09 figure 7.5)  and 0.41 ( -0.78, -0.04 figure 7.6) \nrespectively. Anx iety as measured by the Stait Anxiety Questionnaire (STAI) was \nassessed in two studies ; Vitale 2006 and Block 1991  (figure 7.7). This showed a \nsignificant difference for trait anxiety which was higher in patients who had not had the \npsychological intervention [ P <0.00001, mean difference 7.78 (7.19, 10.61) ]. Post-\noperative nausea and vomiting was studied in 4 studies. Again, no statistically significant \ndifference was found in the pooled effect -0.06 (-0.49, 0.38 figure 7.7). Length of hospital \nstay post operation was assessed in 4  studies. (figure 7.8). Of all the psychological \npreparation techniques, positive suggestion under a general anaesthesia in the Evans 1988 \npaper was the only one which had a statistically significant effect. It reduced len gth of \npost-operative hospital stay -31.00 (-48.35, -13.65), however, this is an older paper and \nthe mean length of stay was much longer than the newer studies. Pooled length of stay for \nthe 4 studies was reduced in the group who had any psychological inte rvention [P 0.03, \n5.65 (-10 82 to -0.48)].  \n\n282 \n \nRisk of bias \nFigure 7.10 shows the risk of bias as assessed by the criteria of random sequence \ngeneration, allocation concealment, blinding of participants and researchers, blinding of \noutcome, incomplete outcome data and selective reporting. Red indicates high risk of bias \nand green indicates low risk. Yellow is where the risk was unclear although there was \nreference to the risk, in some instances, there was no mention of the risk being assessed \nso these were left blank. On the whole, there was mainly high or unclear risk of bias \n \n  \n\n283 \n \nFigure 7.2 \nPain at 24 hours measured by visual analogue scale \n \n \n  \nStudy or Subgroup\nBlock 1991\nCheung 2003\nEvans 1988\nLaurion GI 2003\nLaurion MU 2003\nNilsson 2001 M&T\nNilsson 2001 Music\nOetker-Black 2003\nRidgeway 1982\nTaylor Music 1998\nVitale 2006\nTotal (95% CI)\nHeterogeneity: Chi² = 25.61, df = 7 (P = 0.0006); I² = 73%\nTest for overall effect: Z = 4.21 (P < 0.0001)\nMean\n3.7\n0\n2.4\n1.5\n1.1\n2.3\n1.8\n0\n16.9\n5.83\n3.8\nSD\n0.5\n0\n2\n1.5\n1.1\n1.2\n0.7\n0\n0\n1.63\n2.4\nTotal\n15\n0\n19\n28\n28\n28\n29\n0\n20\n20\n10\n197\nMean\n3.6\n0\n2.7\n2.4\n2.4\n2.7\n2.7\n0\n17.4\n5.83\n5.4\nSD\n0.4\n0\n2.5\n1.6\n1.6\n0.8\n0.8\n0\n0\n1.9\n1.4\nTotal\n17\n0\n20\n28\n28\n27\n27\n0\n0\n20\n12\n179\nWeight\n39.9%\n2.0%\n6.1%\n7.7%\n13.9%\n25.7%\n3.3%\n1.4%\n100.0%\nIV, Fixed, 95% CI\n0.10 [-0.22, 0.42]\nNot estimable\n-0.30 [-1.72, 1.12]\n-0.90 [-1.71, -0.09]\n-1.30 [-2.02, -0.58]\n-0.40 [-0.94, 0.14]\n-0.90 [-1.29, -0.51]\nNot estimable\nNot estimable\n0.00 [-1.10, 1.10]\n-1.60 [-3.29, 0.09]\n-0.43 [-0.63, -0.23]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n284 \n \n \nFigure 7.3 \nPain measured by morphine use in mg \n \n \n \n  \nStudy or Subgroup\nAndrzejowski 1996\nBlock 1991\nDudley 2002\nLaurion GI 2003\nLaurion MU 2003\nNilsson 2001 M&T\nNilsson 2001 Music\nVitale 2006\nTotal (95% CI)\nHeterogeneity: Chi² = 7.05, df = 7 (P = 0.42); I² = 1%\nTest for overall effect: Z = 3.10 (P = 0.002)\nMean\n54\n41\n21.4\n9.6\n7\n26.5\n22.2\n6\nSD\n26.6\n5\n28.7\n9.4\n7.7\n17.7\n13.5\n13\nTotal\n18\n15\n19\n28\n28\n28\n29\n10\n175\nMean\n55.6\n44\n25.9\n9.8\n9.8\n32.8\n32.8\n17\nSD\n29.7\n5\n28.6\n8.2\n8.2\n17.1\n17.1\n15\nTotal\n18\n17\n21\n28\n28\n27\n27\n12\n178\nWeight\n1.3%\n36.4%\n1.4%\n20.6%\n25.3%\n5.2%\n6.7%\n3.2%\n100.0%\nIV, Fixed, 95% CI\n-1.60 [-20.02, 16.82]\n-3.00 [-6.47, 0.47]\n-4.50 [-22.28, 13.28]\n-0.20 [-4.82, 4.42]\n-2.80 [-6.97, 1.37]\n-6.30 [-15.50, 2.90]\n-10.60 [-18.71, -2.49]\n-11.00 [-22.70, 0.70]\n-3.31 [-5.41, -1.22]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n285 \n \n \nFigure 7.4 \nBehavioural recovery: time to walking \n \n \n  \nStudy or Subgroup\nNilsson 2001 M&T\nNilsson 2001 Music\nTotal (95% CI)\nHeterogeneity: Chi² = 0.65, df = 1 (P = 0.42); I² = 0%\nTest for overall effect: Z = 0.07 (P = 0.95)\nMean\n32.8\n28.1\nSD\n12.4\n16.3\nTotal\n24\n23\n47\nMean\n31\n31\nSD\n12.7\n12.7\nTotal\n20\n20\n40\nWeight\n57.5%\n42.5%\n100.0%\nIV, Fixed, 95% CI\n1.80 [-5.66, 9.26]\n-2.90 [-11.58, 5.78]\n-0.20 [-5.85, 5.46]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n286 \n \nFigure 7.5 \nBehavioural recovery: wellbeing day 1 post surgery \n \n \n \n  \nStudy or Subgroup\nNilsson 2001 M&T\nNilsson 2001 Music\nTotal (95% CI)\nHeterogeneity: Chi² = 0.41, df = 1 (P = 0.52); I² = 0%\nTest for overall effect: Z = 2.36 (P = 0.02)\nMean\n2.1\n1.8\nSD\n1\n0.9\nTotal\n30\n30\n60\nMean\n2.5\n2.5\nSD\n1.5\n1.5\nTotal\n28\n28\n56\nWeight\n48.6%\n51.4%\n100.0%\nIV, Fixed, 95% CI\n-0.40 [-1.06, 0.26]\n-0.70 [-1.34, -0.06]\n-0.55 [-1.01, -0.09]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n287 \n \nFigure 7.6 \nBehavioural recovery: fatigue day 1 \n \n \n \n  \nStudy or Subgroup\nNilsson 2001 M&T\nNilsson 2001 Music\nTotal (95% CI)\nHeterogeneity: Chi² = 0.60, df = 1 (P = 0.44); I² = 0%\nTest for overall effect: Z = 2.20 (P = 0.03)\nMean\n3.8\n3.5\nSD\n0.9\n1.4\nTotal\n30\n30\n60\nMean\n4.1\n4.1\nSD\n0.9\n0.9\nTotal\n28\n28\n56\nWeight\n62.8%\n37.2%\n100.0%\nIV, Fixed, 95% CI\n-0.30 [-0.76, 0.16]\n-0.60 [-1.20, 0.00]\n-0.41 [-0.78, -0.04]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n288 \n \nFigure 7.7 \nNegative affect:  STAI Trait questionnaire \n \n \n \n  \nStudy or Subgroup\nVitale 2006\nBlock 1991\nTotal (95% CI)\nHeterogeneity: Chi² = 29.39, df = 1 (P < 0.00001); I² = 97%\nTest for overall effect: Z = 9.17 (P < 0.00001)\nMean\n27\n43.8\nSD\n7.05\n2.6\nTotal\n10\n15\n25\nMean\n38\n34.9\nSD\n9.64\n2.3\nTotal\n12\n17\n29\nWeight\n5.7%\n94.3%\n100.0%\nIV, Fixed, 95% CI\n-11.00 [-17.99, -4.01]\n8.90 [7.19, 10.61]\n7.78 [6.11, 9.44]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n289 \n \nFigure 7.8 \nNegative affect: nausea and vomiting day 1 \n \n \n  \nStudy or Subgroup\nMaroof 1997\nNilsson 2001 M&T\nNilsson 2001 Music\nRidgeway 1982\nTotal (95% CI)\nHeterogeneity: Chi² = 0.46, df = 1 (P = 0.50); I² = 0%\nTest for overall effect: Z = 0.25 (P = 0.80)\nMean\n1.7\n2.1\n1.8\n0\nSD\n1.2\n1.1\n1\n0\nTotal\n25\n30\n30\n0\n85\nMean\n3.1\n2\n2\n0\nSD\n1.2\n1.3\n1.3\n0\nTotal\n0\n28\n28\n0\n56\nWeight\n48.2%\n51.8%\n100.0%\nIV, Fixed, 95% CI\nNot estimable\n0.10 [-0.52, 0.72]\n-0.20 [-0.80, 0.40]\nNot estimable\n-0.06 [-0.49, 0.38]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n290 \n \nFigure 7.9 \nLength of stay \n \n \n  \nStudy or Subgroup\nBlock 1991\nDudley 2002\nEvans 1988\nLobb 1984\nOetker-Black 2003\nTotal (95% CI)\nHeterogeneity: Chi² = 11.61, df = 3 (P = 0.009); I² = 74%\nTest for overall effect: Z = 2.14 (P = 0.03)\nMean\n122\n46\n170\n100\n0\nSD\n9.6\n15\n24\n43.2\n0\nTotal\n15\n19\n19\n10\n0\n63\nMean\n122\n55\n201\n112\n0\nSD\n9.6\n17\n31\n15.8\n0\nTotal\n17\n21\n20\n1034\n0\n1092\nWeight\n60.2%\n27.2%\n8.9%\n3.7%\n100.0%\nIV, Fixed, 95% CI\n0.00 [-6.67, 6.67]\n-9.00 [-18.92, 0.92]\n-31.00 [-48.35, -13.65]\n-12.00 [-38.79, 14.79]\nNot estimable\n-5.65 [-10.82, -0.48]\nExperimental Control Mean Difference Mean Difference\nIV, Fixed, 95% CI\n-100 -50 0 50 100\nFavours experimental Favours control\n\n291 \n \n \nFigure 7.10 \nRisk of bias summary for \nincluded studies \n\n292 \n \n \nFigure 7.11 Funnel plot Pain \n  \n\n\n293 \n \nFigure 7.12 \nFunnel plot morphine use in mg \n\n\n294 \n \nFigure 7.13 \nFunnel plot Time to walking \n \n \n\n\n295 \n \nFigure 1.14 \nFunnel plot Wellbeing day 1 \n \n \n \n \n \n \n \n \n \n \n \n\n\n296 \n \nFigure 7.15 \nFunnel plot nausea and vomiting day 1 \n \n  \n\n\n297 \n \nFigure 7.16 \nFunnel plot Fatigue day 1 \n \n \n  \n\n\n298 \n \nFigure 17 \nFunnel plot STAI Trait \n \n \n \n \n \n \n \n \n \n \n \n \n \n\n\n299 \n \nFigure 7.18 \nFunnel plot length of stay \n  \n\n\n300 \n \nDiscussion \nThe concept of psychological interventions to improve recovery from hysterectomy was \ndebated as far back as 1982 when Valerie Ridgway published her research on cognitive \ncoping and suggested that this was an explanation for the variation in recovery after \nsurgery (91). In our review however, there was  much heterogeneity among studies in \ntheir definition and type of the interventions which makes the comparisons challenging, \nhowever we did see that p sychological interventions could reduce the length of stay after \nsurgery, particularly suggestion under general anaesthesia as well as trait anxiety. We \nrated the quality of most of the evidence for outcomes as ‘low’ and due to the unclear or  \nhigh risk of bias of rep orting. This is similar to other reviews of psychological \npreparation for surgery (169, 170) . Although we know that psychological states affect \nrecovery from surgery (105, 171) and that interventions focussed at these could improve \nrecovery, we need more robust trials to be able to answer the question of which \ninterventions are effective. Furthermore, there is a variety of recovery outcomes which \nwere not always presented using robust measures which could be compared in the \nanalysis and what a favourable outcome might be to clinicians and patients. This review \nwas undertaken as part of early work towards a larger review, where the authors came to \nsimilar conclusions about psychological interventions from all surgery involving a \ngeneral anaesthetic (172). Recovery has many components including measurable clinical \naspects such as vi tal observations, normalising of test parameters, the use of analgesia, \nreturn of physiological function such as passing urine or opening their bowels, number of \ndays as an inpatient and mobility. From the perspective of the patient, a favourable \noutcome m ay be more related to important aspects of their lives such as being able to \n\n301 \n \nsleep normally, looking after their families, socialising, feeling emotionally back to \nnormal or being able to go back to work. There is evidence where psychological \ninterventions have been shown to improve health and recovery such as from ischaemic \nheart disease (173) where a systematic review of intensive relaxation therapy improved \nphysical recovery such as resting heart rate and exercise tolerance. Psychological \ninterventions are used as established therapy in many areas of health and w ellbeing such \nas with psychotherapy and behavioural medicine where they have been shown to be cost \neffective (174). It is likely therefore that there is some merit in psychological \ninterventions to enhance recovery outcomes.  \n \nConclusion \nFrom this review, psychological interventions such as suggestion under general anaesthetic \ncould reduce length of stay; and could reduce trait anxiety. Due to the variation between \ninterventions however, higher quality evidence is needed in order to answer the question of \nwhich psychological interventions work and which recovery outcomes are best affected.  \n \n \n\n302 \n \nChapter 8: Discussion \nOverview of findings \nWe were not able to find any difference in the time women returned to work according to \ntheir employment status or incapacity benefit type. From this study, we have found that \nthere is a great deal of variation in the beliefs of UK gynaecologists regarding  recovery \nfrom laparoscopic, vaginal and abdominal hysterectomy, particularly in longer term \nreturn to normal activities once discharged from hospital. The difference was not \nexplained by geography; however there was some explanation by experience and grade of \nspecialist. This is likely due to the building of personal experience with patients. \nMoreover, this variation of advice was seen in the gynaecology nursing staff at \nBirmingham Women’s’ Hospital. Health care professionals reported that their advice was  \nbased on personal beliefs rather than on national or local evidence based guidelines such \nas NICE. This study on variation in the beliefs of healthcare professionals highlights the \nimportance of understanding actual recovery experiences of women who have undergone \nhysterectomies from each of the surgical routes.  \nMy study of the experiences of women who have had a hysterectomy highlighted that \nregardless of route of surgery, the expectations and fears of women were similar before \nsurgery such as difficulti es making sense of the large amounts of information available, \nthe influence of friends and family who have previously had this surgery as well as their \nown experiences of previous surgery. It is important to remember that women who have a \nhysterectomy are likely to have responsibility of dependent children, and the cohort in \nthis study talked about the concerns they had around childcare and the practical \n\n303 \n \narrangements they had made. Women had tried to improve their health in order to \nenhance their recovery and one woman talked about taking time off work and potentially \nlosing her job. Fears before surgery included the effect on emotions, although some \nwomen felt that the hysterectomy would be a positive influence on their emotions. This \npart of the study confirmed how women required guidance from health care professionals \nabout when to resume activities such as sexual intercourse. Women talked about a variety \nof ways to prepare for t heir recovery and some set goals before surgery. The surgical \nroute of hyste rectomy appeared to be governed by their surgeons and the need to gain \nfurther advice on whether to have their ovaries removed or not. Before surgery, there was \nconfusion with conflicting advice about length of stay, again correlating with the health \ncare professionals’ variation in beliefs. Women talked about listening to their own bodies \nand interpreted pain as a marker to stop the activity associated with this feeling. \nAddressing expectations and concerns before surgery is important as this study has \ndemonstrated that anxiety levels are increased.  \nAfter surgery, there were specific concerns in the group who had had a vaginal \nhysterectomy around pain in sitting and opening their bowels, which is expected due the \nfact that the incision is in the vagina close to the rectum and perineum.  \nThe laparoscopic hysterectomy group did experience a lower length of stay; however, the \nactual recovery milestones were more associated with the individual rather than the \nsurgical route in general. Women who had an abdomina l hysterectomy had higher \nanxiety scores and lower quality of life scores at 3 months than the laparoscopic and \nvaginal group. The vaginal hysterectomy group reported the highest quality of life scores \nafter surgery. Most participants did not drive until a fter 6 weeks, and in general the \n\n304 \n \nrecovery experience was better than women had expected, particularly in relation to \nsexual recovery and effect on their quality of life, again regardless of route of surgery.  \nThis study concurred with the published literat ure on the strong influence of healthcare \nprofessionals in the recovery period.  \nWhen considering what psychological interventions may be useful to enhanc e recovery \nfrom hysterectomy, this  systematic review concluded that there was variation in \ninterventions, making comparison s as a whole a challenge , as well as using differing \noutcome measures. It may be more useful to compare similar interventions such as music \ntherapy or relaxation therapy on the same outcome.  \n \nImpact for future studies and practice \nThis study adds to the understanding of recovery from hysterectomy. In particular, it \nhighlights the variation in advice women receive from their health care professionals, and \nthe gap in evidence based guidance for recovery outcomes.  \nIt raises the question of developing guidelines for both healthcare professionals and \npatients to help with realistic expectations of recovery from hysterectomy and what may \nalter it. Furthermore, it shows that despite research showing that recovery is faster from \nless invasive surgical approaches, the beliefs and behaviours of both patients and \nhealthcare professionals do not reflect this. Guidance would support confidence in \nenhanced recovery particularly for laparoscopic and vaginal hysterectomy routes. \n\n305 \n \nThis study highlights the importance of influencing healthcare using a more holistic bio \npsychosocial model, paying attention to the ideas, expectations and concerns of women \nwho have a hysterectomy in order to enhance their recovery and reduce levels of a nxiety. \nMore patient focussed ways of providing information, addressing concerns and building \nconfidence are required which address multiple aspects of recovery should be developed \nand tested in trials, such as using electronic media, online patient and fa mily resources \nsuch as videos accessible whenever the patient requires them, virtual support networks \nand virtual consulting with health care professionals. This will help us to both understand \nand support longer term recovery better once the patient has b een discharged from the \nhospital.  \nWith limited NHS resources, it is important to empower patients with the tools they \nrequire to aid their own recovery. Further qualitative studies will help us to understand \nwhich recovery outcomes are valued most by wome n recovering from hysterectomy and \nhow we can work to improve these outcomes. \nReflective critical analysis and learning points \nIt has taken 8 years to complete this MD which has posed a number of problems, \nparticularly at the write up stage. The study itse lf was completed within 2 years while I \nwas in a clinical lecturer post; however the analysis and write up was delayed. This was \ndue to a number of factors which were disclosed to the University including being \nappointed to my first consultant post; for wh ich I requested a one year break in order to \nfocus on my new role. Subsequently, I experienced a number of major personal issues \nwhich were life changing and I took a break from the MD in order to focus on my \n\n306 \n \npersonal life. It has taken 3 years to get back  into a position to find balance to come back \nto my MD. Once I did come back to my MD, I found that I had to re -learn the data and \nre-familiarise myself with the literature as well as those chapters I had already written. \nFurthermore in this time one of my  supervisors moved jobs to Manchester, this made \nsupervision with her challenging as I was not able to meet with her. My primary \nsupervisor advised me to continue with him. Once I re -organised my work, I found that I \nneeded to update my literature search. Unfortunately, in the time which had passed. Even \nthough my search was saved online, the National Electronic Library for Health database \nhad been wiped and all saved searched were lost. Therefore, I had to re -run the search \nagain using the saved search ter ms in 2015. By this time, my librarian advised me to run \nthe search on the individual databases rather than the collection National library due to \nsome unreliability in the system. Once the search was completed, again I had to start the \nprocess of collecti ng new abstracts, reviewing the literature for new publications and \napplying it to my work, in some cases, having to re -write chapters as a result.  Upon \nreflection, this process was like starting my MD over again and I had not appreciated the \namount of wo rk and time it would take. With time, the literature around enhanced \nrecovery had moved on, particularly in gynaecology oncology. Although there were \ncohort studies of total abdominal hysterectomy showing reduced length of stay without \nan increase in readm ission rates or post -operative complications (11), (175), (176). In \n2016, Lena Wijk (11) suggested that outcomes from gynaecology oncology could be \nextrapolated to benign gynaecology recovery. Further studies of enhance d recovery in \ngynaecology have focused on ovarian cancer such as early re -feeding to improve bowel \nfunction and nutritional status  with ERAS guidelines published for gynaecology \n\n307 \n \noncology (12). In benign gynaecology, there have been published studies showing \nreduced length of stay, increased cost effectiveness and decreased nursing time in \nprolapse and vaginal hysterectomy su rgery with ER protocols (177, 178). Future studies \nin ER are now looking at protein loading rather than carbohydrate loading to reduce \nlength of stay and infection rates after colorectal surgery   (179).Once I had updated \nmyself on the literature, was able to continue with analysing my data. Unfortunately, I \nfound that I had missing data on the returned postal quality of life questionnaires, and \nthere was no plan applied for as part of my ethics application to contact participants for \nthis. The missing data was significant in some questi onnaires and in particular, for the \nMenorrhagia Outcomes Disease Specific Questionnaire. Due to the fact that there was \nover 10% missing data, the analysis was not reliable according to the instructing \nhandbook. In order to learn the statistical methodolog y of analysing the questionnaire, in \nparticular how to deal with Z and T scores, I decided to run the analysis but to disregard \nthe results. I am pleased that I persevered with this approach as I now have a greater \nunderstanding of this statistical methodo logy which I can use in future analyses and to \nunderstand research which has used these methods. From analysis of my qualitative data, \nparticularly the quality of life questionnaires, I have learnt that it is important to check \ndata during the study and to  check and run the analyses as you go along to pick up any \ndata problems early. If I had done this while I was running the study, I could have applied \nfor an amendment to the ethics application to obtain the missing data. I feel that this was \na missed opportunity which has greatly affected the quality of my study. As a result, any \nevaluation programme or audit I have lead since, I have designed it to capture data \n\n308 \n \nelectronically from the outset with mechanisms to alert me to incomplete data or analysis \nproblems.  \nReading and analysing the qualitative interviews also took much longer than I had \nanticipated. In order to really understand the interviews, it was important to read them \nmultiple times and then think about what the participants had talked about, bef ore being \nable to code them into themes. I have realised that the main part of the work for a \nqualitative study is in fact in the analysis of the interviews. This was different to other \nresearch I had been involved in where the collection of data or runnin g of the trial or \nexperiments took most of the time. In the future, I would plan my time differently and \nstart to familiarise myself and start to analyse the interviews at the same time as \nconducting them in order understand them better, and to keep the li nk with the rest of the \nstudy. When I have come across qualitative studies since, I have found people using a \nconcurrent analysis approach to direct future interviews. On reflection, I also think that I \nconducted too many interviews so I was left with a hu ge amount of data. It would have \nbeen a better idea to either run focus groups with the 3 routes of hysterectomy \nparticipants or to select a sample of 2 or 3 women in each hysterectomy route to speak to \nat the different time points. The multiple time point s was interesting to track and \nunderstand the evolution of recovery, however again, it left me with a great deal of data. \nIt may have been more useful to choose a time point after surgery to interview and use \nquality of life questionnaires at the other time points alone.  \nIf I were planning this study again, I would think more carefully at the quality of life \nquestionnaires I used. There are other more relevant questionnaires that I may have \nchosen such as the Hospital and Anxiety Depression Score instead o f the STAI. More of \n\n309 \n \nthe literature I came across had used the HADS score, so it would have been more useful \nto compare my findings with other published studies. Thinking from the participant \nperspective and in order to understand why there was missing data, I think that there were \ntoo many questionnaires. The EQ5 was easier to complete and gave a good impression of \noverall quality of life. I feel that the SF12 and Menorrhagia Outcomes study overlapped \nin outcome measures to an extent. In the future, I would  stick with the SF12 or updated \nsimilar questionnaire for measures of functioning.  I think that the volume of questions \ncontributed to the missing data as I found that some participants had returned the \nquestionnaires half completed particularly the Menorrhagia outcomes one.  \nI have however learnt a great deal by using all these questionnaires in how to code them \nand analyse them as well as how to present their results and draw conclusions. With this \nstudy, the aim of using the questionnaires was to triangulate the interview findings; hence \na power calculation was not carried out for rigour of statistical analysis. Now that I am \nfamiliar with the methodology of administration and analysis of these questionnaires, I \nfeel that I would know how to use them in larger studies if required where I could ensure \nthe study was powered enough to answer the question.  \nI have also learnt how to conduct a systematic review using software such as RevMan, \nhow to critically analyse the literature and how to interpret and pre sent the results in \nforest plots. Since starting my MD, I have successfully co -authored a Cochrane \nsystematic review and a National Guideline as a result of the skills I have learnt during \nthis MD. Other software I am now familiar and confident in using is  SPSS and reference \nmanagement software, which I now use as a matter of routine in many aspects of my \nwork, such as writing reports which require references, conducting literature reviews to \n\n310 \n \ninform my clinical practice and evaluating services and therapies  using statistical \nanalyses. \n  \n\n311 \n \nConclusion \nIndividual psychological wellbeing and any post -operative complications have the most \nsignificant effect on recovery and programmes should be developed to target recovery outcomes \nby enhancing education, empowerment and a more positive psychological state. In order to \nreduce confusion, there should be a consensus amongst health care workers of recovery \nexpectations and when to predict variations from normal recovery. \n  \n\n312 \n \n \nReference list \n1. H K. Multimodal approach to control postoperative pathophysiology and \nrehabilitation. 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Protein intakes are \nassociated with reduced length of stay: a comparison between Enhanced Recovery After \nSurgery (ERAS) and conventional care after elective colorectal surgery. The American \nJournal of Clinical Nutrition. 2017:ajcn148619. \n \n  \n\n322 \n \nAppendices:","source_license":"CC0","license_restricted":false}