An evaluation of recovery after hysterectomy
dissertation
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Abstract
Differences in recovery from types of hysterectomy may be due to different advice, rather
\nthan different incisions alone.
\n
\nAims: What are the beliefs and experiences of women who have a hysterectomy and the practices and beliefs of health care professionals?
\n
\nExplore the evidence for psychological preparation for surgery.
\n
\nMethods:
\n.Retrospective structured questionnaires
\n.Semi-structured interviews and validated quality of life questionnaires
\n.Systematic review
\n
\n
\nResults: No significant difference in return to work for type of employment and incapacity pay. Variation between the advice given for recovery by UK gynaecologists and nurses. Regardless of route of surgery, the expectations and fears of women are similar and rely on health care advice, with conflicting advice and varied recovery experiences. Women who had a vaginal hysterectomy had concerns around sitting, laparoscopic route had a lower length of
\nstay and abdominal hysterectomy had higher anxiety scores (P 0.003). Mean quality of life scores by EQ5 were not different based on route of surgery (pre-surgery P 0.4446, 1 week P 0.447, 4 weeks P 0.876,12 weeks P 0.850). There was a reduced length of stay [P 0.03, 5.65 (-10 82 to -0.48)] and reduced trait anxiety intervention [P <0.00001, mean difference 7.78 (7.19, 10.61)] for psychological interventions.
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Abstract
Background
A hysterectomy for benign disease can be vaginal, abdominal or laparoscopic depending
on the incision used. The recovery from each type is traditionally believed to be different
by health care professionals based principally on the incision used. We know that the
beliefs of health care professionals are an important determinant of recovery from surgery
(2).It may be that differences in recovery from types of hysterectomy are due to different
advice from health care professionals prior to surgery, rather than the different incisions
alone.
Aims:
What are the beliefs and experiences of women who have a hysterectomy and the
practices and beliefs of health care professionals?
What is the evidence for psychological preparation for surgery?
Methods
1. To examine factors which might affect return to work after a hysterectomy.
A quantitative retrospective structured questionnaire
2. To examine the beliefs and practices of health care professionals with respect
to hysterectomy through the abdominal, vaginal and laparoscopic routes.
A quantitative retrospective structured questionnaire
3. To explore the expectations, beliefs and experiences of women who have a
hysterectomy through the abdominal, vaginal and laparoscopic routes.
3
Qualitative semi -structured interviews and validated quality of life
questionnaires, anxiety and specific disease related questionnaires at various time
points before and after hysterectomy.
4. To compare the literature on psychological interventions for surgical
recovery
Systematic review of literature.
Results
There was no significant difference in return to work experience for women based on
type of employment and incapacity pay. There is a great deal of variation between the
advice given for recovery by UK gynaecologists and nurses at Birmingham Women’s
hospital, particularly after 1 week post-surgery. Regardless of the route of surgery, the
expectations and fears of women are similar and that they rely on health care
professionals to guide them with advice. Their experience confirmed conflicting advice
from health care professionals and varied recovery experiences based on the individual
rather than route of surgery. Women who had a vaginal hysterectomy had specific
concerns around sitting, the group who had a laparoscopic route had a lower length of
stay and women who had an abdominal hysterectomy had higher anxiety scores (P
0.003). Mean quality of life scores by EQ5 were not different based on route of surgery
(pre-surgery P 0.4446, 1 week P 0.447, 4 weeks P 0.876,12 weeks P 0.850). Fewer
women felt steady at 3 months after an abdominal hysterectomy than after a vaginal or
laparoscopic hysterectomy. The systematic review to compare psychological
interventions for recovery after gynaecological shows a reduced length of stay [P 0.03,
4
5.65 (-10 82 to -0.48)] and reduced trait anxiety intervention [P <0.00001, mean
difference 7.78 (7.19, 10.61)] for women who have psychological interventions. The
interventions themselves were varied.
5
Dedication
This thesis is dedicated to my son Arran who grew up with my work, spent research days
at home with me instead of the usual play dates and remains my motivation. To John who
endured many years of work and to Duncan who has supported me to complete this work.
6
Acknowledgments
I would like to acknowledge the contribution of my second supervisor at the time, Rachel
Powell for her contribution to the outline and plan of literature search for the systematic
review in chapter 7. It was part of a larger registered and published Cochrane review
protocol.
Dr Manjo Doug, Research Fellow UHB for the second reviewer on the systematic review
chapter.
Prof J.K. Gupta as my first supervisor.
7
Contents
Page
List of tables 2
List of figures 5
List of appendices 10
Chapter 1 Overview 11
Chapter 1b Methodologies 24
Chapter 2 Return to work: a qualitative analysis. 33
Chapter 3 Health care professionals’ beliefs and practices about recovery 52
after hysterectomy: A quantitative cross sectional study
.
Chapter 4 Experiences of women who have a hysterectomy: a qualitative 97
interview study
Chapter 5 Validated health status questionnaires to women who 176
have had a hysterectomy
Chapter 6 Anxiety and surgery: a validated survey to women who 242
have had a hysterectomy
Chapter 7 A systematic review of psychological preparation 258
for recovery after gynaecological surgery
Chapter 8 Discussion and conclusions 296
References
306
Appendices 316
8
List of tables Page number
Chapter 2
Table 2.1 Return to work after hysterectomy for 49
heavy menstrual bleeding
Table 2.2 Mean time back to work according 50
to type of organisation
Table 2.3 Type of sick pay according to 50
employment in public or private organisation
Table 2.4 Mean time back to work according to type 51
of sick pay
Table 2.5 Mean time of return to work after hysterectomy 51
with consultants
Chapter 3
Table 3.1 Number of inpatient days gynaecologists would 63
routinely advise after different types of hysterectomy
Table 3.2 Advice about number of weeks patients will need care 65
at home after different types of hysterectomy
Table 3.3 Advice after abdominal hysterectomy for 66
physical recovery
Table 3.4 Advice after vaginal hysterectomy for physical 69
recovery
Table 3.5 Advice after laparoscopic hysterectomy for physical 71
recovery
9
Table 3.6 How would you routinely counsel your patients 82
regarding numbers of post-operative days stay in hospital?
Table 3.7 How many weeks of care at home would you advise 84
Table 3.8 Number of weeks for advice after abdominal 86
hysterectomy for physical recovery
Table 3.9 Number of weeks for advice after vaginal hysterectomy 88
physical recovery
Table 3.10 Number of weeks for advice after laparoscopic 90
hysterectomy physical recovery
Chapter 4
Table 4.1 Codes of analysis 106
Chapter 5
Table 5.1 Participants 181
Table 5.2 Number of women who reported problems
in EQ5 at each time point 181
Table 5.3 Mean EQ5 scores at each time point 182
Table 5.4 ANOVA for mean EQ5 VAS scores according to 183
route of hysterectomy and time point
Table 5.5 Total outcome scale scores 235
Table 5.6 Quality of life/satisfaction scale scores 236
Table 5.7 ANOVA of mean change in global evaluation
Of symptoms before and after surgery 237
Table 5.8 ANOVA for mean scores by route of surgery 237
10
Chapter 6
Table 6.1 Demographics 248
Table 6.2 Mean STAI scores at time points 249
Table 6.3 Significant ANOVA by question and route
of hysterectomy for STAIT anxiety 250
Table 6.4 Significant ANOVA by question and route of 252
Hysterectomy for trait anxiety, 1 week post operation
Table 6.5 Significant ANOVA by question and route of 253
Hysterectomy STAIT and TRAIT anxiety 3 months post operation
Chapter 7
Table 7.1 Characteristics of included studies 256
11
List of figures Page number
Chapter 1
Figure 1.1 Schematic difference between qualitative 29
And quantitative research methodology
Chapter 2
Figure 2.1 Box plot of mean return to work time by 42
operating consultant
Figure 2.2 Perception of return to work, actual mean time 44
Of return to work and operating consultant
Figure 2.3 Patient perception of return to work and 46
actual mean time of return
Chapter 3
Figure 3.1 Regional distribution of responses 73
Figure 3.2 Proportion of gynaecologists who perform 74
types of hysterectomy
Figure 3.3 Regional variation in decision for route of hysterectomy 75
Figure 3.4 Experience level and decision for route of hysterectomy 76
Figure 3.5 Regional variations in offering a routine follow up 77
appointment
Figure 3.6 Variations in follow up appointment and grade 78
Figure 3.7 Regional variations in reasons to offer routine follow 79
up appointment
Figure 3.8 Variations in decision making for offering
A follow up appointment and experience in grade 80
12
Chapter 5
Figure 5.1 SF12 1 pre-surgery 186
Figure 5.2 SF12 2 pre-surgery 187
Figure 5.3 SF12 3 pre-surgery 188
Figure 5.4 SF12 4 pre-surgery 189
Figure 5.5 SF12 5 pre-surgery 190
Figure 5.6 SF12 6 pre-surgery 191
Figure 5.7 SF12 7 pre-surgery 192
Figure 5.8 SF12 8 pre-surgery 193
Figure 5.9 SF12 9 pre-surgery 194
Figure 5.10 SF12 10 pre-surgery 195
Figure 5.11 SF12 11 pre-surgery 196
Figure 5.12 SF12 12 pre-surgery 197
Figure 5.13 SF12 1 at 1 week 198
Figure 5.14 SF12 2 at 1 week 199
Figure 5.15 SF12 3 at 1 week 200
Figure 5.16 SF12 4 at 1 week 201
Figure 5.17 SF12 5 at 1 week 202
Figure 5.18 SF12 6 at 1 week 203
Figure 5.19 SF12 7 at 1 week 204
Figure 5.20 SF12 8 at 1 week 205
Figure 5.21 SF12 9 at 1 week 206
Figure 5.22 SF12 10 at 1 week 207
Figure 5.23 SF12 11 at 1 week 208
13
Chapter 5
Figure 5.24 SF12 12 at 1 week 209
Figure 5.25 SF12 1 at 2 months 210
Figure 5.26 SF12 2 at 2 months 211
Figure 5.27 SF12 3 at 2 months 212
Figure 5.28 SF12 4 at 2 months 213
Figure 5.29 SF12 5 at 2 months 214
Figure 5.30 SF12 6 at 2 months 215
Figure 5.31 SF12 7 at 2 months 216
Figure 5.32 SF12 8 at 2 months 217
Figure 5.33 SF12 9 at 2 months 218
Figure 5.34 SF12 10 at 2 months 219
Figure 5.35 SF12 11 at 2 months 220
Figure 5.36 SF12 12 at 2 months 221
Figure 5.37 SF12 1 at 3 months 222
Figure 5.38 SF12 2 at 3 months 223
Figure 5.39 SF12 3 at 3 months 224
Figure 5.40 SF12 4 at 3 months 225
Figure 5.41 SF12 5 at 3 months 226
Figure 5.42 SF12 6 at 3 months 227
Figure 5.43 SF12 7 at 3 months 228
Figure 5.44 SF12 8 at 3 months 229
Figure 5.45 SF12 9 at 3 months 230
Figure 5.46 SF12 10 at 3 months 231
Figure 5.47 SF12 11 at 3 months 232
14
Figure 4.48 SF12 10 at 3 months 233
Chapter 7
Figure 7.1 Process from initial search to final inclusion for
psychological preparation in gynaecology surgery 270
Figure 7.2 Pain at 24 hours measured by visual analogue scale 277
Figure 7.3 Pain measured by morphine use in mg 278
Figure 7.4 Behavioural recovery: time to walking 279
Figure 7.5 Behavioural recovery: wellbeing day 1 post surgery 280
Figure 7.6 Behavioural recovery: fatigue day 1 281
Figure 7.7 Negative affect: STAI Trait questionnaire 282
Figure 7.8 Negative affect: nausea and vomiting day 1 283
Figure 7.9 Length of stay 284
Figure 7.10 Risk of bias 285
Figure 7.11 Funnel plot pain VAS 286
Figure 7.12 Funnel plot morphine use (mg) 287
Figure 7.13 Funnel plot time to walking 288
Figure 7.14 Funnel plot wellbeing day 1 289
Figure 7.15 Funnel plot Nausea and vomiting 290
Figure 7.16 Funnel plot fatigue day 1 291
Figure 7.17 Funnel plot STAI trait 292
Figure 7.18 Funnel plot length of stay 293
15
List of Appendices Page numbers
Appendix 1 Sponsor authorisation 317
Appendix 2 Participants information sheet 318
Return to work questionnaire
Appendix 3 Return to work questionnaire 320
Appendix 4 Health care professional participant information sheet 324
Appendix 5 Invitation letter to health care professionals 326
Appendix 6 Questionnaire to UK Gynaecologists 327
Appendix 7 Questionnaires to General Practitioners 329
Appendix 8 Questionnaire to nursing staff 331
Appendix 9 Participant information sheet interviews 332
Appendix 10 Consent form Expectations & Experience 335
Of Women who have had hysterectomy
Appendix 11 Consent Form Recovery from hysterectomy 336
Appendix 12 Interview schedule pre-operation 337
Appendix 13 Interview schedule post operation 338
Appendix 14 SF12 Short form 340
Appendix 15 EQ 5 Questionnaire 343
Appendix 16 STAI questionnaire 344
Appendix 17 Menorrhagia Outcomes Questionnaire 348
Appendix 18 Systematic review data extraction form 352
Appendix 19 Ethics application 355
Appendix 20 Cochrane Protocol 398
16
Chapter 1: Overview
Recovery from surgery
Surgery induces physiological and psychological stresses to the body which are known to
affect organ function and recovery. Perioperative pathophysiology is multifactorial
contributing to postoperative morbidity, length of stay in hospital, and convalescen ce (1).
This thesis is the study of experiences of recovery from different routes of hysterectomy,
the beliefs of health care professionals around recovery from hysterectomy and the actual
experiences of patients who undergo a hysterectomy.
Hysterectomy
Hysterectomy is one of the most common gynaecological procedures performed in the
non-pregnant woman. It involves the removal of the womb (u terus) combined sometimes
with removal of the ovaries as well. It can be performed through an incision in the
abdomen, vagina or by key hole surgery using a laparoscopic assisted method. The
incision is often decided upon by the indication for the hysterec tomy, the surgical
expertise of the surgeon and their beliefs. Recovery from the various routes of
hysterectomy is believed to be different anecdotally by health care professionals and
17
patients, in order to understand why this may be the case, some underst anding of the
anatomy of hysterectomy is useful.
18
Anatomy of a hysterectomy
The uterus is supported by the uterosacral ligaments and the transverse cervical ligaments
at the level of the cervix. It is attached to the pelvic side walls by the round ligam ent and
ovarian pedicle, which houses some of its blood supply from the ovarian vessels. The
remainder of its blood supply is from the internal iliac vessels which enter via the broad
ligament either side in the form of the uterine vessels. Any type of hys terectomy involves
1. ligating the blood supply at the ovarian and uterine vessels, 2. exposing the uterus by
reflecting the bladder in the utero-vesical peritoneal fold with concurrent reflection of the
ureters and 3. Releasing the supports of the uterus at the round, utero -sacral and
transverse cervical ligaments. Regardless of the abdominal incision, the actual procedure
for the hysterectomy is the same for all types.
Hysterectomy can be carried out via the abdominal, laparoscopic or vaginal routes. In a
total abdominal hysterectomy, the abdominal wall is opened which is believed to add to
the length of recovery and mobility of the patient afterwards . This is due to the fact that
the abdominal wall forms part of the core strength of the body which is un der strain
during any movement post -surgery. In a laparoscopic procedure, the abdominal incisions
are small and do not disrupt the abdominal wall strength and function as much, leading to
the assumption that recovery is faster. In a vaginal hysterectomy, t here are no abdominal
incisions, instead all incisions are in the vagina, and therefore is not under the same strain
as the abdominal wall incisions, possibly leading to faster recovery.
19
Recovery advice from hysterectomy
Traditional recovery relies on adv ice given by health care professionals in the form of
verbal and leaflets. Many units have a pre -operative service where patients are seen by
pre-operative nurses who spend time going through what to expect during recovery and
how to aid recovery. At BWH, the pre-operative service is run by specialist nurses who
explain the procedure around hysterectomy including practicalities of what to bring into
hospital, how long to expect to stay, what to expect on the ward and what to expect
during recovery. This is supplemented by patient information leaflets which outline how
to aid recovery for example by early mobilisation, rehydration and pain relief. The advice
relies on the experience of the nurse giving it, although it is structured around a guidance
framework in a protocol. There are no agreed definitions of recovery time nor return to
normality.
Enhancing recovery from surgery in general
Enhancing recovery is a desirable outcome for patients and the health system leading to a
number of studies to how to impr ove recovery. There is already evidence that a formal
enhanced recovery (ER) programme (or ‘fast track’) for surgery improves recovery and
reduces hospital stay. ER is now a recognised model of care advocated by the NHS
Institute for Innovation and Improvement (2) for the elective surgery pathway which aims
to reduce the physiological and psychological stress responses d uring surgery to
minimise organ dysfunction and aid faster recovery. The pathway was first described by
Kehlet in 1990 (3) in a Danish model for colorectal patients taking into account the
decision for surgery, surgical work up, anaesthetic, surgery post -operative care and
advice for the recovery period. In the UK, the ESTReP (Enhanced Surgical Treatment
20
and Recovery Programm e) has transformed the way in which colorectal surgery is
delivered (4). The programme combines known clinical predictors of r ecovery (such as
early feeding after surgery, not using nasogastric tubes or surgical drains) with positive
psychological factors such as patient education and health promotion. The ESTReP
programme has led to a reduction in the average hospital stay from 9-10 days per patient
to 6 days. The authors of the study conclude that this has helped to generate extra bed
space to treat more patients, and under the payment by results scheme, has generated
more income for their trusts as well as to help meet 18 -week targets They have shown
that the programme is cost efficient based on the daily cost on a general or surgical ward
of £400, and have gaining support from the Department of Health.
Further programmes have now been developed with a variety of components of the ER
pathway. They have been compared in two meta -analyses, Varadhan et al’s review
included 6 randomised controlled trials (RCTs) with a total of 452 patients (5). This
review found a significant reduction in length of hospital stay (weighted mean difference
[MD] -2.55, 95% CI -3.24 to -1.85) and complication rates (RR 0.53, 95% CI 0.44 -0.64)
in the ER group if at least 4 individual elements of the pathway were implemented. The
second meta -analyses by Gouvas et al looked at 11 studie s including 4 RCTS and 7
controlled clinical trials with a total of 1021 patients (6). It also found a significant
reduction in hospital stay (weighted MD -2.47, CI -3.43—1.48) without an increase in re-
admission rates or mortality.
21
A Cochrane review of ER in gynaecological cancer (7) concluded that the re were no
RCTs of ER in this context and The Enhanced Recovery Partnership Programme was set
up as a partnership with the Department of Health, the National Cancer Action Team,
NHS Improvement and the NHS Institute of Innovation and Improvement in 2009 -2011.
This initiative included studies in gynaecology, urology and musculo -skeletal surgery.
The ER pathway considers the pre-operative period which includes a risk assessment and
opportunity to provide information and psychological preparation. The discharg e plan is
criteria based upon mobilisation, control of pain by oral analgesia, passing flatus and
being able to eat and drink. In 2012, the the Enhanced Recovery After Surgery (ERAS)
Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and
European Society for Clinical Nutrition and Metabolism (ESPEN) published guidelines
for peri-operative care in colonic surgery (8) It is recommended that patients should be
given Preadmission information, education and counselling regarding practical advice to
aid recovery, diminish fear and anxiety and expected length of time until they return to
normal function. When a Cochrane review did not recommend the ERAS programme as
the new st andard of care due to the lack of published trials, a meta -analysis of 16 trials
and 2376 patients was published confirming a reduction in length of stay and morbidity
rates without an increase in readmission rates.
Recovery from gynaecological surgery
In 2016, Lena Wijk (11) published how enhanced recovery from gynaecology oncology
could be applied to benign gynaecology . Further studies looked at enhanced recovery
22
after ovarian cancer surgery with early feeding improvi ng bowel function and nutritional
status (12).
Despite these recommendations in other surgical specialities and an opinion paper from
the Royal College of Obstetricians and Gynaecologists UK (RCOG) there is no agreed
national evidence based guideline for enhanced recovery in benign gynaecology surgery,
and in particular around long term recovery to normal function (9) (10). NICE have
published guidance in a 24 hour discharge programme after Caesarean Section. There are
a number of published local enhanced recovery programmes after Caesarean (13) and the
Scottish Government guidelines (14)which publish an increase in 24 hour discharge using
their programme from 5% to 33% .
Steps for Enhanced recovery (ER)
Traditionally ER has a number of components:
1. Pre-operative education
2. Carbohydrate drinks
3. Fluid balance and warming
4. Early feeding
5. Removing tubes early
6. Early mobilisation
This thesis considers the first step of pre -operative education, including whether better
information and counselling with psychological preparation could alter behaviour to
improve recovery from hysterectomy in the long term beyond the traditional boundaries
of ER which is discharge from hospital . Enhanced recovery programmes have been
23
established and shown to reduce length of stay and morbidity for benign gynaecology
procedures (15). A Cochrane review of approaches to hysterectomy (16) found a shorter
hospital stay in women who have had a vaginal rather than a laparoscopic assisted or
abdominal hysterectomy and the National Institu te for Clinical Excellence (NICE) has
recommended a vaginal approach as first line (17). Regardless of this, in the real life
pragmatic situation, hospital st atistics report that women who have undergone a vaginal
hysterectomy, with no abdominal incisions, have an average post -operative stay of 3.2
days in England, which is longer than the laparoscopic approach and not much different
to the stay after the abdo minal route (HES Statistics 2012 (18)) and NHS Choices advise
between 1 and 4 days for a laparoscopic or vaginal hysterectomy and 5 days for an
abdominal hysterectomy (19).
This may indicate that in strictly controlled experimental designs clinicians are
potentially achieving optimum care efficiency through their beliefs about therapy and
through the inadvertent physiological and psychological preparation of all patients. Thi s
could be in the form of stringent trial inclusion and consent procedures with increased
access to support mechanisms and follow up. It may be that patients’ and health care
professionals’ beliefs and expectations of recovery play a more significant part in what
actually occurs outside clinical trial settings. Aspects of this could be amenable to
psychological intervention to improve recovery outcomes.
ER programmes consider psychological interventions by involving the patient at every
step of their surgery from planning to recovery to provide women with all the information
24
and support they require regarding treatment options, the surgery, recovery and
discharge.
Psychological preparation
Psychological preparation incorporates a range of strategies designed to influence how a
person feels, thinks or acts (emotions, cognitions or behaviours). The benefits of
psychological preparation for surgery have been evaluated in a meta -analysis. It
identified many different types of psychological preparation, i ncluding procedural
information, sensation information, behavioural instruction, hypnotic and relaxation
training, psychotherapeutic interventions and cognitive behavioural approaches. They
were found to be beneficial for a range of outcome variables such as negative affect, pain,
and pain medication, length of hospital stay, behavioural recovery, clinical recovery,
physiological indices and satisfaction. Psychological interventions consider people’s
cognition, beliefs of control, empowerment and self -efficacy and the behaviours they
associate with them.
Control
The locus of control is a psychological term referring to the extent to which individuals
believe they control events that affect them. People can have a perceived internal or
external locus of control. People with external locus of control will believe s trongly in
other people, fate and in their destiny, whereas someone with a strong internal locus of
control will believe that they have the ability to influence their own future. Information
seeking is more common in people who have an internal locus of co ntrol. They benefit
25
from knowing more information and are able to reduce their anxiety levels about
forthcoming surgery, whereas the same information may increase the anxiety levels of
someone with an external locus of control as they may rather not know the details (20). A
shorter time interval to achieving a straight leg raise was found with patients who had an
internal locus of control after total knee surgery (21). The effect of psychological
preparation before surgery is questionable on patients with an external health locus of
control (22). A consideration of the individual’s locus of control can be made through
offering a choice of information to reduce anxiety and to increase their ability to cope
(23).
Coping strategies
The patient’s coping tendency has also been studied in relation to the information patients
need. People can cope with situations through mainly problem focused strategies or
emotional focused strategies. Those who use problem focused strategies make plans to
improve the situation and feel better when these are followed through. Emotio nal focused
individuals tend to alter their own cognitive interpretation of the situation rather than
change it, for example, ‘looking at the bright side’ (24). It may be that there is a
continuum of control and coping strategies, which may also be influenced by the situation
of undergoing surgery and by the feeling of conforming to social bias (assuming the sick
role of being a patient). Research is needed into whether psychological support is mor e
effective if matched with coping styles.
26
Empowerment and self-efficacy
In the past, patient education followed the traditional disease based model, where the
provider was the expert who decided what information and how much of it the patient
should receive. The provider becomes the primary decision maker and problem solver.
Outcomes of this model are the patient’s compliance with the provider’s suggestion. In an
empowerment model, health providers assist patients in gaining knowledge, developing
skills and identifying resources. Empowerment enables others to take control of their
own lives. This model recognises the psychosocial as well as the physical aspects of
health and disease. Empowerment and self -efficacy are closely related constructs. Self -
efficacy is the belief that you can effectively perform a given behaviour to produce the
desired outcome (24). Motivation and perseverance is dependent on the individual’s
evaluation of their self -efficacy. If the individual does not believe they can perform
behaviour, their motivation will decrease.
Using psychological interventions to improve the quality of post-operative recovery.
Although psychological interventions have been shown to improve outcomes, it would be
important to establish which interventions improve which outcome. There is much
heterogeneity among studies in their definition of a favourable recovery outcome, and
what a favourable outcome might be to clinicians and patients. Recovery has many
components including measurable clinical aspects such as vital observations, norm alising
of test parameters, the use of analgesia, return of physiological function such as passing
27
urine or opening their bowels, number of days as an inpatient and mobility. Clinical
interventions need to be evaluated for quality as well as importance and value to patients.
From the perspective of the patient, a favourable outcome may be more related to
important aspects of their lives such as being able to sleep normally, looking after their
families, socialising, feeling emotionally back to normal or be ing able to go back to
work. In the past, patient education followed the traditional disease based model, where
the provider was the expert who decided what information and how much of it the patient
should receive. The provider becomes the primary decisio n maker and problem solver.
Outcomes of this model are the patient’s compliance with the provider’s suggestion. In an
empowerment model, health providers assist patients in gaining knowledge, developing
skills and identifying resources. Empowerment enable s patients to take control of their
own lives. This model recognises the psychosocial as well as the physical aspects of
health and disease. Empowerment and self -efficacy (the belief in one’s ability to succeed
or accomplish a task) are closely related con structs which can affect behaviour .
Psychological interventions which increase empowerment and self-efficacy could be a
cost effective way of improving those aspects of recovery which the patients value as
well as traditional clinical measures. More resear ch is needed into which psychological
interventions improve which recovery outcomes. Through qualitative in-depth analysis of
patient’s views and experiences, we can understand their recovery and which outcomes
are valued by them, and how they perceive their experiences to influence recovery.
Psychological preparation has been shown to be an important factor in the patient’s
surgical experience. These can be affected by the beliefs of health care providers in the
28
way t hey counsel and advise their patients (25). With an increasing drive towards a
shorter length of stay in all specialities, efficient patient preparation is an important area.
In the example of the route taken for hysterectomy, operativ e incision itself does not
seem to account for the differences in recovery and the discrepancy between the everyday
clinical situation and that of clinical trials. Psychological variables in the patient which
are influenced by the beliefs and practices of health care professionals could play a part
in accounting for these differences. The rigorous consent procedures in clinical trials and
the participant support facilities through access to health care professionals and
researchers as well as activities such as newsletters will have psychological consequences
on the patients involved, regardless of which treatment arm they are in. This could
account for the better outcomes seen in trials. Recovery outcomes could be improved in
real life situations through th e use of psychological interventions aimed at recovery
outcomes which are valued by patients in particular, the use of well -designed information
giving, cognitive therapy and emotion focussed therapy to match those seen in clinical
trials.
Research Aims:
1. To examine factors which might affect return to work after a hysterectomy from
heavy menstrual bleeding.
2. To examine the beliefs and practices of health care professionals with respect to
hysterectomy through the abdominal, vaginal and laparoscopic routes.
3. To explore the expectations, beliefs and experiences of women who have a
hysterectomy through the abdominal, vaginal and laparoscopic routes.
29
4. To search the literature in a systematic way for psychological interventions which
may influence recovery after hysterectomy.
This thesis presents in each chapter, the background to each research aim, the study and
findings with a discussion and conclusion of each. It will then consider how each of these
studies has contributed to the overall understanding of recov ery from hysterectomy for
heavy menstrual bleeding using the different surgical routes and the implications for
patients, future research and clinical practice.
30
Chapter 1b
Methodologies
Methodologies chosen for this study by research aims:
5. To examine factors which might affect return to work after a hysterectomy.
A quantitative retrospective structured questionnaire was chosen to answer these
questions which included closed questioning for demographic data and outcome
measures.
6. To examine the beliefs and practices of health care professionals with respect
to hysterectomy through the abdominal, vaginal and laparoscopic routes.
A quantitative retrospective structured questionnaire was chosen to answer these
questions which included closed ques tioning for demographic data and outcome
measures.
31
7. To explore the expectations, beliefs and experiences of women who have a
hysterectomy through the abdominal, vaginal and laparoscopic routes.
This part of the study included qualitative semi -structured interviews which
covered the expectations, beliefs and experiences of women as well as
considering physical emotional, social and sexual aspects of recovery. The
interviews were carried out before and after the hysterectomy with each woman.
It also used validated quality of life questionnaires, anxiety and specific disease
related questionnaires at various time points before and after hysterectomy,
analysed in a quantitative method.
8. To compare the literature on psychological interventions f or surgical
recovery
Using systematic review of literature.
32
Background
on qualitative research methodology
As a health care professional, I am trained and familiar with the methodology of
quantitative research and systematic review, however, I have limited experience of the
basis and methodology of qualitative research, and hence I feel I need to explore this
topic in this part of the introduction.
Qualitative research aims to answer questions of ‘why and how’ through in depth
exploration and under standing of human behaviour. Shank (26) defines qualitative
research as “a form of systematic empirical inquiry into meaning”. By systematic he
means “planned, ordered and pub lic”; following established methodologies. Denzin and
Lincoln (27) suggest that qualitative research involves an interpretive and naturalistic
approach: “This means that qualitative researchers study things in their natural settings,
attempting to make sense of, or to interpret, phenomena in terms of the meanings people
bring to them”. In order to study in the naturalist setting, the researcher needs to enter that
setting. In this way, qualitative research is different from quantitative research, where the
researcher attempts to study a phenomenon from a position outside the research setting so
that the researcher does not bring any effect such as bias to the setting (figure 1).
Qualitative research has a wide range of approaches and methodologies such as grounded
theory, phenomenology, ethnography, narrative research and case study, but they
describe all types having a focus on natural settings, an interest in meanings, perspectives
and understandings, an emphasis on the process and involve inducing meaning (28). For
33
example, quantitative research may look at demographics such as socio -economic
Background
and the prevalence of smoking, but qualitative research would explore what
influences certain groups to smoke.
In qualitative research few assumptions as possible are made beforehand and it is about
generating possible hypotheses, unlike quantitative research which starts with a
hypothesis to test. An example is inductive methodology generally seeking to generate or
induce a theory from the data, theory is then said to be ‘grounded’ in that data as in
grounded theory (29).Qualitative research places importance on situations whic h
influence behaviour, and the context in which the behaviour is being studied, with
various layers of study and interpretation which can be lengthy to discover deeper
meaning that participants attach to behaviour, how they interpret situations and their
perspectives. For example, a study by Measor and Woods (30) to attempt to understand
how to dissolve gender boundaries at a secondary school by introducing a common
curriculum found that boys used cakes as weapons and sewing machines as trains, while
girls complained about nasty smells and unisex goggles in physical science. It was by
observing the behaviours of the girls and boys in the natural setting of the classr ooms
whereby the researcher was able to explore what happened and the meaning each gender
gave to the subjects on the curriculum; gaining an understanding of the barriers which
may be experienced in dissolving gender boundaries. In order to gain deeper mea ning,
the researcher needs to gain a certain rapport with the subjects, and needs to consider
their own influence on the subjects’ behaviour. Researchers should also consider the
34
effects of time and sample across time as the same activity or item could mea n different
things at different times (28).
Qualitative research is sometimes criticised for not being generalizable although there are
examples of where it has been used and debated to determine health care and educational
policy (31). For example, Hargreaves (1967) and Lacey (1970) used mainly qualitative
Methods
to study a secondary modern and grammar school respectively and the data they
gathered generated the theory of differentiation and polarisation, used in educational
policy. They suggested that where pupils were differentiated by ability, then a
polarisation of attitudes into pro - and anti -school would occur among them. Some
qualitative research does not aim to produce a theory but to understand the quality of
social life, including the emotions and complex social interactions which accompany it.
35
Figure 1: Schematic difference between qualitative and quantitative research
methodology.
Natural setting
Phenomenon
Researcher
Phenomenon
Researcher
Research setting
Qualitative research
Quantitative research
36
Methods
of qualitative research
Many methods are used in qualitative research such as observation, diaries, interviews
and documentary analysis (32, 33).
In observation, the researcher aims to be an unobtrusive observer to the natural situation
where the researcher adopts a role in th e natural setting, such as a member in a group, or
a non-participant observer where the researcher watches the natural situation and tries not
to disturb the scene, such as in ethnography (34, 35) .
Interviews can be formal or more casual conversations to explore the participant and their
responses (33, 36, 37). The best format in order to minimise the effect of the researcher is
the unstructured interview where the researcher has some general ideas or topics but the
flow of the interview is dictated by the subject in the natural course of discussion. The
researcher tries to appear to be natural rather than someone with the role of research and
attention is paid to where the interview happens, the seating arrangements, how the
interviewer dresses and the manner of approach in order to keep the setting as natural as
possible. The researcher is careful not to appear to be leading along the topic areas, but
uses skills and techniques to explore clarity and depth to allow the participant to lead the
interview in a non -structured way in order to explore where the participant wants to take
the conversation. A disadvantage of the unstructured interview is that it may not cover all
aspects which the researcher is interested in (33).
37
A structured interview is useful when the study is more focussed where the researcher
decides the structure of the interview with pre-determined broad topic questions requiring
an in depth response from the participant. Semi -structured interviews use some structure
but questions which have scope for open -ended answers. Semi -structured interviews are
useful to compare responses to themes from different participants or groups (33, 37).
When qualitative research is compared to quantitative research, it is sometimes criticised
as lacking vigour in validity, interpretation and bias by the researcher and not being
reproducible or generalizable to other situations (38). There are techniques which need to
be considered in order to increase the validity of qualitative research (39), i.e. to ensure
that the interpretation of find ings is real by recognising the researcher’s impact on the
participant and the natural situation. Such techniques include respondent validation and
triangulation. Respondent validation is a technique where the interpretation of findings is
given to the par ticipants to judge whether it is an accurate understanding and portrayal
after the study is complete (40). Method triangulation uses multiple methods to study an
issue to increase accuracy and depth, such as combining structured interviews with
observation or questionnaires. Time triangulation studies the issue at different time
points, for example before during and after the event. Triangulation of persons might
involve consulting with a range of people involved in th e issue who may have differing
roles where their accounts can then be studied to look for differences. In this study,
validity will be attempted using triangulation of method by using semi - structured
38
interviews and validated questionnaires, time by interv iewing at different time points and
person by interviewing a number of women in the three groups of route of hysterectomy.
39
Chapter 2 Return to work: a quantitative analysis.
Introduction
Heavy menstrual bleeding (HMB) is an important cause of ill health in women. Surgical
treatment of HMB often follows failed or ineffective medical therapy and the definitive
treatment is hysterectomy. This is a major surgical procedure with significant physical
and emotional complications as well as economic cost. Resumption of work activities
after gynaecological surgery takes much longer than expected, irrespective of the surgical
technique used and the severity of the surgery (41-44). Return to work is perceived by
patients and increasingly by the health care industry as a highly important outcome and
recovery promotion ideas after surgery are not new. There is documented evidence that
long periods of sickness absence can result in detrimental personal consequences for the
individual in work disability, social exclusion, poorer general health, increased risk of
mental health problems and higher mortality (45). An Individual’s personal consequence
of delayed resumption of normal activities has an impact on the health service resulting in
more physician consultations, medical treatment and higher hospital admission rates.
Longer absences are associated with a reduced probability of eventual return to work and
subsequent economic and social deprivation (45, 46). Sickness absence is a major public
health and economic problem. In 2003, 176 million working days were lost through
sickness absence, the cost of which to the economy is enormous. Each absent employee
cost their employer £760 per year on average in 2010 through a combination of direct
costs in sick pay, lost output and provision of cover. Across the economy as a whole, the
40
direct costs alone amount to more than £17bn a year and after non-work related injury
post-operative recovery time is the second most common cause of absence (47).
Interventions aimed at reducing the post-operative recovery time to resumption of normal
activities have a huge potential benefit to individual patients, the health service, Society
and the economy. Return to work is a complex concept, influenced not only by the type
of surgical procedure but also by a multitude of other variables such as age, education
level, income level and type of occupation (23;25) as well as the attitudes and advice
given by health care practitioners (25;26). There are reports of immediate ambulation
after herniorrhaphy to aid recovery since the 1960’s (30) and many since such as studies
to investigate return to work rates and factors that influence it in patients undergoing
surgical procedures like inguinal hernia repair, coronary artery bypass graft and renal
transplant (22-24). There is now evidence that a formal enhanced recovery programme
for surgery improves recovery and reduces hospital stay (18) and the ESTReP (Enhanced
Surgical Treatment and Recovery Programme) has transformed the way in which
colorectal surgery is delivered in the UK (4). Their programme combines known clinical
predictors of recovery (such as early feeding after surgery, not using nasogastric tubes or
surgical drains) with positive psychological factors such as patient education and health
promotion. The ESTReP programme has led to a reduction in the average hospital stay
from 9-10 days per patient to 6 days. The authors of the study conclude that this has
helped to generate extra bed space to treat more patients, and under the payment by
Results
scheme, has generated more income for their NHS Trusts as well as to help meet
18-week targets (19). They have shown that the programme is cost efficient based on the
daily cost on a general or surgical ward of £400, and have gained support from the
41
Department of Health. The ENHANCE surgery programme is now a national initiative
from the NHS Institute of Innovation and Improvement and focuses on patients playing
an active role in their recovery (8).
Improving post-operative recovery after a hysterectomy is important to the NHS as it is
one of the commonest surgical gynaecological procedures performed; around 40,000 are
carried out in the NHS every year (37). Most of these are done on women of working age
between 40-50 years (37). Therefore the disease burden on the NHS is high, as is the
cost to the economy and society during the post-operative convalescence period.
This study is to identify the baseline return to normal data for women who have had a
hysterectomy in our local population at Birmingham Women’s Hospital, and to find any
factors which may have influenced their return to work.
Aims
This study aimed to establish the baseline data for time of return to work after a
hysterectomy and to find any variables such as type of employment and operating
consultant which may affect return to work rates following a hysterectomy in our local
population at Birmingham Women’s Hospital. In particular, data for women who had a
hysterectomy for heavy menstrual bleeding was studied. This questionnaire only looked
at return to work, not return to normality.
42
Objectives
Primary research question:For women who have had a hysterectomy for heavy
menstrual bleeding, how is time of return to work affected by:
Type of employment organisation (public or private)
Type of sick pay (usual, reduced, statutory sick pay, incapacity benefit, none)
Employment status (full, part time or self-employed)
Responsible consultantSecondary research questions
How is time of return to work related to the patient’s perception of whether they
returned at the right time, too early or too late?
Is the patient’s perception of their time of return to work influenced by the
consultant who operated on them?
Methods
Design
Ethical approval (appendix 1) was gained and a patient information leaflet was sent to all
participants (appendix 2). A retrospective structured questionnaire study (appendix 3)
which was developed using the standard Department of Work and Pensions questions and
variables for sickness pay and employment status. In particular, we were interested to see
if there was an association with whether there was further loss of income if women were
self-employed or if they did not have any sickness pay cover. The questionnaire was
piloted on 3 women in a benign gynaecology clinic waiting room to ensure construct
43
validity. There were no standard questionnaires known of which we could utilise to
answer the research questions for this section.
Study sample
This was a study of women who had a hysterectomy at the Birmingham Women’s
Hospital over a 12 month period from January 2008-2009. A total of 150 women were
identified as having had a hysterectomy using clinical coding systems during this time
period for total abdominal hysterectomy, vaginal hysterectomy, laparoscopic assisted
hysterectomy and subtotal hysterectomy. The participant information letter (appendix 2),
and questionnaire (appendix 3) was posted to the home addresses of all women along
with an invitation letter (appendix 3). Responses were then stratified and analysed for
women who had a hysterectomy for heavy menstrual bleeding in order to reduce
confounders in recovery such as carcinoma; which is known to have more prolonged
recovery due to the disease process. Other benign conditions such as endometriosis may
have differences in recovery as well associated with the increased pain and surgical
complexity associated with the disease per se.
Procedure
The questionnaire was mailed to women at their home address which was identified from
hospital databases. A stamped addressed envelope was included for return post. A
reminder letter and questionnaire was sent around 3 weeks later.
44
Analysis
Data from completed questionnaires was analysed using IMB SPSS v16 © by MS.Data
was analysed by descriptive statistics of frequency and means. Data distributions were
visually examined for normality using histograms. Scatter plots were drawn to explore
patterns between time of return to work and type of incapacity benefit, type of
employment contract, public or private sector employment and consultant gynaecologist
under whose care the surgery was performed. Differences in mean time back to work
with the type of employing organisation (private or public) were tested using an
independent-samples T-Test. The relationships between time of return to work and
employment status (full, part time or self-employed) and type of sick pay were explored
by analysis of variance (ANOVA). If significant differences were found between groups,
post hoc testing and tests of multiple comparison were performed.
Ethical considerations
Ethical approval was gained from Black Country Research Ethics committee
(09/H1202/66) (Appendix 17) and sponsorship from UoB (Appendix 1).
Results
A response rate of 53% was achieved (80/150). Of the respondents, 15 women did work
and only 1 did not return to work after her hysterectomy (table 2.1). Of the women who
did work, 16 women worked in a private organisation (11 full time, 3 part time, 2 self-
employed) and 40 worked in a public organisation (21 full time, 19 part time). During
their convalescence, the total number of women who received incapacity benefit as their
main source of income was 2, statutory sick pay (SSP) was 12, a reduced income from
45
their employer was 3 and their usual pay was 35. One woman did not receive any income
and 2 women did not answer this question.
Results
for data on women who had a hysterectomy for heavy menstrual bleeding
(Table 2.1)
Data was split to include only those women who had a hysterectomy for heavy menstrual
bleeding. There were a total of 63 women in this group of whom 55 returned to work. Of
those who did not return to work, 1 woman had retired, 3 who were unemployed and 4
who did not answer this question. Women in this group were in full time employment in
42.5% of cases, part time in 24% and self-employed in 1.5%. The mean time for return to
normality was 11.6 weeks (SD 4.84, table 2.1). Most of these women felt that they had
returned to work at the right time (49%) with 15% feeling they had returned too early and
only 1.8% feeling they could have returned earlier than they did. For this group of
women, 43% received their usual pay while they were on sick leave, 16% received
statutory sick pay only, 4% received reduced pay from their employer, and 1.8% received
incapacity benefit.
i) Return to work and organisation type
Table 2.2 shows the mean time of return to work according to whether the patient worked
for a private (n=16) or public (n=40) organisation. An ANOVA did not show a
significant difference between mean time of return to work and public organisation and
private organisation F 0.165 p= 0.686.
46
ii) Return to work and type of sick pay
Most women received their usual pay during their recovery, but a lower proportion of
women received any category of sick pay if they worked for a private organisation (table
2.3). An ANOVA was conducted to explore the impact of type of sick pay received on
when patients returned to work (RTW) after a hysterectomy measured in weeks. Type of
sick pay was categorised as usual pay, reduced pay, statutory sick pay (SSP), incapacity
benefit and no pay (table 2.4). There was no statistically significant difference at the
p<0.05 level in the RTW time for the type of sick pay. F (2 50) = 0.187, P=0.48.
iii) Return to work and employment status
An ANOVA was conducted to explore the impact of employment status on when patients
returned to work (RTW) after a hysterectomy, measured in weeks. Employment status
was categorised as full time, part time and self-employed. There was no statistically
significant difference in the RTW time for the type of sick pay.
F (2 52) = 0.76, P=0.59
As none of the above variables had a significant effect on RTW, no further statistical tests
(such as multiple comparison and post hoc tests) were carried out.
iv) Mean time of return to work and operating consultant
The mean time that patients went back to work according to the consultant who operated
on them is shown in figure 2.1 and table 2.5.
47
An ANOVA was conducted to explore the impact of consultant on when patients
returned to work (RTW) after a hysterectomy measured in weeks. There was no
statistically significant difference at the p<0.05 level in the RTW time for the type of sick
pay F (2=1.087), P=0.38.
48
Figure 2.1: Box plot of return to work time by operating consultant
Consultant N
A 7
B 7
C 1
D 5
E 4
F 18
G 2
H 1
I 2
J 2
K 6
Total 55
49
The influence of operating consultant on patient perception of time of return to work.
Figure 2.2 shows patient perception of return to work, actual mean time of return to work
and the consultant who operated on them. For most consultants, patients felt they
returned to work about the right time or too early. There was no pattern for any particular
consultant suggesting that in this cohort, there was no obvious influence of the operating
consultant on the patient’s perception of time to return to work.
50
Figure 2.2: Perception of return to work, actual mean time of return to work and
operating consultant.
Mean time of
return to work
(weeks)
Patient perception
Consultant
51
v) Patient perception of return to work and actual mean time of return.
There were no differences in the meantime return to work and whether the patient
perceived their return time to be about right, too early or too late (figure 2.3).
52
Figure 2.3: Patient perception of return to work and actual mean time of return to
work.
27
8
1
19
Right Early Late No answer
Patient perception of time of return
to work
53
Discussion
Return to work is a complex concept influenced by not only the disease and type of
surgery, but by socioeconomic factors and attitudes of patients and health care workers. It
is encouraging from this survey that most women return back to normal after a
hysterectomy. This study does not show any differences in when women return to work
in relation to the type of incapacity benefit they receive, the type of employment contract
they have or whether they work in the private or public sector. However, the numbers in
the study are currently too small to be able to detect a difference if it exists, especially for
the self-employed versus employed group. There were no real differences in time of
return to work and the consultant under whose care the hysterectomy was performed.
This may be due to a difference in the type of hysterectomy they had (laparoscopic,
vaginal or abdominal) and a difference in the advice about recovery given by each
consultant. A larger sample size in a future study will help to confirm whether this
difference is statistically significant. Return to work after different routes of hysterectomy
was not measured in this survey but other surveys of laparoscopic surgery have shown a
positive association with laparoscopic approaches (49). There is no published data to
compare the results from our study at BWH to other hospitals for return to work.
Other studies have demonstrated factors which are associated with return to work and
have been compared in a literature review for cancer survivors (50). Positive associations
included positive reactions of work colleagues and patient reaction to the disease and
treatment. Negative associations with return to work included a lack of discussion with
health care professionals. Counselling and giving patients realistic expectations pre-
operatively and during recovery are therefore important in nurturing a positive attitude
for return to work. This review did not find any association with return to work and
income or education. There will be specific factors in cancer survivors which cannot be
extrapolated to surgery for benign conditions, but pre-operative patient preparation has
been shown to be important in other conditions such as laparoscopic cholecystectomy
(51), inguinal hernia repair (44) and coronary artery bypass graft (52). These studies did
54
find a difference in return to work with age, education level, income and type of
occupation.
55
Table 2.1: Return to work after hysterectomy for heavy menstrual bleeding.
Number of women returned to work 87% (55/63)
Reasons for not returning
Retired 1
Unemployed 3
No answer 4
Full time employment 42.5% (27/63)
Part time employment 24% (15/63)
Self-employed 1.5% (1/63)
Mean time of return to work 11.6 weeks (SD 4.84)
Opinion of return to work
Right time 49% (27/55)
Too early 15% (8/55)
Too late 1.8% (1/55)
No answer 35% (19/55)
Type of pay while off sick
Usual 43% (24/55)
SSP 16% (9/55)
Reduced 4% (2/55)
Incapacity
Benefit 1.8% (1/55)
56
Table 2.2: Mean time back to work according to the type of organisation.
Type of
organisation
Number Mean time back to
work
(weeks)
SD time back to
work
(weeks)
Private 16 11.14 5.53
Public 40 11.76 4.65
Table 2.3: Type of sick pay according to employment in a public or private
organisation.
Total
Number
Incapacity
(%)
No
pay
(%)
Reduced
pay
(%)
SSP
(%)
Usual
(%)
Not
mentioned
(%)
Public
organisation
40 0 0 2
(10%)
10
(25%)
27
(67.5%)
1
(2.5%)
Private
organisation
16 2
(12.5%)
1
(6%)
1
(6%)
2
(12.5%)
8
(50%)
2
(12.5%)
57
Table 2.4: Mean time back to work according to type of sick pay.
Type of sick pay Number Mean time back to
work
(weeks)
SD Mean time back
to work (weeks).
Incapacity benefit 2 16 11
No pay 1 8
Reduced pay 3 13 2
SSP 12 12 4
Usual pay 35 11 5
Not mentioned 3 6 3
Table 2.5: Mean time of return to work after a hysterectomy with Consultant.
Consultant Number Mean time back to
work (weeks)
SD time back to
work (weeks)
A 6 9 7
B 1 4
C 30 8 7
D 4 8 7
E 18 12 7
F 2 7 1
G 2 6 8
H 6 4 6
58
Chapter 3
Health care professionals’ beliefs about recovery after hysterectomy: A quantitative
cross-sectional study.
Introduction
Doctor-patient communication and physicians’ beliefs about efficacy of surgery are
known to be important factors when both patients and doctors make treatment decisions
for elective surgical procedures (55, 56). Physician factor has been implicated as a source
of practice variation (57, 58) which could represent a set of beliefs which have a powerful
effect on the behaviour of patients (59). The UK Department of Work and Pensions
(DWP) has produced guidance for some surgical procedures but published evidence
shows that there is a lack of awareness of them (41). Patients give high importance to the
information given to them by health care professionals over other sources and it
influences behaviours such as when to return to normal activity. In addition, shared
clinical decision making has been shown to improve patient outcomes such as satisfaction
and improved functional status (60, 61) . However shared clinical decision -making is
more difficult than it appears due to divergent perspectives relating to beliefs about health
and illness, expectations of medical care, treatment priorities and ways in which
information is interpreted (62, 63). As patient behaviour is influenced by the information
given to them by health care professionals, and there are variations in their beliefs and
advice, there may be a resultant dif ference in patients’ behaviour. Hence study of health
care professional beliefs could help us to understand what they think of patient recovery
experiences.
59
Guidance for health care professionals in post-operative recovery has been shown to
reduce illness related work absenteeism by several weeks compared to unstructured
standard advice (48, 64-70). Well defined postoperative recommendations have been
shown to reduce sick leave by several weeks in comparison to standard care given
without any structural convalescence recommendations (18, 71-75). In section 1.8 of
NICE guidelines for Heavy Menstrual Bleeding (48), the following recommendations are
made:
1.8.2 Women offered hysterectomy should have a full discussion of the implication of the
surgery before a decision is made. The discussion should include: sexual feelings, fertility
impact, bladder function, need for further treatment, treatment complications, the
woman's expectations, alternative surgery and psychological impact. [2007]
1.8.5 Individual assessment is essential when deciding the route of hysterectomy. The
following factors need to be taken into account:
presence of other gynaecological conditions or disease
uterine size
presence and size of uterine fibroids
mobility and descent of the uterus
size and shape of the vagina
history of previous surgery. [2007]
1.8.6 Taking into account the need for individual assessment, the route of hysterectomy
should be considered in the following order: first line vaginal; second line abdominal.
[2007]
However detailed recommendations on the resumption of activities are not alwa ys
provided by medical specialists as a result of the lack of recognised guidelines on the
60
gradual resumption of activities and because of a lack of knowledge about the physical
demands of the patient’s job (45, 71, 76). We know there is variation between the advice
given by different health care professionals on convalescence from illness which is not
evidence based or specific to the type of surgery (77-84) and this will lead to confusion,
complications (85) and longer absenteeism for patients. Long periods of sick leave are
known to result in work disability, poorer health, an increased risk of mental health
disease and mortality (85, 86) Therefore it follows that structured guidance on recovery
from specific types of surgery based on evidence and patient experience will provide
consistent advice which may lead to better patient satisfaction and expectations and
shorter illness related absenteeism.
In this study we will examine the beliefs of health care practitioners upon which their
advice to patients is likely based. The advice given to women on recovery after
hysterectomy is anecdotal and historical, based on the experience of health care
professionals with other patients or on their beliefs. There is substantial variation in the
convalescence recommendations given by gynaecologists, general practitioners and
occupational physicians (20, 45, 73, 75, 87 -89), however we do not know which
healthcare professionals patients are more likely to be influenced by . In one study (45),
433 Danish gynaecologists were surveyed about their convalescence recommendations
after a vaginal repair procedure for prolapse. Post -operative stay ranged from 1 to 7 days
and the recommended sick leave was 2 to 12 weeks with a median of 6 weeks for women
with heavy lifting work. The recommended time for r ecommencement of sexual
intercourse was 0 to 12 weeks with a median of 4 weeks. The recommended range of
61
time for non -strenuous activity was 0 to 24 weeks. These differences could not be
explained by demographic differences between gynaecologists. Studie s have looked at
the educational and informational needs of hysterectomy patients (73, 74, 90) and the
quality and management of written information given to patients undergoing
hysterectomy was evaluated as poor quality and unsuited to patients’ needs in NICE
guidance 2007 (48). These guidelines also addressed treatment options, indications for
surgery and type of surgery, but not return to normality . In a consensus of surgical
experts, a reference guide of 4 to 6 weeks after a total abdominal hysterectomy and 2 to 4
weeks after a vaginal hysterectomy has been proposed for recovery (91). More recently
an expert multidisciplinary group in Holland made recommendations of 3 -4 weeks for
laparoscopic hysterectomy, 4 weeks for vaginal hysterectomy and 6 weeks for an
abdominal hysterectomy (92) after a modified Delphi Study of 5 gynaecologists, 2
general practitioners, 5 occupational physicians and a representative sample of 63
medical doctor.
Aim:
To explore the beliefs and current practices of UK gynaecologists, South Birmingham
PCT general practitioners and local gynaecology nurses in counselling patients before
and after hysterectomy.
The following questions were addressed:
What proportion of health care professionals are aware of the NICE guidelines for
Heavy Menstrual Bleeding
What are the current practices of different health care professionals?
62
Health care professional opinions on what influences the practices and beliefs of
different health care professionals?
What advice do different he alth care professionals give to women after a
hysterectomy through the abdominal, vaginal and laparoscopic routes?
Is there a difference in the above questions for Gynaecologists, General
Practitioners and gynaecology nurses?
What are the beliefs and practices for UK Gynaecologists in the different regions?
Study design.
A cross sectional structured questionnaire study for each health care professional group
(UK Gynaecologists, South Birmingham PCT General Practitioners, Gynaecology
nursing staff Birmingham Women’s Hospital).
63
Methods
Study sample
There were three sample groups to this study: UK Gynaecologists, South Birmingham
Primary Care Trust General Practitioners (SBPCT GPs) and Gynaecology Nursing staff
at Birmingham Women’s’ Hospital (BWH). Contact details of UK gynaecologists were
sourced from the Royal College of Obstetricians and Gynaecologists database, SBPCT
GP details were sourced from SBPCT databases and practice managers and details for
BWH Nursing staff was obtained from the Gynaecology Dire ctorate at the hospital .
BWH nurses were chosen as there were no databases available for UK or regional
gynaecology nurses which we could access. An information sheet and invitation letter
was sent to all participants (appendix 4,5).
Measures (appendices 6-8).
The questionnaires were developed using standard measures from SF36 questionnaire as
well as to answer the objectives. The questionnaire was divided into three sections asking
questions about the health care professional, their usual practice and about their usual
counselling to patients. All the questionnaires asked about awareness of National
Guidelines for the management of Heavy Menstrual B leeding (48), whether the health
care professional performs or looks after women who have had a hysterectomy by the
abdominal, vaginal or laparoscopic routes, and what would influence the routine practice
of the professional. The counselling section asked how the health care professional would
counsel patients about recovery. This included inpatient stay, length of time they would
64
advise care would be needed for at home, and when certain physical activities could be
performed. These physical activities were taken from the physical functioning subscale of
the SF36. SF -36 is a multi -purpose, generic, non -disease targeted health survey which
measures functional health and wellbeing. The SF36 has been shown to be both reliable
and valid in psychometric evaluation (93, 94).
The questionnaires were piloted on 3 hea lth care professionals and research colleagues
from each group to test for understanding. They were adapted for each group to take into
account their role in the recovery process, although the bulk of the questionnaire was the
same. Items which varied for example was to ask general practitioners about the common
complications symptoms they may see such as constipation as this is unlikely to have
presented to hospital and therefore gynaecology nurses and gynaecologists may not have
as much of an idea about i ts prevalence. The SF36 questions for recovery were the same
in all three questionnaires. Gynaecologists were asked if their practice of choice of
surgery route and follow up appointment is based mostly on local, National or personal
experience. This quest ion was not relevant for nurses or general practitioners as they
would not be making those decisions.
Procedure
Each questionnaire was accompanied with an explanation of the study and its use towards
a Doctorate of Medicine (MD) thesis (appendix 9) and invitation letter emailed to
participate in the study (appendix 5) with. An email of returned completed questionnaire
was taken as participant consent. Questionnaires were sent by electronic -mail using a
Survey Monkey link on an Outlook email (appendix 6-8).
65
Ethical considerations.
Ethical approval was gained from Black Country Research Ethics committee
(09/H1202/66). Research and Development approval was gained from Birmingham
Women’s Hospital Foundation Trust and South Birmingham PCT. Approval of the
questionnaires and study was also gained from the Royal College of Obstetricians and
Gynaecologists.
Analysis
Descriptive analysis via surveymonkey.co.uk was used to gain an understanding of
current practices and beliefs.
Results
UK Gynaecologists
There were a total of 2600 members and fellows on the RCOG database sent to us. Of
these, 1090 were consultants who currently practiced in gynaecology. Questionnaires
were emailed to these 1090 with a single reminder. There were 120 emails which were
undeliverable d ue to incorrect email addresses and an overall response rate of 39%
(378/970) was achieved.
South Birmingham PCT General Practitioners
A total of 291questionnaires were mailed out to GP practices with a single reminder.
Unfortunately only 1 GP replied an d therefore this data was not analysed despite
reminders.
66
Nursing staff at Birmingham Women’s Hospital
A total number of 40 questionnaires were sent with a response rate of 43% (18/40) after 1
reminder.
UK Gynaecologists
A total of 378 questionnaires were returned. Figure 3.1 shows the regional distribution of
responses. There is good representation from all regions of the UK and Northern Ireland.
Most respondents were in a senior position with 71% of the respondents in a consultant,
staff grade or post certificate of completion of training (CCT) grade.
There was a spread in time of experience in their grade from 41% being in their grade for
over 10 years and 23% between 1 to 2 years.
The vast majority of gynaecologis ts performed abdominal (99%) and vaginal (93%)
hysterectomies with only 35% reporting that they perform laparoscopic hysterectomies
(figure 3.2).
When asking about their practice, 97% of gynaecologists reported that they are aware of
the NICE Guidelines on Heavy Menstrual Bleeding, but only 22% reported that they
would follow NICE recommendations in surgical route of hysterectomy if there were no
other clinical indication.
67
Most (78%) gynaecologists reported that they would decide on hysterectomy route
according to their personal confidence in performing the procedure as opposed to NICE.
Most UK gynaecologists offer a follow up appointment after hysterectomy (60%). The
decision for follow up is based on personal belief/experience for 55%, unit policy for
41% and on evidence for only 4%.
68
Recovery advice
Inpatient days (table 3.1)
There was a large spread in the recovery advice after a hysterectomy given by UK
gynaecologists. Most (46%,) of gynaecologists advised 3 inpatient days routinely after an
abdominal hysterectomy, but 15% advised 2 days, 28% advised 4 days and 10% advised
5 to 7 days. One gynaecologist advised less than 1 inpatient day routinely and 1 advised
more than 7 days. After a vaginal hysterectomy, 40% routinely advised 2 inpatient days
but 37% advised 4 days. There was one gynaecologist who advised less than day, 16%
advised 1 day only, 4% advised 4 days and 2% advised 5 to 7 days. Routine advice on
inpatient days after a laparoscopic hysterectomy was 2 days in 41% of gynaecologists
and 2 days in 40%. There were 8% who routinely advised less than 1 inpatient day, 10%
who advised 3 days and 1% who advised 5 to seven days.
69
Table 3.1:
Number of inpatient days gynaecologists would routinely advise after different types of
hysterectomy
Type of
hysterectomy
Number of days advised routinely for inpatient stay
(% and frequency of response)
Less
than 1
1 2
3 4 5-7 More
than 7
Abdominal 0.5%
(1)
0 15.2%
(30)
46%
(91)
28.3%
(56)
9.6%
(19)
0.5%
(1)
Vaginal 0.5%
(1)
16.2%
(32)
39.9%
(79)
37.4%
(74)
4%
(8)
2%
(4)
0
Laparoscopic 8.1%
(16)
41.4%
(82)
39.4%
(78)
10.1%
(20)
0 1%
(2)
0
70
Number of weeks for care at home (table 3.2).
After an abdominal hysterectomy, 33% of UK gynaecologists would advise patients that
they need 5 -6 weeks of care at home. Again there was wide variation in advice ranging
from 1.5% advising only 1 week of care and 5% advising 11 to12 weeks of care. For a
vaginal hysterectomy, 21% would advise 1 to 2 weeks of care at home but almost as
many (19%) would advise 3 to 4 weeks of care. This advice ranged from 6% advising 1
week and 3% advising 11 to 12 weeks of care. After a laparoscopic hysterectomy, 29%
advised 1 to 2 weeks of care at home. The range was 13% advising only 1 week of care
and 1.5% advising 11 to 12 weeks.
71
Table 3.2:
Advice about number of weeks patients will need care at home after different types of
hysterectomy.
Type Routine advice for number of weeks patients will need care at home
(% and frequency of response)
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-
9
9-10 10-
11
11-
12
>1
2
Abdominal 1.5%
(3)
10.3
%
(20)
12.9
%
(25)
16.5
%
(32)
3.1%
(6)
33%
(64)
9.3
%
(18)
6.7
%
(13)
1
%
(2
0.5
%
(1)
0 5.2
%
(10)
0
Vaginal 6.2%
(12)
20.6
%
(40)
12.4
%
(24)
18.6
%
(36)
11.3
%
(22)
17.5
%
(34)
5.7
%
(11)
4.6
%
(9)
0 0.5
%
(1)
0 2.6
%
(5)
0
Lap 13.4%
26
28.9
%
(56)
16%
(31)
17.5
%
(34)
8.8%
(17)
7.7%
(15)
4.1
%
(8)
2.1
%
(4)
0 0 1.5
%
(3)
0
72
Advice regarding physical recovery after different types of hysterectomy
Abdominal hysterectomy (table 3.3)
After an abdominal hysterectomy 21% of UK gynaecologists would advise 5 -6 weeks
post operation before vigorous activity such as running, lifting heavy objects and
participating in st renuous sports. The range was 1% advising 4 weeks and 6% advising
more than 16 weeks. For moderate activities such as moving a table, pushing a vacuum
cleaner, bowling and playing golf, 25% advised 5 to 6 weeks after an abdominal
hysterectomy and 23% advis ed 6 to 7 weeks. The range was 0.5% advising 1 week and
0.5% advising more than 16 weeks. Advice was varied for lifting or carrying groceries
with 28% advising 4 weeks with a range of 1% advising 1 week and 0.5% advising more
than 16 weeks. For climbing se veral flights of stairs, 24% advised 4 weeks with a range
of 1% advising 1 week and 1% advising more than 16 weeks. There was more consensus
on the advice for climbing one flight of stairs with 52% advising 1 week; however the
0.5% reported advising 14-16 weeks. For bending, kneeling and stooping, 38% advised 1
week with a range up to 0.5% advising more than 16 weeks. The advice for walking more
than a mile was 26% advising 4 weeks with a range of 1.5% advising 1 week and 0.5%
advising more than 16 weeks, w hereas the advice for walking several hundred yards was
21% advising 1 week, 27% advising 2 weeks and 23% advising 4 weeks. The range for
advice for walking several hundred yards was up to 0.5% again advising over 16 weeks
for this activity. There was better consensus for the advice for walking one hundred yards
with 45.5% advising 1 week (up to 1% advising 12-14 weeks) and for bathing or dressing
where 82% advised 1 week (up to 0.5% advising 10-12 weeks).
73
Table 3.3: Advice after an abdominal hysterectomy for physical recovery
Activity Number of weeks
1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-14 14-
16
>16
Vigorous
*1
0 0 0.5%
1
1%
2
15.7
%
31
21.2
%
42
8.6
%
17
3.5
%
7
3.5
%
7
27.3
%
54
12.1
%
24
0.5
%
1
6.1
%
12
Moderate
*2
0.5%
1
2%
4
7.1%
14
18.7
%
37
24.7
%
49
23.2
%
46
6.1
%
12
7.1
%
14
4%
8
4%
8
1.5%
3
0.5
%
1
0.5
%
1
Lifting or
Carrying
groceries
1%
2
4.5%
9
10.6
%
21
27.8
%
55
22.7
%
45
18.2
%
36
5.1
%
10
3%
6
1%
2
3.5%
7
1%
2
1%
2
0.5
%
1
Climbing
several
flights of
stairs
9.1%
18
18.7
%
37
14.1
%
28
24.2
%
48
15.2
%
30
10.6
%
21
1.5
%
3
0.5
%
1
0 2.5%
5
1%
2
1.5
%
3
1%
2
Climbing
one flight
of stairs
52%
103
28.8
%
57
6.1%
12
3%
6
1.5%
3
0.5%
1
0.5
%
1
0
0.5
%
1
1%
2
0
0.5
%
1
0.0
Bending,
kneeling,
stooping
37.9
%
75
32.3
%
64
5.6%
11
13.6
%
27
5.1%
10
3%
6
1%
2
0 0 1%
2
0 0 0.5
%
1
Walking
more than
1 mile
1.5%
3
16.2
%
32
11.1
%
22
26.3
%
52
17.7
%
35
15.2
%
30
3%
6
2%
4
2%
4
3%
6
1%
2
0.5
%
1
0.5
%
1
Walking
several
hundred
yards
21.2
%
42
26.8
%
53
12.1
%
24
23.2
%
46
9.6%
19
3%
6
0.5
%
1
1.5
%
3
0 1%
2
0 0.5
%
1
0.5
%
1
Walking
1 hundred
yard
45.5
%
90
28.3
%
56
12.1
%
24
7.1%
14
4%
8
0.5%
1
0.5
%
1
0 0 1%
2
1%
2
0 0
Bathing/
dressing
yourself
81.8
%
162
13.1
%
26
2.5%
5
1.5%
3
0 0 0.5
%
1
0 0 0.5%
1
0 0 0
*1 Running, lifting heavy objects, strenuous sports *2 Moving a table, pushing a
vacuum cleaner, bowling or playing golf.
74
Vaginal hysterectomy (table 3.4)
After a vaginal hysterectomy 20% of UK gynaecologists would advise 5 -6 weeks post
operation and 20% would advise 6 -7 weeks before vigorous activity suc h as running,
lifting heavy objects and participating in strenuous sports. The range was 1% advising 2
weeks and 4.5% advising more than 16 weeks. For moderate activities such as moving a
table, pushing a vacuum cleaner, bowling and playing golf, 25% advis ed 5 to 6 weeks
and 21% advised 4 weeks. The range was 1.5% advising 1 week and 0.5% advising more
than 16 weeks. Advice was varied for lifting or carrying groceries with 30%% advising 4
weeks with a range of 4.5% advising 1 week and 0.5% advising more tha n 16 weeks. For
climbing several flights of stairs, 24% advised 4 weeks with a range of 19%% advising 1
week and 0.5% advising more than 16 weeks. There was more consensus on the advice
for climbing one flight of stairs with 67% advising 1 week; however the 0.5% reported
advising 14-16 weeks. For bending, kneeling and stooping, 58% advised 1 week with a
range up to 2.5% advising 10 to 12 weeks. The advice for walking more than a mile was
28% advising 4 weeks with a range of 12% advising 1 week and 0.5% advi sing more
than 16 weeks, whereas the advice for walking several hundred yards was 34% advising
1 week and 25% advising 2 weeks. The range for advice for walking several hundred
yards was up to 0.5% again advising over 16 weeks for this activity. There was better
consensus for the advice for walking one hundred yards with 64% advising 1 week (up to
0.5% advising 10-12 weeks) and for bathing or dressing where 89% advised 1 week (up
to 0.5% advising 9-10 weeks).
75
Table 3.4: Advice after a vaginal hysterectomy for physical recovery
*1 Running, lifting heavy objects, strenuous sports *2 Moving a table, pushing a vacuum cleaner, bowling
or playing golf
Activity Number of weeks
1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-14 14-
16
>16
Vigorous*1 0 15
2
1.5%
3
10.1%
20
20.2%
40
20.2%
40
8.6%
17
5.1%
10
3.5%
7
18.7%
37
5.6%
11
1%
2
4.5%
9
Moderate*2 1.5%
3
10.6%
21
11.1%
22
20.7%
41
24.7%
49
15.7%
31
5.1%
10
4%
8
2.5%
5
2%
4
1%
2
0.5%
1
0.5%
1
Lifting or
Carrying
groceries
4.5%
9
13.6%
27
9.6%
19
30.3%
60
14.1%
28
16.2%
32
4.5%
9
1%
2
0.5%
1
2%
4
1%
2
0.5%
1
0.5%
1
Climbing
several
flights of
stairs
19.2%
38
22.2%
44
11.1%
22
23.7%
47
11.6%
23
6.1%
12
0.5%
1
0.5%
1
0 2.5%
5
0.5%
1
1.5%
3
0.5%
1
Climbing
one flight
of stairs
67.2%
133
17.7%
35
4.5%
9
4.5%
9
2%
4
1.5%
3
0.5%
1
0.5%
1
0 1%
2
0 0.5%
1
0
Bending,
kneeling,
stooping
57.6%
114
22.2%
44
3%
6
9.1%
18
4%
8
1%
2
0.5%
1
0 0 2.5%
5
0 0 0
Walking
more than
1 mile
12.1%
24
18.7%
37
11.6%
23
28.3%
56
12.1%
24
8.6%
17
3.5%
7
1%
2
0 2.5%
5
1%
2
0 0.5%
1
Walking
several
hundred
yards
34.3%
68
25.3%
50
9.6%
19
20.7%
41
5.1%
10
1.5%
3
0.5%
1
0 1%
2
0 0.5%
1
0 0
Walking 1
hundred
yards
64.1%
127
18.2%
36
7.1%
14
4.5%
9
3%
6
1%
2
0.5%
1
0 0 0.5%
1
0 0 0
Bathing/
dressing
yourself
89.4%
177
8.6%
17
0.5%
1
0.5%
1
0 0 0.5%
1
0 0 0.5%
1
0 0 0
76
Laparoscopic hysterectomy (table 3.5)
After a laparoscopic hysterectomy 21% of UK gynaecologists would advise 4 weeks post
operation, 17%% would advise5 to 6 weeks and 17% 6 -7 weeks before vigorous activity
such as running, lift ing heavy objects and participating in strenuous sports. The range
was 2% advising 1 week and 2.5% advising more than 16 weeks. For moderate activities
such as moving a table, pushing a vacuum cleaner, bowling and playing golf, 25%
advised 4 weeks. The ran ge was 5.6% advising 1 week and 1% advising more than 16
weeks. Advice was varied for lifting or carrying groceries with 29% advising 4 weeks
with a range of 11% advising 1 week and 1% advising more than 16 weeks. For climbing
several flights of stairs, 27 % advised 1 week and 27% advised 2 weeks. However, 1%
advised more than 16 weeks. There was better consensus on the advice for climbing one
flight of stairs with 73% advising 1 week; however the 1.5% reported advising more than
16 weeks. For bending, kneel ing and stooping, 63% advised 1 week with a range up to
1% advising more than 16 weeks. The advice for walking more than a mile was 25%
advising 4 weeks, 21% advising 1 week and 23% 2 weeks. Again 1% reported advising
more than 16 weeks. The advice for wal king several hundred yards was 42% advising 1
week with a range up to 1.5% again advising over 16 weeks for this activity. Again there
was better consensus for the advice for walking one hundred yards with 70% advising 1
week (up to 1% advising over 16 wee ks) and for bathing or dressing where 91% advised
1 week (up to 1% advising over 16 weeks).
77
Table 3.5: Advice after a laparoscopic hysterectomy for physical recovery
Activity Number of weeks
1 2 3 4 5-6 6-7 7-8 8-9 9-10 10-12 12-
14
14-
16
>16
Vigorous*1 2%
4
3.5%
7
7.1%
14
21.2%
42
16.7%
33
16.7%
33
9.6%
19
4.5%
9
2.5%
5
12.6%
25
0 1%
2
2.5%
5
Moderate*2 5.6%
11
21.2%
42
11.6%
23
24.7%
49
15.2%
30
13.1%
26
1.5%
3
1.5%
3
0.5%
2
4%
2
0 0 1%
2
Lifting or
Carrying
groceries
11.1%
22
22.2%
44
12.1%
24
28.8%
57
9.6%
19
8.1%
16
2%
4
2%
4
0.5%
1
2%
4
0 0.5%
1
0.5%
1
Climbing
several
flights of
stairs
26.8%
53
26.8%
53
12.6%
25
20.2%
40
5.6%
11
2%
4
0 0.5%
1
0 3.5%
7
0 1%
2
1%
2
Climbing
one flight
of stairs
73.2%
145
15.7%
31
3.5%
7
2%
4
1.5%
3
0.5%
1
0 0 0 1.5%
3
0 0.5%
1
1.5%
3
Bending,
kneeling,
stooping
65.2%
129
19.7%
39
3%
6
5.1%
10
2.5%
5
0.5%
1
1%
2
0 0.5%
1
1.5%
2
0 0
1%
2
Walking
more than
1 mile
20.7%
41
22.7%
45
13.6%
27
25.3%
50
8.1%
16
4%
8
0.5%
1
0.5%
1
2.5%
3
1.5%
3
0 0 1%
2
Walking
several
hundred
yards
41.9%
83
27.8%
55
12.6%
25
10.6%
21
2%
4
1%
2
0 1%
2
1%
2
0.5%
1
0 0 1.5%
3
Walking 1
hundred
yard
70.2%
139
15.7%
31
6.6%
13
2%
4
1.5%
3
0.5%
1
0.5%
1
0.5%
1
1%
2
0.5%
1
0 0 1%
2
Bathing/
dressing
yourself
90.9%
180
3.5%
7
1%
2
1.5%
3
0 0.5%
1
0.5%
1
0 0.5%
1
0.5%
1
0 0 1%
2
*1 Running, lifting heavy objects, strenuous sports *2 Moving a table, pushing a
vacuum cleaner, bowling or playing golf.
78
Variations in advice
We were not able to demonstrate regional variations in whether gynaecologists choose
route of hysterectomy according to NICE guidance or personal confidence (figure 3.3), or
according to specialist grade or years of experience in that grade (figure 3.4). A follow up
appointment seemed to be made routinely more often in London and least in the North
East and North West (figure 3.5). Consultants seemed to be less likely to make a routine
follow up appointment (71%) and trainees in years 6-7 appeared to be most likely to offer
them (figure 3.6). Consultants mainly followed personal belief in this (75%), although
48% of consultants reported their choice as unit policy (figure 3.7). A lower proportion of
gynaecologists made a routine follow up appointment if they were more experienced in
their grade (44%), and of these, 44% followed personal belief and only 23% reported
following evidence (figure 3.8). These differences may be as a result of variations in local
health care set ups and commissioning agreements.
79
Figure 3.1:
Regional distribution of responses (Ireland is Northern Ireland)
Number of responses
80
Figure 3.2:
Proportion of gynaecologists who perform types of hysterectomy
Do you perform the following types of
hysterectomy ?
y…
n…
81
Figure 3.3:
Regional variation in decision for route of hysterectomy
82
Figure 3.4:
Experience level and decision for route of hysterectomy
83
Figure 3.5:
Regional variations in offering a routine follow up appointment
84
Figure 3.6:
Variations in follow up appointment and grade
Follow up
appointment
requested
85
Figure 3.7:
Regional variations in reasons to offer routine follow up appointment
86
Figure 3.8:
Variations in decision making for offering a follow up appointment and experience in
grade
87
Results
Gynaecology nurses Birmingham Women’s Hospital
There were 18 responses out of 40 after a single reminder (43%). The mean number of
years of experience was 11.88 years (3 -30). Statistical comparisons were not made
between the UK gynaecologists and BWH nurses due to the small number of responses
from nurses.
In-patient days after each type of hysterectomy (table 3.6).
After a total abdominal hysterectomy, two thirds of nurses would advise a stay of 4 to 6
days, with the remaining one third advising 2 to 3 days. After a vaginal hysterectomy,
there was more consensus with 94.5% advising 2 to 3 days. After a laparoscopic
hysterectomy, only 28% of nurses would advise a I day stay in hospital with the
remainder advising 2 to 3 days.
88
Table 3.6:
How would you routinely counsel your patients regarding numbers of postoperative days
stay in hospital?
Number
of days %
(number
of
responses)
Number
of days %
(number
of
responses)
Number
of days %
(number
of
responses)
Number
of days %
(number
of
responses)
0-1 2-3 4-6 7-12
Abdominal
hysterectomy
0
39%
(7)
61%
(11)
0
Vaginal
hysterectomy
0
94.6%
(17)
4.5%
(1)
0
Laparoscopic
hysterectomy
28%
(5)
72%
(13)
0 0
89
Number of weeks of care at home (table 3.7)
The majority of nurses (79%) advised between 2 to 6 weeks care at after an abdominal
hysterectomy, this was also similar after a vaginal hysterectomy where 89% also advised
2 to 6 weeks. After a laparoscopic hysterectomy, most nurses (79%) advised 0 to 3 weeks
of care at home.
90
Table 3.7:
How many weeks of care at home would you advice?
Route
hysterectomy
0-1
%
(number of
responses)
Weeks
2-3
%
(number
of
responses)
4-6
%
(number
of
responses)
7-12
%
(number
of
responses)
Abdominal
hysterectomy
4.5%
(1)
39%
(7)
44%
(8)
11%
(2)
Vaginal
hysterectomy
11%
(2)
50%
(9)
39%
(7)
0
Laparoscopic
hysterectomy
39%
(7)
44%
(8)
17%
(3)
0
91
Advice after an abdominal hysterectomy for physical recovery.
All nurses felt that vigorous activity was only advised after 6 weeks and most felt that
this was the same for moderate activity (94%) and lifting (65.5%). The majority of nurses
would advise climbing one flight of stairs (83%), bending, kneeling and stooping (61%)
walking a hundred yards (83%) and bathing and dressing (94%) after 1 week. Half of all
nurses would advise walking several hundred yards after 1 week with only 17% advising
to wait more than 2 weeks, whereas 90% of nurses would advise waiting more than 2
weeks to walk more than 1 mile. A third of nurses advised climbing several flights of
stairs after 1 completed week, but a third advised to wait until after 6 completed weeks
(table 3.8).
92
Table 3.8:
Number of weeks for advice after abdominal hysterectomy for physical recovery
Activity Weeks (% responses)
1
2
3 4 5-6 6-7 8-9 12-14 >16 Don’t
know
Vigorous*1 0 0 0 0 0 50%
9
11%
2
22%
4
4.5%
1
11%
2
Moderate*2 0 0 0 4.5%
1
0 83%
15
0 0 4.5%
1
4.5%
1
Lifting or
Carrying
groceries
0 0 4.5%
1
22%
4
0 61%
11
0 0 0 4.5%
1
Climbing
several
flights of
stairs
33%
6
22%
4
0 11%
2
4.5%
1
11%
2
0 4.5%
1
0 17%
3
Climbing
one flight of
stairs
83%
15
11%
2
0 0 0 0 0 0 0 4.5%
1
Bending,
kneeling,
stooping
61%
11
11%
2
0 11%
2
0 11%
2
0 0 0 4.5%
1
Walking
more than 1
mile
4.5%
1
4.5%
1
22%
4
33%
6
0 17%
3
0 0 4.5%
1
11%
2
Walking
several
hundred
yards
50%
9
66%
6
0 0 0 0 0 0 0 17%
3
Walking 1
hundred yard
83%
15
4.5%
1
4.5%
1
0 0 0 0 0 0 4.5%
1
Bathing/
dressing
yourself
94%
17
0 0 0 0 0 0 0 0 4.5%
1
93
Advice after a vaginal hysterectomy: physical recovery (table 3.9)
After a vaginal hysterectomy, most nurses advised waiting until after 6 weeks before
vigorous activity (89%), and 66% advised lifting only after 4 weeks. For climbing stairs,
89% advised being able to climb one flight and 39% advised climbing several fligh ts in a
week. The majority of nurses advised bending (67%), walking 1 hundred yards (83%)
and bathing and dressing (94%) in 1 week.
94
Table 3.9: Number of weeks for advice after vaginal hysterectomy: physical recovery.
Activity Weeks (% number of responses)
1 2 3 4 6-7 8-9 12-
14
More
16
Don’t
know
Vigorous*1 0 0 4.5%
1
4,5%
1
50%
9
4.5%
1
17%
3
4.5%
1
11%
2
Moderate*2 0 0 0 28%
5
61%
11
0 0 4.5%
1
4.5%
1
Lifting or
Carrying
groceries
0 11%
2
4.5%
1
4.5%
1
55%
10
0 0 0 4.5%
1
Climbing
several
flights of
stairs
39%
7
28%
5
17%
3
4.5%
1
11%
2
0 4.5%
1
0 17%
3
Climbing
one flight
of stairs
89%
16
4.5%
1
0 0 0 0 0 0 4.5%
1
Bending,
kneeling,
stooping
67%
12
4.5%
1
0 22%
4
0 0 0 0 4.5%
1
Walking
more than
1 mile
11%
2
17%
3
11%
2
28%
5
17%
3
0 0 4.5%
1
11%
2
Walking
several
hundred
yards
50%
9
33%
6
0 0 0 0 0 0 17%
3
Walking 1
hundred
yard
83%
15
4.5%
1
4.5%
1
0 0 0 0 0 4.5%
1
Bathing/
dressing
yourself
94%
17
0 0 0 0 0 0 0 4.5%
1
95
Advice after laparoscopic hysterectomy: physical recovery (table 3.10)
No nurses advised waiting after 7 weeks for any of the physical recovery activities.
Thirty nine percent felt that vigorous activity and 44% felt that moderate activity could be
advised by 2 weeks. The majority felt that climbing a flight of stairs (94%), bending
(81.5%), walking several hundred yards (77%), walking 1 hundred yards (94%) and
bathing and dressing (94%) could be advised by 1 week.
96
Table 3.10 Number of weeks for advice after laparoscopic hysterectomy: physical
recovery.
Activity Weeks (% number of responses)
Less
1
1 2 3 4 5-6 6-7 Don’t
know
Vigorous*1 0 11%
2
28%
5
0 11%
2
4.5%
1
33%
6
4.5%
1
Moderate*2 0 22%
4
22%
4
0 22%
4
0 28%
5
4.5%
1
Lifting or
Carrying
groceries
0 22%
4
28%
5
4.5%
1
17%
3
0 22%
4
4.5%
1
Climbing
several
flights of
stairs
0 50%
9
33%
6
0 0 0 0 17%
3
Climbing
one flight
of stairs
0 94%
17
0 0 0 0 0 4.5%
1
Bending,
kneeling,
stooping
4.5%
1
77%
14
4.5%
1
4.5%
1
4.5%
1
0 0 4.5%
1
Walking
more than
1 mile
0 28%
5
33%
6
0 11%
2
0 11%
2
11%
2
Walking
several
hundred
yards
0 77%
14
4.5%
1
0 0 0 0 17%
3
Walking 1
hundred
yard
0 94%
17
0 0 0 0 0 4.5%
1
Bathing/
dressing
yourself
0 94%
17
0 0 0 0 0 4.5%
1
97
Discussion
This survey represents the practice and beliefs of 378 gynaecologists representing all
regions in the UK and a small number of gynaecology nurses in one unit. The main
findings from this study are that there is great variance between the advice UK
gynaecologists and nurses would give after all types of hysterectomy. There is better
consensus for activities which are appropriate within the first week such as walking a few
hundred yards, bathing and dressing and climbing one flight of stairs. This may be due to
the fact that all these activities are usually achieved before discharge from hospital and so
gynaecologists and nurses are familiar with these milestones. Longer term recovery
advice is surprisingly varied, suggesting that UK gynaecologists and nurses are less
familiar or confident about this. There seems to be a difference in the type of advice
given between the three different routes of hysterectomy such as vigorous activity. Most
UK gynaecologists would advise 4 weeks after a laparoscopic hysterectomy, 5 to 6 weeks
after a vaginal and 10 to 12 weeks after an abdominal hysterectomy. Advice for other
activities such as moderate activities was more similar (most recommending 5 to 6 weeks
for abdominal and vaginal and 4 weeks for laparoscopic) and no diff erence in the advice
to walk more than a mile between route of hysterectomy (4 weeks for all routes). The
advice given by gynaecology nurses is similar for all types of hysterectomy route for
immediate postoperative activities, but is lower for longer term recovery activities for the
laparoscopic route. There is surprisingly less difference in longer term recovery advice
after an abdominal or vaginal hysterectomy for heavy menstrual bleeding. Limitations of
this study include differences in the sample demog raphics for gynaecologists and nurses.
It would have been useful to have been able to compare responses between these groups.
98
A better study design would have been to have UK gynaecology nurses; which could
have been via a survey to gynaecology units in th e UK. Another limitation is that
gynaecology nurses were not asked if they follow NICE guidelines in their approach to
counselling, again making it difficult to then compare or draw meaningful conclusions.
The results from this survey differ to one carri ed out in the Netherlands (95) with UK
gynaecologists advising longer convalescence in all categories of activities. In the
Netherland survey, a Delphi technique was used to come to a consensus of opinion from
a total of 12 experts (5 gynaecologists, 2 GPs and 5 occupational physicians). In a Delphi
technique, the survey options are reduced according to the most popular responses and
the survey is re -issued a number of times repeating this step at each issue. In this way,
participants are forced to choose and prioritise between the reduced opti ons until a
consensus is reached. The UK survey is a one off survey with all options available.
Therefore, the difference in methodology of survey may explain the differences. In the
Netherlands survey, advice for recovery was shorter in all categories an d for all routes of
hysterectomy. For light work, the UK opinion was 4 to 7 weeks (55% of cases) for
laparoscopic hysterectomy whereas the Netherland consensus was 1 week, for moderate
activity UK was 4 weeks (25%) versus 2 weeks and for heavy activities U K was 4 weeks
(29%) versus 3 weeks. For abdominal hysterectomy, UK opinion on light activities was 4
weeks (28%) versus 2 weeks in Netherlands, for moderate activities it was 5 to 7 weeks
(53%) against 3 to 4 weeks and for heavy activities it was 5 to 6 we eks (21%). For
vaginal hysterectomy, the UK opinion on light activities was 4 weeks (30%) compared to
2 weeks, for moderate activities it was 4 to 6 weeks (46%) compared to 3 weeks and for
99
heavy activities it was 5 to 7 weeks as compared to 4 weeks for the Netherlands
consensus. The difference in results may be explained by the differences in methodology
and slightly different examples of heavy, moderate and light activities. It may be that a
Delphi study on our UK gynaecologists would find a different con sensus of opinion due
to the methodology of a Delphi where multiple surveys are sent around to participants
based on the results of the previous survey. In this way, the participants of the survey
would be presented with fewer options in each survey round and are then asked to choose
their most appropriate response for the focussed options (so in a way are forced to choose
between options that they may not have originally considered). However, the larger
number of gynaecologists in our survey would suggest that this survey is more
representative of gynaecologist opinion and practice and patients may be influenced by
differing advice. If recovery, especially long term is influenced mainly by health care
professionals, then conflicting advice to patients is li kely to cause confusion and
frustration. It may also have an impact on the economy if patients are advised to stay off
work for longer than they need to or conversely, be contributing to problems if patients
are advised to return to work too soon. It seems that the published advantage of faster
recovery from laparoscopic or vaginal routes is not conveyed to UK patients, and hence
may be reflected in longer and similar actual recovery times for all routes. NICE
guidance advice using a vaginal approach as fir st line, then abdominal as second line
taking into account the need for individual assessment (59). Although there is National
NICE Guidance in recommendations for the route for hysterectomy, most UK
gynaecologists use their own experience and confidence t o decide on the surgery despite
knowing of the evidence, and do not follow the pattern of guidance set out by NICE. The
100
reason for this may be due to the quality of the evidence upon which the
recommendations in guidelines have been made. If it is poor qua lity or based on
consensus opinion, some health care practitioners may choose to follow their own
experience and beliefs. This finding is in keeping with the published literature for
difficulties in implementing research findings.
This survey also gives information on the current hysterectomy practice in the UK at the
time of the survey, with only 35% performing laparoscopic hysterectomies. Conversely, a
similar and high proportion (99 and 93%) of UK gynaecologists perform abdominal and
vaginal hysterectomies.
There is also a culture of offering a routine follow up appointment after surgery (60%),
which seems to be derived from personal belief or experience (55%) as well as unit
policy (41%). This is interesting in a climate of efficiency with commissioners tryi ng to
reduce follow up rates in secondary and tertiary centres. It may be that NHS Trusts and
individual gynaecologists will be asked to reduce their post-operative follow up rates and
it is likely that Trusts will not get remunerated for unnecessary follo w up appointments.
In my opinion, unless there are specific concerns, most post-operative follow ups can be
managed in primary care as long as there has been good communication from the hospital
to the GP. At the post-operative hospital visit, the majority of women will have
recovered, but will have had to take time out of their schedules to travel to hospital and
wait to be seen to be told they have recovered. The post-operative visit is an opportunity
to answer patient questions and review any complicatio ns. However, we should aim to
communicate with our GP colleagues so that this follow up is not necessary. If there are
101
specific concerns, then those patients should be re -referred. Complications requiring re -
presentation to the hospital will still be monit ored on hospital statistics, but it seems
inefficient to see patients in a clinic to gain information on minor complications e.g.
urinary tract infections. Other more innovative ways of checking on patient progress
should be found such as telephone consult ations by nursing staff at recovery time points
which are agreed to be important for each type of surgery. This is an area where Trusts
can increase their efficiency with relative ease without compromising the quality of care.
A limitation to this study i s the lack of responses from GPs which leaves open the
question of what GP beliefs are, whether they will give appropriate or consistent advice.
It may be that GPs are too busy in responding to research questionnaires, which raises the
question of whether they would have the time or resources to arrange follow up visits
after surgery. Unfortunately, I was not able to get any feedback from GPs so I was not
able to ask why they did not respond to the survey, it may be that they were not interested
in the surv ey, in research or it may have been that the methodology of emailing the
survey was flawed. At the time of the survey email, the local GPs were going through a
transition in email addresses from individual practices to NHS.net accounts. It is
therefore likely that a number of emails did not reach the GPs and I did not receive any
response to indicate that there was a change in email address. A similar issue occurred
when our trust changed to NHS.net where a number of emails were lost. I came to know
after t he completion of the study that there had been a technical issue with GP email
addresses and this cross over and this may have affected the email survey. Similar to the
Dutch Delphi study, other health care professionals such as physiotherapists are not
102
usually involved in the recovery process for hysterectomy and therefore were not part of
this survey.
Conclusion
UK gynaecologists and gynaecology nurses at Birmingham Women’s hospital give
variable advice on recovery from all route of hysterectomy. There is more consensus in
opinion for activities which would be expected to be accomplished while still an
inpatient. It is reassuring that there are no differences in opinion according to different
regions, but there is variation by experience and grade, whic h is what we expected to see.
Furthermore, there was variation by personal belief as opposed to by national or local
policy. As patients are greatly influenced by the advice given by health care
professionals, particularly by doctors (50, 51) it is important to provide consistent advice
based on evidence and actual patient experience.
103
Chapter 4: Experiences of women who have a hysterectomy; a qualitative interview
study
Introduction
The experiences which women go through during and after a hysterectom y have been
discussed for many years. In December 1982, an article in the Guardian: Every Woman’s
Right to Know (Perry C) stated:
‘Having a hysterectomy is an emotional as well as a physical operation, it is to do with
being a women, it is to do with conc eption and sex; the children you’ve had or won’t be
able to have’.
Better counselling and preparation for hysterectomy can improve the way women cope
and recover from the surgery. The hysterectomy often comes at a time in their lives when
they are also f acing other personal crises such as going through the menopause, children
growing up and changes in the roles they perceive themselves in. A post hysterectomy
syndrome has been described where depression is the primary component, although there
is a wide range of reported incidence for the syndrome of 4 -70% (96, 97) but overall the
estimate of depression is 2 to 4 times higher than the general po pulation, peaks at 2 years
post-surgery and lasts for 2 to 3 times longer than in age matched controls who have had
other surgeries.
104
We know that information patients are given has an effect on their experience (76) and
that patient expectations influences patient satisfaction of medical treatment (64).
Dissatisfied patients are less likely to comply with medical advice, default from follow up
appointments and show less improvement in symptoms than satisf ied patients (65).
Patients seek information from various sources including the internet, where a search for
the term hysterectomy presents 7,160,000 links including a variety of we b pages, chat
rooms, patient’s forums and patient support groups. One such patient website is
Hysterosisters Online (http://www.hysterosisters.com), which describes itself as a social
support site for women who are undergoing the experience of a hysterecto my. This
website published the results of a survey in which they found that patients sought
information and advice more than emotional support or self-esteem (p<0.01) (98).
Despite the huge array of published literature there is concern regarding the provision of
information for women undergoing treatment for heavy menstrual bleeding, particularly
in the recovery phase (48, 99, 100) and women and their partners still express wishes for
more information (101). There have been specific questions regarding the reliability and
accuracy of information on the internet and its effect on the relationship between the
patient and health care professional (79, 80).
At Birmingham women’s Hospital, women are prepared for hysterectomy by trained pre-
operative nurses during a pre-operative appointment. At this appointment, the nurse talks
about the hysterectomy and provides written information in the form of leaflets. The
details cover what will happen on the day, when to arrive and wher e, what to pack and
bring in with them as well as fasting information. Recovery information includes
105
Discussion
and leaflets about pain, movement and self -help such as how to get out of bed
easier and breathing techniques to ease pain. Recovery advice once discharged includes
symptoms to look out for in case of complications, driving advice and general advice on
how long the recovery might take. There is also advice about the effect of surgery on
sexual function and when it is safe to resume sexual intercourse. If the patient asks for
more detailed advice about any aspect in particular, the nurse gives individualised
information based on their own experience. The patient is encouraged to bring the leaflets
into hospital with them as a reference guide. This p rocess is the same for both benign and
non-benign disease. There is not published literature on how this pocess varies from
Most published studies of patient experience and belief ask retrospective questions about
clinical outcomes from hysterectomy such as effectiveness and safety; or look at a single
time point s in the patient journey such as length of stay, and satisfaction at time of
questionnaire (102, 103) . Some studies acknowledge these limitations and recommend
longer follow up periods for recovery outcomes (104). A more recent published study has
looked at 3 and 12 month recovery from hysterectomy; however it focused on chronic
pain only and did not consider other recovery outcomes or experiences. A literature
review of qualitative studies for enhanced recovery high lighted how patients required
additional support to be motivated in recovery during times of symptoms such as pain,
nausea and weakness. This study concluded that patients still required more consistency
in information pre and post -operatively in order to feel confident about symptom
management (107). In this qualitative study, we have followed women through fr om the
pre-operative period to three months after the hysterectomy in order to gain a longitudinal
106
understanding of the women’s experiences of hysterectomy by the vaginal, laparoscopic
and abdominal routes.
We know that recovery is affected by the underlyi ng pathology of the specific disease
process as well as co -morbidity. In breast cancer, a study reported on the experiences for
young women taking into consideration their unique situation of cancer diagnosis at early
age (108), and similarly for recovery 6 months after colorectal cancer surgery (109).
These studies showed how individuals required specific support in their recovery because
of their diagnosis. In ord er to reduce the differences in experiences due to underlying
variation from disease process, this study is limited to recovery from hysterectomy for
heavy menstrual bleeding in order to reduce the confounding effect of disease process on
recovery such as cancer.
Aim:
To explore in depth the beliefs, longitudinal experiences and expectations of women who
have a hysterectomy for heavy menstrual bleeding through the vaginal, abdominal and
laparoscopic routes.
Study design
A longitudinal semi-structured interview study of women who are having a hysterectomy
at the Birmingham Women’s Hospital through the abdominal, vaginal or laparoscopic
routes.
107
Methods
Sample
We recruited women who were on the waiting list to have a hys terectomy for heavy
menstrual bleeding by the abdominal, vaginal or laparoscopic routes at Birmingham
Women’s Hospital. An estimated target sample of ten women from each hysterectomy
group was set. We did not delineate between whether women were planned to or had
their ovaries removed as the study was mainly looking at route of surgery. A total number
of 26 women were finally recruited which represented 10 from the abdominal route, 7
from the vaginal route and 9 from the laparoscopic route. Recruitment was stopped at this
stage as no new themes were emerging from the interviews. All women were identified
from Birmingham Women’s Hospital elective waiting list databases and they were
invited to join the study during their pre-operation visit to the hospital, which was usually
between 1 and 4 weeks before surgery where consent for the study was taken after an
explanation of the study with the participant information leaflet (appendix 9).
108
Measures
Semi-structured interview topic guides were drawn up for the pr e-surgery interview and
the post-surgery one (appendices 10,11). They were tested in interviews to 3 lay people
and patient volunteers to ensure that they were coherent.
Procedure
Participants were telephoned to arrange convenient times for the interview s. Some
participants opted to have the interview at home, whilst others came to the Birmingham
Women’s Hospital. If the interview was at the hospital, a private room without
disturbance was arranged each time. If the researcher went to a participant’s home for the
interview, the details of the venue were left with the research secretary who was included
in the ethical application. The researcher telephoned on arrival and departure from the
interview venue for safety. The researcher informed participants tha t she would be
carrying identification, and produced this at each interview. Before the start of the
interview, the consent was again confirmed. The consent form included options for doing
and recording the interview, completing questionnaires and the part icipant’s General
Practitioner being informed of their participation in the study (appendix 10 and 11). Once
the participant agreed to continue, the microphone was tested and each interview was
carried out as set out in the interview topic guide. Interview s were transcribed by the
research team secretary and checked by Dr M Shehmar by reading the transcripts while
listening to the interviews. Interviewers were undertaken pre -surgery and at around 3
months post-surgery. Interviews before surgery focussed on preparation for recovery and
109
expectations of recovery at 1 week, 1 month, 2 months and 3 months post -surgery.
Interviews post-surgery focused on actual experiences.
110
Analysis
Interviews were analysed by thematic analysis (33) in order to gain an understanding of
the common themes which emerged from the study , which is a more feasible method
rather than reporting each experience comment made . As the themes were identified
through interrogation of the interview transcript by the researcher retrospectively and not
in the natural setting of the recovery (i.e. not alongside the patients in their recovery
environments), the validated methodology of thematic analysis was chosen to meet the
aims of the study rather than other methods described in chapter 1b . The methodology of
thematic analysis used a framework as described below was followed:
Steps of thematic analysis (84).
Step 1: Familiarization of the data
The in terviews were read and listened to multiple times to become familiar with their
content.
Step 2: Thematic analysis
Common themes were identified in the interviews and were labelled as codes (table 4.1).
Step 3: Indexing
All interviews were then read again in detail and the codes were applied to each line of
the interview transcript manually.
Step 4: Charting
Charts of summaries of the data arranged by codes were made to see across themes and
the whole data set. Summaries were then referenced back to the whole data set.
111
Step 5: Mapping and interpretation.
Where possible, inferences were made by looking at relationships between the codes by
using diagrams and tables.
112
Table 4.1 Codes of analysis
T subtheme Code
Theme Subtheme Code
Preparation 1
Practical preparation 1.1
Emotional preparation 1.2
Physical preparation 1.3
Experiential preparation 1.4
Informational preparation 1.5
Social preparation 1.6
Cognitive preparation 1.7
Sexual preparation 1.8
Decision making 2
Type of hysterectomy 2.1
Expectations 3
Hospital stay 3.1
Recovery 3.2
Influences 3.3
Support 3.4
Recovery 4
1 week 4.1
Emotional 4.1.1
Physical 4.1.2
Behavioural 4.1.3
Social 4.1.4
Sexual 4.1.5
4 weeks 4.2
Emotional 4.2.1
Physical 4.2.2
Behavioural 4.2.3
Social 4.2.4
Sexual 4.2.5
8 weeks 4.3
Emotional 4.3.1
Physical 4.3.2
Behavioural 4.3.3
Social 4.3.4
Sexual 4.3.4
12 weeks 4.4
Emotional 4.4.1
Physical 4.4.2
Behavioural 4.4.3
Social 4.4.4
Sexual 4.4.5
113
Theme
Subtheme
Code
Thoughts of surgery 5
Negative 5.1
Positive 5.2
Others attitude 6
Partner 6.1
Children 6.2
Family 6.3
Friends 6.4
Effects 7
Of surgery 7.1
Illness 7.2
Experiences 8
Of surgery 8.1
of hospital stay 8.2
Recovery 9
1 week 9.1
Emotional 9.1.1
Physical 9.1.2
Behavioural 9.1.2
Social 9.1.3
Sexual 9.1.4
4 weeks 9.2
Emotional 9.2.1
Physical 9.2.2
Behavioural 9.2.3
Social 9.2.4
Sexual 9.2.5
8 weeks 9.3
Emotional 9.3.1
Physical 9.3.2
Behavioural 9.3.3
Social 9.3.4
Sexual 9.3.5
12 weeks 9.4
Emotional 9.4.1
Physical 9.4.2
Behavioural 9.4.3
Social 9.4.4
Sexual 9.4.5
Experiences vs.
expectations
10
As expected 10.1
Positive 10.2
Negative 10.3
114
Results
Sample characteristics
All participants were women who had a hysterectomy for heavy menstrual bleeding as a
primary diagnosis. They underwent a total abdominal hysterectomy vaginal hysterectomy
or laparoscopic hysterectomy . The pa rticipants had a range of occupations involving
varying degrees of physical activity including stocking heavy items as a bar worker,
teacher, housing officer, carer, nurse, retired and house wife.
Qualitative interview thematic analysis.
Part I Preparation Pre-surgery
Information
All groups talked about the variety of information available as books, leaflets and on the
internet. They all felt that there was a large amount of information and that it was
difficult to sift through to find what was useful. They talked about how some of the
information made them worry, including videos on you tube showing the whole
procedure from start to finish, and sites where they felt it was easy to try and self -
diagnose to their own detr iment. Some participants talked about buying the wrong books
and some about trying to distract themselves from the information. There was no
difference in the three routes of surgery and the laparoscopic hysterectomy (LH)
hysterectomy group were no less concerned.
115
TAH group
IB06- Bought a book, ‘And I think I will bin it. It’s not my sort of book. But it tells you
week one what you can do, week two, week three you know right up to week 6. Em, and
it’s just you can’t do anything, according to this book. But obviously it depends on how
you are.’
IB18- ‘I try not to think about IT’ – preparing going into hospital.
LH group
IB16 ‘There is so much help on the internet now for people to self-diagnose a bit which is
a bit of a worry for the doctors I suppose cos you talk yourself into having lots of things
can’t you? But em I think I used to be a nurse anyway and I was pretty clear headed
where I was looking. I knew exactly what my symptoms were’.
IB22 was having mixed feelings – ‘It’s I’ve been on the intern et and I kind of read about
some of the complications and so on. …and not that I am not confident in the doctors and
everything, but in the back of your mind wondering you know is this going to happen to
me… You know the fact that you can you can have pro bably injury to the bladder …not
that I’ve known anyone that has experienced anything like that but it’s just sometimes you
stumble over information, that do you more harm than good to be honest’.
IB22- ‘Sometimes you stumble on things on the internet that do you more harm than good
to be honest.’ IB22 – Had not intended to go on the internet but her husband asked
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something ‘and I thought I will try and get some information to explain….and I saw this
video on you tube, you know, and it kind of shows you from start to finish what they
basically do and it just looks terrifying to be honest’.
IB22 – A nurse watched a video on YouTube on start to finish of surgery ‘I felt better
seeing it to be honest.’
VH group
IB09 ‘And having the two kids they keep me busy so I’ve just been trying to find things to
take my mind off it’.
IB14- Internet , use long words. ‘ then I thought no I’m not gonna look at this anymore
because I am going to frighten myself…..because unless you are a medical person some
of the terminology and expressions used could be a little worrying.’
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Practical preparation
A number of participants outlined the practical preparation they had made before their
surgery which included child and pet care arrangements, tying up loose ends such as
paying bills, completing housework in case they could not do it for a while after surgery
and arranging for help with cooking and shopping. This did not differ in the three routes
of surgery, and there were examples of this theme in all routes and the responsibil ities
this age group of women have.
TAH group
IB005 – ‘I’ve got so many animals and that, that I have had to arrange for like
neighbours who are gonna be coming in and you know, it’s just like, probably because
I’ve got so many, I’ve gotta arrange for them to be fed’.
IB005 – ‘I live with my husband so he’ll be doing all the day to day things like cooking
and things like that.’
IB01- ‘I have been doing all my windows and changing me curtains and everything
because I know I’m not gonna be able to do it.’
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LH group
IB13 – ‘There is people who have offered to come in and help with the kids. And people
have offered to come in and do my housework and stuff…I’ve got a good network around
me’.
IB21- plans to look after granddaughter ‘My other daughter i s coming to stay here, and
em, she is going to get her on the bus, get her dressed you know certain things like that’.
IB07 ‘I have made arrangements with school, em because of me not driving or anything,
they will come and collect him and fetch him back for me…Because there is no plans for
single parents with the government to help out with transport’.
IB16 ‘My sister is a nurse and she has offered to take some time off work to look after me
for the first few days anyway…or to help out with the shopping and bits and pieces’.
IB22 ‘husband is taking 2 weeks off work’.
IB14 (VH) ‘I have organised that my husband will do the housework and my sister in
law’.
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IB14- ‘I have tried to get on top of everything. I have washed all the clothes, washed all
the bedding, seen to me curtains.’
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Physical preparation
In the abdominal and laparoscopic hysterectomy group, there were examples where
participants had talked about trying to improve their fitness before surgery. However, this
was not the case with the vagi nal hysterectomy group, in fact one participant described
how due to her problems she had stopped her fitness regime of dancing as she thought it
was making it worse and would wait until after surgery to resume.
IB16 (TAH) ‘I had physiotherapy every coupl e of weeks and I had an exercise plan as
well. He has been building up my core muscles’ . Walking and getting fit, tried to lose
weight to help with recovery.
IB06 (LH) – Walking to get fit ‘I’ve tried to lose a bit of weight.’
Emotional preparation
Both the abdominal and laparoscopic group talked about how the surgery had affected
their emotions. Some participants had not thought about their emotions and whether they
would change and some were quite concerned about how they would emotionally cope
with the surgery. One participant talked about the fear of losing her job if she was going
to need much time off after her surgery and the financial effect. Some participants saw
the hysterectomy as a positive influence on their emotions and that it would lead t o a
reduction in the stressors in their life.
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IB004 (TAH) ‘I don’t think men understand do they. It’s part of you at the end of the day
that you are having to give up.’
IB004 ‘His attitude to it is well I’ll pick you up and drop you off and I’ve gotta g o to
work meself like, you know.’
IB004 ‘He’s frightened as well as I am am but they don’t show it. Do they. And, em, I’m
hoping after everythings done I can get me life back in order because it has been an
emotional up and down roundabouts circle’
IB004 – Fear of effect on lifestyle, although her sisters’ have had a hysterectomy,
concerned that her life is busier and that she still goes to work when they do not ‘And it’s
just sort of grabbed my life and held it. You know, I’ve had 10 months off work where I
couldn’t cope with that’.
Fear of sickness – IB004 ‘I just basically thought, you know I’m gonna lose ma job’.
Financial strain – IB004 ‘As obviously it affects your money..so, now he is doing extra
days overtime. He is working 6 days a week.’
IB16 (LH) ‘Emotionally, I haven’t really thought about it ..I am just, well it’s part of life,
you know you’ve had children…and with the pain I have had over the last year with the
amount of problems..I am just looking to see this hopefully resolve….then I can get back
on track’.
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Worried about complications – IB22(LH) ‘…the fact that some people get depressed and
everything you know. I am just hoping that doesn’t come my way, cos you know, that’s
probably something I wouldn’t be able to deal with’.
Sexual preparation
Some women were concerned about how removal of their ovaries would affect their
emotions and the consequences.
IB07 ‘I’m having my ovaries out I should imagine all them strange. A bit like the baby
blues…And that’s horrible….Mood swings….Yeah and that’s worrying me really because
you shout at your kids don’t you. They suffer’.
IB005 – ‘They (hormones) are probably going to be a bit all over the place, like. You
know, probably weepy and things like this and probably irritable’.
Cognitive preparation
There were not many participants who spoke about preparing for the loss of their fertility
however, there were examples of both apprehension about losing their fertility and
philosophical views where a participant saw it as a natural life cycle event.
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IB007 (TAH) ‘I think it really hits home. … it is and you can’t even think about having
any more children’.
LH ‘Well its part of life, you know you’ve had children. I am 49 tomorrow. I am not
gonna have any more children em and with the pain I have had over the year I will be
just so happy if it it does resolve the problems that I’ve got my life because I used to be
very fit and active .’
Some participants did talk about whether they had prepared themselves and their partners
for any changes in their sexual lives after the surgery. It seemed that most women would
ask their doctors for advice on when it would be safe to continue with their sexual lives,
and they felt they needed review first before being confident to resume.
IB22 ‘I understan d that I can’t be sexually active until maybe up to 6 weeks or so. I
haven’t even spoken to him to be honest. I probably told him at one point that you know
definitely I will be unable to do anything like that until you know been seen or reviewed
by my doctors’.
IB24 ‘I’m just trying to think what it’s going to be like, is everything going to be normal
in you know your private life, is everything going to be perfect again?….I spoke to him he
said just speak to the doctor’.
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One participant assumed it would mark the end of her sexual life, IB10 - ‘Well I won’t
have any sex drive.’
One participant did talk about how she had actively asked the question from the pre -
operative nurse, who explained to the participant’s satisfaction.
IB007 – ‘I asked her (pre -operative nurse) ..you know what happens actually to the sex,
sexual side and she explained it all to me. So I know what to expect when it comes down
to that. And I said well its not gonna be any different from what it already is really for
me’. (Said she had lost her libido years ago).
It was interesting how many women were reluctant to speak about their sexual
preparedness and the most usual answer was that it was not going to make any difference
or that it was not a concern to them.
A couple of partici pants talked about how they had booked activities to look forward to
which they believed would aid their recovery by having something to aim towards, such
as a 40th birthday party, holidays, booking cinema tickets (IB16), Christmas and Easter
celebrations.
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Some participants talked about getting mentally prepared for the surgery through positive
attitudes or by rationalising and justifying the surgery to bring about an improvement in
their lives afterwards.
IB13 ‘Gotta have it done, that’s it isn’t it. So carry on the way I was, which is not making
me any happier or have it out and we will see’.
IB21 (LH) ‘Mentally I’m gonna be fab because I am not gonna have a period anymore
and that’s it, it’s a big thing in my life. I can’t go swimming. You know. Can’t g o out and
about’.
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Decision making
Participants talked about how they had tried other options to manage their heavy
menstrual bleeding before and how they had finally come to the decision of surgery.
There was a theme of surgery being seen as a last resort with delays due to their situation
excluding surgery as an option at the time. Participants talked about wanting an option
which gave them a definitive end to their problems.
IB16 had an ablation before – ‘I know that em the NHS does like you to try lots of
different options first before you go for a major operation…but because I’m a single
parent…em really I would have hoped for the hysterectomy earlier really…and really it
has taken so long you know it’s a big impact on our lives at the moment..the fact that I
am not at work’.
IB18- ‘I’ve been having heavy periods..I’ve had em since I was15..And I had the bilation
(ablation) 2 years ago. And that didn’t work’.
IB07 ‘I know I’ve got to do it but because I am on the Prostat (Prostap) injections I
haven’t had a period now for 3 months, and my iron levels are 14.3, and I feel really
good, like I used to feel’.
IB07 ‘I hadn’t gone for it before now. I’ve had other things, I’ve had the Mirena coil
which didn’t work. I’ve had tablets and goodness know what else. I havn’t gone for it
before now because of the situation with somebody looking after the children..so really I
suppose I put myself on the back burner’.
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IB005 – Had the Mirena but had side effect – ‘And once I had it fitted, I started getting
really bad dizzy spells…to the point where I would be at work and get this floating feeling
in my head and I’d have to hold on to something’.
IB010- ‘I just feel I’ve suffered for 20 years and I feel like the, the people I’ve spoken to
have all said it was the best thing they ever did’.
IB09 ‘I have also had the coil fitted and had various tablets to try and stem the bleeding.
And I know there is a procedure where you can burn the lining of the womb, but to me I
have had enough done that has let me down because the hospital has done everything
that they thought was right to try and stop it and help. I just think my body needs
something final to say that’s it no more’.
IB16 – Had a failed ablation ‘I don’t think it worked very well for me. I had a lot of pain
after it and I was hoping that it would resolve and it didn’t ever resolve.’
Participants understood that a hysterectomy via any route was major surgery and that
they had considered the decision in this light.
IB06 ‘It’s the only guarantee, em because I was offered the ablation …but the c onsultant
said it was about 30% successful..and I didn’t want to go through that and find that it
hadn’t worked. And then of course you go back on the waiting list for everything….I
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know it’s a major decision and it’s a major operation, but I don’t wanna h ave to go back
in 12 months and try something else’.
Sometimes, the decision was influenced by other co -existing problems such as prolapse
or ovarian cysts, completion of their family and those affected had an understanding of
the rationale and there was evidence of joint decision making with the gynaecologist.
Associated breast cancer in family with HRT after hysterectomy - IB01- ‘before when
they first told me I was going to have the hysterectomy I didn’t want to know. I refused
point blank I wasn’t go nna have because I’ve got my aunty who had it done, my mother
had it done and obviously they both got breast cancer and that was my main issue’.
…The HRT tablets and that was one of my biggest worries actually’.
There was no difference with the route of s urgery in the reasons given for choosing
surgery, and all groups talked about the effect of heavy bleeding on their quality of life
and how they saw surgery as a way to improve this.
IB01- ‘Because if I arrange to go out with my friends….and I came on. Fu ll stop I can’t
go.’
IB 013 ‘ I mean I was out shopping one day, came back and just got covered in blood.
It’s not nice when you have got children here…the reason they decided it was the best
solution was, because I had been sterilised 4 years ago’.
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IB21- ‘And because I am a carer for my grand -daughter, I need to be on top form really.
So the only option is to have a hysterectomy….I am on iron tablets, I am on the pill at my
age em I am on tablets to stop the flow and but I have had a thrombosis so all th ose
tablets are just not right for me’.
IB06 ‘Em, its just a necessary evil so to speak. You know my periods have been bad for
so long that I just wanna stop the bleeding’.
Choice of surgical route
In some instances, the participants talked about how the route was determined by their
doctors and some of them although they had an understanding of why that route was
advised found it was different from what they had hoped for. For the laparoscopic route,
the main understanding for this choice seemed to be smaller scars and better recovery.
IB010- ‘I was hoping that I wouldn’t have to be cut across the stomach…But (consultant
name) has said it was too big to do that.’
IB24 ‘Then it won’t leave a lot of scars cos as I said before, if your body would be
normal, I don’t like lots of cutting on your body. So that, he said the keyhole is just a little
hole’.
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IB06- ‘Well em that wasn’t my choice, that was the surgeon’s. So hopefully if there are
no complications with the keyhole, less invasive, quicker recov ery’. Recovery time –
single woman dependant on her car and needing to be able to drive quickly to be able to
get out of the house’.
Single parent -IB07 ‘Because there is no way I would have gone through with an 8 week
recovery thing..because I just coul dn’t…there’s no leeway, you know school they’ve just
gotta be there’.
IB21 ‘The doctor suggested it’. She thought ‘Yes great Quick recovery rather than a
bigger recovery…you know with the scar across there then it takes you more time to
recover. Whereas two little ones I am hoping that I will be up and about quicker.’
IB16 ‘I’m having which one is it now..the laparoscopic hysterectomy. But em, until they
look inside they don’t know what they are gonna do…but if they can’t do the procedure
then they will do the abdominal hysterectomy….I am not too happy about having lots of
scars on my tummy but there is no other way round it, so you know. And I do heal up
pretty quickly…and it’s not like I go round showing my tummy all the time…so it’s not
too bad’.
Only a few women talked about how they had actively thought about the route they
wanted and why.
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IB06 ‘Thought a lot and looked online for route ‘But I think I went a bit too far, You
know. Because does it really matter what they are gonna do to me under ana esthetic. I
know they are gonna remove my womb which is the whole point of it.’
Ib16 ‘I’m not too happy about having lots of scars on my tummy but there is no other way
round it.’
One participant had changed her mind on the route once reading the informa tion leaflet,
and was concerned with her recovery. Furthermore, she was influenced by her mother’s
experiences.
IB09 After pre op ‘Em I signed the consent form for a vaginal hysterectomy but I have
read the leaflet…And I’m swayed off that now so I want t he abdominal hysterectomy so I
see there is a few questions round that and if I can still change’
When asked why: IB09 ‘Em, oh sounds a bit, I am funny about anything coming out like
that end…. Em and I know I am gonna be sore if I have the abdominal, sort of on my
stomach line and yes I will be sore down there but I think I will be more sore if I have it
out of there and I don’t like being uncomfortable down there.’
IB09 ‘I don’ t like being swollen in my vagina area. And that makes me more
apprehensive and stressed and I don’t know if that will lengthen the recovery time…And
my mon had a hysterectomy (abdominal) ..so I’ve seen how people recover from
that….And looking at the two, I think you go with what you know really’.
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Removal of ovaries
Although the number of women who had their ovaries removed was not considered in
this study, nor was it balanced in the sample of women interviewed, s ome participants
talked about their understanding and questions around the decision as to whether their
ovaries would be removed as well as the hysterectomy.
IB13 – ‘I understand that if I keep my ovaries I will go through the change normally and
if I don’t then I will have to go on HRT’.
IB007 Did not know where her eggs would go if the ovaries were left in place once the
womb was removed ‘and then I learnt that you still have the oestrogen hormone ….and
that you need that for your bones and whatever. And that, you see I didn’t know that’.
IB16 ‘The only thing that I am unsure about is the HRT whether I will need that . I mean
that’s a bit confusing. Because one of my doctors has told me that even if you do need
HRT that sometimes it is best for maybe a homeopathic type which is like plant
oestrogens. ..Cos it’s not clear at the moment 100% what’s gonna actually be done on the
day’ [removal of ovaries].
One participant talked about how she was finding it difficult to make the decision herself
and had looked for advice and wanted someone to tell her what she should do.
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IB07 –‘ I was unable to go to the evening thing (information evening), but I did speak in
depth with one of the people there at the hospital….I was trying to ask the doctors and
nurses and nobody would actually say yeah I think you should have this done or no you
should have that done. It’s all my decision but…I just felt that I didn’t have enough
information. …but there again the more information I found the more that I felt …at the
end of the day again we are coming down to an individuality. …And I haven’t got t he
medical knowledge to say well okay I need my ovaries or I don’t need my ovaries, that’s
what I wanted someone to tell me’.
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Influences
Participants were influenced in their expectations by people around them who had had
previous experience of a hyster ectomy. Participants were concerned that from what other
people had said, that they would not be able to do much after surgery, and they were
inclined to believe the advice they had been given in order to learn from them and avoid
delays in recovery.
IB14- People told her things ‘That I won’t be able to do much at all. They have said that
you will have to sit quiet and just toddle round the house a bit…..And I shall be happy to
do what they say because I want to be right.’
IB16 ‘..my sister’s had a hystere ctomy, my mum…my auntie and I’ve listened to all their
experience. My best friend as well and em they are all back at work. You know they are
all back to their normal selves’.
IB22 ‘Information that I have shared with friends…you know nothing too negativ e but
just that they have been quite fatigued and tired, off work for long periods of time, but
overall they basically said you know that they made the best decision. But you know I
know each individual is different so I am just kind of wondering what is g oing to happen
in my situation’.
IB21- sister had the same – expects recovery of 6 weeks ‘rather than 12 weeks’.
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This participant was due for a VH but took advice from her mother who had had a TAH
but she did not expect that her recovery was going to be any different due to the route so
was inclined to listen to the advice.
IB09 ‘Just what I won’t be able to do really and how long I won’t be able to do them for.
But she has been really supportive and encouraging.’
A participant who was expecting a LH talked about the advice she had received again
from women who had had a TAH.
IB22 – ‘you know they have been quite fatigued and tired, off work for long periods of
time.’
Again, she did not expect any difference due to fact that her surgery was planned for a
different route.
One participant did talk about how she was surprised at the experiences of others and that
she expected her recovery to be better.
IB06 ‘They said at work get your friends to make you a sandwi ch before they leave you
and I’m thinking I will be able to make a sandwich. Surely I will be able to make a
sandwich. I don’t think I will have my arms cut off.’
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Some participants were influenced by their previous experiences of other types of surgery
they had and were worried about the hysterectomy being a larger procedure. In particular,
they spoke about how they would cope with recovery in their different circumstances
from their pervious surgery.
IB005 ‘Well, when I broke my leg, things like, you kno w when you are straining to do
something or you are finding it a little bit hard and just in that sort of way. I think you
know yourself.’
IB010 – ‘Em quite worried in one respect. I’ve had lots of surgery before….So there is a
part of me that knows what’s coming. Em but it’s the, this is a little bit more serious than
what I’ve had done before and it’s the after effects I’m more concerned about. Having my
children to cope with. And how long it’s going to be before I’m back to normal so to
speak. Like with my husband working away’.
Previous major surgery – IB21 ‘And as long as they give me injection for being sick
after…I will be fine.’
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Part II Expectations Pre Surgery
Expectations about length of hospital stay
Participants all talked about confusion in their expectations of how long they would stay
in hospital. They attributed this mainly down to conflicting information they had received
from various health care professionals, including discrepancies between their consultants
and the pre-operative nurses.
IB06 laparoscopic- ‘He [consultant] said to me if you choose a hysterectomy you will be
in hospital for one night, within a couple of weeks you should be feeling more of less back
to normal, then when I saw him in July and I said is it just one night, and he was like
maybe two or three, and then at the pre -op the nurse said usually 3 to 5 nights it might
you know be longer…So now it’s almost gone from sort of like 24 hours, which I could
cope with, to sort of 3 nights minimum which is like oh my God, to maybe 5 may be
longer’.
Other participants in the laparoscopic group expected to stay in between 3 and 5 nights as
well.
IB24 ‘3-4 nights’
IB22 – ‘Hospital stay 3 to 4 days’
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IB21 – ‘I am in Tuesday and hoping to come out Friday’.
IB16 ‘I suppose they said the average is 4 and I think …I would be a bit worried if I was
only staying for 2.’
IB13 ‘Em originally they said 2 -4 days, now they are saying 3 -5… Because they were
not aware of the problems with my bladder and the problems with my discs.’
In the vaginal hysterectomy group, most participants expected a stay of 3 to 5 days.
IB09- Mum had TAH ‘I mean mom had hers on Friday and came home on the
Monday….I mean I have read the leaflets and the leaflets say 3-5 days’.
One participant talked about how if she needed to stay longer than she expected, it would
be in her best interests. She felt that if she was in hospital then at least she was in the
safest place and that if they kept her in she probably needed the time in, but would like to
come out as soon as possible.
IB005 ‘Well obviously I’d rather be out than in hospital, than lets, so if I was ok on the
Sunday I would rather come out. The sooner the better’.
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Expectations of recovery
Pain was something that participants associated as a marker of their recovery. They
talked about how pain would concern them and stop them from doing things they might
feel they could.
IB07 ‘But if you get more pain….then obviously something’s a bit wrong so you have to
get advice’.
There was no difference in the expectations of participants in the activities they would
have to refrain from regardless of the route of surgery they were having.
IB005 (TAH) – ‘I suppose I’m going to have to stop myself from you know just like
bending down, picking things up and you know changing the cat litters, just things that I
do every single day.’
IB14 (VH) ‘I can’t go picking my grandson up.’
IB14- ‘I’m going to be staying upstairs for the first few weeks. I am going to stay out of
the way.’
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IB24 ‘There’s an old saying that once God made your body perfect and then once the
doctor get inside you, you are not normal again cos that cut will always be there….It’s an
old saying from my parents…You know if it’s gonna heal properly you know’.
IB010- ‘I’m not looking forward to staying in.. Because I can never sleep.’
IB01-‘I think you can heal better at home’.
Driving 3 weeks from pre-op nurse
IB06 (LH)– Driving 3 weeks- at pre-op, patient thinks it will be 6 (from family member
who had CS).
IB16 (LH) ‘Well I am hoping maybe after 6 weeks I will feel well enough to think about
going back to work.’
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Thoughts about recovery
All groups regardless of route of surgery had similar concerns about their recovery. This
stemmed sometimes from the experience of other people they knew;
IB005 (TAH) – ‘three of my closest friends have had hysterectomies……all of them have
actually said the one thing that is the worst for all of them, is the terrible terrible
constipation after. And that’s what they said they found the hardest. I mean some of them
said they went home from hospital they would be there all night crying. Trying just to go
to the toilet because they felt bloated and that inside’.
Recovery expectations were associated more with the indiv idual, there were participants
who were keen for a fast recovery and those who felt that they would not want to rush
themselves.
IB16 (TAH) ‘I am hoping that I can manage to do the general household stuff pretty
quickly…Em, you know manage to go back to work. You know as soon as possible..Well I
am hoping maybe after 6 weeks I will feel well enough to think about going back to
work’.
Some participants were quite negative about their immediate recovery and the effect it
would have on their lives and respo nsibilities, again this trend was seen across all
surgical routes;
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IB07 (TAH) ‘I live on the other side and he goes to school (son) and most of the people
live by school. It’s definitely a car drive away…So you have got to walk to the bus stop,
wait for buses and I couldn’t do that in the beginning anyway’.
IB09 (VH) ‘You won’t be able to walk…I probably would’t even get to the end of my
road’.
IB06 (LH) ‘It’s almost as if things will never be the same again but 6 weeks in reality is
nothing’. It just seems, oh well I can walk 4 miles any day I like now. But I am not gonna
be able to do that next week. And, you know, I am gonna struggle to get out of bed and I
don’t wanna be, you know gonna have to be dependent on people and have lots of people
around me that I am not really looking forward to’.
In this part of the study, most women spoke about physical and behavioural recovery
rather than emotional or sexual. These areas were addressed with prompt questions later.
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One week after surgery
In gener al, regardless of route of surgery, participants expected to not be able to lift
heavy things, do the vacuuming, bend or stretch. A number of participants had
expectations but were mindful again that there is individual variation and that their
recovery may be different. They spoke about listening to their bodies.
TAH Group
IB18 – ‘I know I won’t be ironing’ ‘Em just think its down to your body really and you
listen to your own body.’ ‘I won’t know until I you know probably experience pain or
whatever…That I’m not supposed to be doing what I am supposed to be doing’.
IB008- ‘Em one of the things I suppose I think I won’t be able to do is probably wear
normal clothes for a while. Eh, I have got a few loose things that I have not thrown out’.
IB01- ‘Just me normal things, like cleaning up and vacuuming and you know.’
IB01- ‘Like I say it all depends on that person…you know and I think me myself, I am a
stronger person. I am not gonna think I’ve had that operation like oh I can’t do this. I am
still gonna get up and try.’
In the LH group, there did not appear to be any difference in recovery expectations from
the TAH group and were mostly around lifting, vacuuming and driving.
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IB16 ‘Maybe just walk up to the shops which is 10 minutes’ walk from my house’.
IB22 – ‘I won’t be able to push them (kids) in the chair (pushchair) or lift them out of the
bath.’
IB13 ‘I know I’ve got to sleep and eat properly.’
VH Group
In this group, there were some specific concerns around pain when sitting down, and
opening their bowels. They expected more pain with both of these activities due to the
positioning of their vaginal scar.
IB14 ‘sitting down in the bath might be a bit awkward. And the toilet. Just going to the
toilet because I remember when I had the children I was quite stitched up after I had the
children. I am just hoping my bowels and all that, it’s a terrible thing to talk about , but
yeah I don’t look forward to down there.’
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One month post-surgery
At one month, there was again little difference in the expectations of participants
according to their route of surgery. In the TAH group, participants felt they could partake
in light exercise only, lying down exercises, no driving, no sexual intercourse and no
heavy lifting still such as children. Again, th ere was reference to listening to your own
body and individual variation.
IB005 ‘doing the normal things then…Just like going back out socialising and just doing
the normal things, like putting the washing on and things like that. I won’t be vacuuming
or anything like that’.
IB005 ‘Just take it at my own pace and sort of, I think you can tell if you are over doing it
with your own body’.
IB10- ‘Em-, well I won’t be back at the gym.’
IB18- No heavy lifting ‘Will have to do light jobs like working on the wards’ – works in
theatres. ‘They reckon I might be at work after 6 weeks’.
One participant was optimistic and felt that they should be almost back to normal in the
TAH group.
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IB01- ‘I should be hoping by then things would be getting back to normal then. I would
be expecting to be getting, not 100% but at least 85% back to normal.’
In the LH group, there were participants who felt that they may be driving by 1 month but
on the whole, their expectations were similar to the TAH group. Again, they expe cted not
to be able to do strenuous exercise, vacuuming and listening to their bodies.
IB21- ‘I’m gonna see how I go and then perhaps in a month I might be driving.’
IB06 ‘I hope after a month I will be able to do almost everything…Maybe not vacuuming
but maybe.’
IB16 ‘I don’t think I’ll be taking any strenuous exercise.’ ‘Just general things around the
house.’
IB22 – ‘No driving’
IB13 ‘Well hopefully I will be able to do the majority of things apart from like real
physical exercise.’
One participant talked about how she was not expecting to be back at work because of the
advice her doctor had given her. None of the group talked about being back at work by 1
month.
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IB06 – ‘The consultant said we sign you off for 6 weeks straight away’.
There were s imilar expectations around sexual recovery regardless of route of surgery,
and this seemed to be due to what they had been told;
IB22 (LAH) ‘I understand that I can’t be sexually active until maybe up to 6 weeks or
so.’
IB10 (TAH) ‘The sex possibly not as it says on the thing. …on the leaflets that potentially
it is 6 weeks.’
IB09 (VH) Sexual ‘And like after childbirth as well, you have to refrain from sexual
intercourse for 6 to 8 weeks anyway so it’s just the same to me’.
The VH group had similar expectations at 1 month around driving, strenuous activity,
heavy lifting.
IB09 ‘Possible drive, depending on whether you can get the seatbelt round you with my
insurance’. IB09 Has a night out paid for ‘Well. I have paid for it in the hope that I’ll go.
Its gonna give me something to, to work for’.
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IB14 –‘Would not be expecting to do vacuuming, going out shopping and driving, picking
up grandson, gardening and dancing, driving – 6 weeks. ‘Yeh I’m worried about the
muscles. I am not sure what happens about your muscles so I will have to ask about that.’
Expectation of recovery two months post-surgery
At this time period, there were differences in the expectations of recovery in the different
surgical route participants, but this was more marked in the VH group. The TAH and LH
talked about how they should be expecting to get back to normal and start thi nking about
exercise again, vacuuming, pushing children’s prams, shopping and sexual intercourse.
The VH group were expecting to be careful around lifting and strenuous housework still
at this stage.
TAH group
IB07’ As long as I can do a bit of Christm as shopping and make sure that, coz he (son)
still believes in Santa so I’ve still gotta hide the presents so whether I out them in the attic
this year I don’t know’.
IB10-‘I would hope 2 months after that the only limitations I would have would be at the
gym. And I would expect that everything else would be back to normal.’
IB01- ‘I’m hoping by the 6 weeks I will be flying round the block.’
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There was still reference to not pushing it and taking account of your body’s signals.
IB18- ‘More or less the same but not pushing it’
LH Group
IB21 ‘I should be as fit as a fiddle’.
IB06 ‘Expecting to do everything and will be completely back to normal’.
IB16 ‘Em hopefully I will be back to normal.’
IB013 ‘Intercourse obviously cos they reckon 6-8 weeks for that. …obviously a lot of it is
common sense isn’t it. Your body tells you how you are feeling’.
In the LH group, there were differences in expectations about whether they would be
going back to work and these appeared to be related to their activity type at work.
IB16 – ‘work 6 weeks’ (office worker).
IB22 ‘Active but not necessarily back to normal. No vacuuming, thinking about going
back to work (nurse).
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VH group
IB09 ‘Heavy lifting might hurt, can’t do some house work ‘But I hope to be able to at
least walk to the school and pick my kids up.’
IB14- ‘No heavy shopping or picking up grandson. ‘I may be able to take him to
playschool’.
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Recovery expectations three months post-surgery
All groups felt that they would be back to normal by 3 months. Th e LH group were more
optimistic and used more positive words such as ‘great’ and ‘distant memory’ and being
back at work, whereas the TAH group were talking about starting to feel normal.
TAH group
IB10 – ‘thinks should be able to do everything’.
IB18- ‘By 6 months I will be more or less doing everything’.
IB005 ‘Actually in my own mind I think I will be off about 3 months (from work)’.
LH group
IB21- ‘Oh I’ll be great’.
IB06 – ‘Oh God, it’ll be a distant memory’.
IB16 – ‘Can do everything’.
IB22- ‘Hopes to be back at work then’.
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IB13 ‘I should be fine.’
Again, the VH group were more cautious in their recovery expectation at 3 months.
IB09 ‘I would like to be doing everything….work is my only grey area….But that’s
something obviously my doctor and hospital would discuss with me.’
IB14- ‘I was hoping I would get to a bit of normal. Exercise, I will probably have to ask
about that.’ Didn’t think she would be completely back to normal’.
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Expectations of sexual recovery
All groups regardless of their route of surgery felt that there would be a positive change
in their sexual functioning. There was some apprehension about sexual feelings and how
to approach the subject with their partners.
IB16 ‘Well I’d like to be but at the moment , no, well it would be too painful…Well I am
hoping that my body feels better afterwards, so you know I am not worried about it but I
am hoping I am optimistic that maybe I will get back to being a normal human being that
can take up any activities’.
IB21- ‘Oh (it will be) a lot better. Because we are not at the moment…We haven’t for
about 18 months. Because every time we get in the mood it just happens. You know…I
bleed you know and I am in pain.’
IB22 ‘You’ve asked me about how I, how I feel you know, I am going to approach things
sexually, but I was wondering, I mean some people probably have reduced feelings
afterwards, and for some it makes no difference. But you know that’s probably something
I probably need to sit down with my husband and talk about. I am just wondering you
know it, how it will affect me personally.’
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Thoughts about surgery
Positive
Positive cognition was framed around trust in doctors, going through the stress of surgery
in order to gain a solution to their problems and even a bet ter quality of life than they
have had (pain for gain), focussing on a good outcome and the positive experiences of
others. This was similar across all surgical routes.
TAH group
IB16 ‘Well I know I trust the doctors here and I know they are gonna do the ir best.
They’ve got the best available medication…so I know I’m gonna be in the best hands
really…you know that I’m gonna be on the mend’.
IB22 ‘Well I’m quite nervous to be honest. Just in case something should go wrong but I
have gotten to the point w here I am quite happy that I have made the decision, you know
between my gynaecologist and myself. You know based on the problems that I have been
having in the past’.
IB01 ‘I’m just thinking to myself now hopefully all the problems will go away…You know
the periods, the heavy periods, the pain, just hoping it all, I hope it’s worthwhile
actually.’
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VH Group
IB01- ‘Everybody’s told me who I know who’s had an hysterectomy, it’s the best thing
they ever did, even the woman at the bus stop said to me today, she was telling me it was
the best thing that ever happened to her.’
IB14 – Hoping to get back to dancing ‘I found that awkward , planning holidays’.
LH group
IB006 – ‘So once that’s gone (bleeding) you know, I will be able to go if people are
saying oh do you wanna walk up mount Everest at the weekend I will be oh yeah
course…I haven’t gotta worry where the toilets are.’
IB21 ‘Em, quite looking forward to it actually. It’s gonna change my life hopefully’.
The LH group talked about how they were stil l comfortable about their decision despite
the risks associated with surgery;
IB21- Positive despite risks - ‘it can perforate your bowel or whatever but I am kind of
not bothered about that. You know I mean I just need this hysterectomy.’
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IB22 – ‘Well I’m quite nervous to be honest. Just in case something should go wrong but
I have gotten to the point where I am quite happy that I have made the decision, you
know between my gynaecologist and myself.’
Negative thoughts
Participants who talked about negati ve cognition were those who had a poor experience
previously of surgery, mostly associated with anaesthetic or complications;
IB16 (TAH) ‘It’s just that I have had a few operations in the past and I know what it’s
like when you come round and you don’t fe el too good and you know the amount of time
that it does take to recover sometimes.’
IB14 (VH) Anaesthetic, pain after. ‘Because when you are put out….I mean you don’t
know whether you talk in your sleep or something or what. So I am a bit apprehensive
because people say that you feel sick.’
IB13 (TAH) ‘My last operation they burst the discs in my back and damaged my
bladder…so obviously there are some of my concerns…Being catheterised after the
operation. They said it could be anything up to 72 hours. I am worried about that cos my
bladder doesn’t, I don’t know when my bladder is full. The operation itself doesn’t worry
me. Em, apart from when my sister had a laparoscopy, she nearly died…..she got
septicaemia in it….I have friends who have been in. Like w omen who have had
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hysterectomies and you know, so I’ve seen that not all of them go the same, so what will
be will be’.
There were also participants who were afraid because they had not experienced surgery
or a hospital stay before;
IB06 (LH) ‘Petrified, I’ve never been in hospital before. ..I’m scared that I’m gonna
wake up in pain. …and the whole hospital situation is very much out of my comfort
zone….and because I’ve lived on my own for a while, I am used to doing everything for
myself’.
IB21(LH) ‘I am dreading it..Being in hospital. The thought of just being in hospital
terrifies me…But the MRSA things like that you know…….but the operation no. Not at
all, I’ll be in and I’ll be out’.
There were anxieties around being able to carry out their usual roles and responsibilities
such as child care and housework, as well as lose their independence and rely on others;
IB07 (TAH) (single mother) ‘ I am anxious, em not just because of the surgery but
because my son has got to go and stay somewhere for a wee k and I’m not gonna see
him…coz I’ve no family in the vicinity…so it’s just extra extra pressure I suppose. …He
is off school that week it fell really well actually, so he will be in Manchester with my
brother’.
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IB010 (LH) Leaving children - ‘And the fact that they are gonna go and stay with my
parents on Thursday and I’ve got to say goodbye to them and I get emotional and that
and I’ve never really felt like that.’
IB24 (TAH) ‘My independence is gonna go..In like cos I won’t, for a while I won’t be
able to tidy up, I won’t be able to cook, I won’t be you know to do like, somebody is
gonna have to take over everything and it bothers me’.
IB01(LH)– ‘I just thought I’m gonna be bed ridden and that’s what I didn’t wanna do
that’. I spoke to the nurse…she sa ys that I would be able to walk to the little corner
shop’.
IB06 (LH) ‘Scared to death…I’m scared that I’m gonna wake up in pain…That I’m not
gonna be able to cope very well with the pain and with the whole hospital situation is
very much out of my comfort zone. Coz it’s completely unknown.’
Only one participant talked about the fear of sexual recovery and what it will be like
afterwards;
IB01 (LH) ‘I’m worried about all the dos and don’ts you can do. But my main issue was
em sex. That was my main worry and but obviously I spoke to somebody (the pre -op
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nurse) about that….and I was quite happy with what they told me about it. You know.
That it’s just as normal as it could be.’
Again, there were similar negative thoughts about surgery and surgical recovery across
all surgical route groups.
Loss of fertility
There were a few women who talked about the effect of surgery on their fertility and how
this had made them feel;
IB13 I’ll cry my eyes out, but you know, like I say I don’t want no more chil dren so that’s
not gonna be, it’s not like as if em Iv’e been just told I’ve gotta have this and no choice in
the matter’.
IB24 ‘My partner hasn’t got any kids…I feel really emotional that I have a kid and he
hasn’t got any. But I have to do it. So I am j ust thinking down the line. Where we go from
here, cos he is gonna want kids. But he doesn’t want any you know. I don’t know how he
is gonna react. He said he is fine..but you never know later on’.
IB07 (LH) ‘I’m too old now to have any more children…But..I don’t know really. It’s..It
seems a bit sad the thought of it’.
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Some women were philosophical or had decided that they did not want children and so
did not mind losing their uterus.
IB06 (LH) ‘I’ve not had children so I’ve not had any sort of major interference with my
body. You know I’ve not had any other illnesses. So I suppose when you have a child you
know a bit about what maybe is to come. I mean I know most women in my situation
would be like oh gosh I can’t have any children…And here I am saying I’m afraid of the
pain. It’s like oh well if I had wanted a baby I would have had one years ago or
whatever…I just want an end to this bleeding’.
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Part III Post-surgery experiences
1. Post-surgery attitude of others
Some women spoke about the attitudes of family members and the effect of surgery and
hospital stay on them.
IB17- ‘Told the kids that I was gonna be going into hospital for a couple of days but I
would be back which scared my son a lit tle bit. Cos he is sort of 7, so he was a bit
concerned about me going in but I promised him that I would be fine, that I would be
back, you can come and see me I won’t be long’.
This participant had been quite tearful before surgery about whether her hu sband would
understand and how he would react to her recovery needs after surgery. She went on to
talk about her experience of how this was after surgery:
IB02 – ‘He was leaving me half a kettle of water, so I could just tip it and make me own
cups of tea…I says I’ll get by. He’d do me a sandwich you know, ready for me tea, make
sure I was fed before he went to work.’
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Effects of surgery and illness
Participants who talked about the effects of surgery were positive and spoke about how it
had solved their problems and improved their quality of life;
IB05 (TAH) ‘I feel like I know what it’s like to be in your 80s or something, to be a really
old person, and it’s sort of been reversed and I am just really happy.’
IB17 (TAH) ‘I had to sort of limit what I could do cos of how bad my periods were. Now
I can do whatever I want it’s gonna make no difference whatsoever.’
IB21 (LH) ‘Quality of life much better now, can do much more ‘Gardening, going out, I
used to have to take a bag with me with pads and a new set of trousers or skirt. I am
looking forward to my holiday…last year was horrendous. I had a period from the time I
went to the time I came home. You know and it was just, I couldn’t do nothing. I felt dirty
and you know even though I was showering every day, well about 3 times a day, it was
just horrendous. But this time I am looking forward to it.’
IB06 (LH) ‘I’ve got 3 little dashes on me belly. They’re nothink. You know, they’re
nothink and to have you know such a major thing removed.’
IB 13 (LH) ‘I had gone from this tired, bleeding person to like this happy sparkly person.
So like totally changed me straight away.’
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Experiences of hospital and surgery
Here there were differences between the three surgical routes, in particular a lower length
of stay in the LH group.
IB05 (TAH) ‘I had it done on Tuesday late afternoon, Thursday morning they let me go
home. . So I just went back and had the stitches out 5 days later and then just been
getting better and better. ‘‘I was thinking I would be in for about 5 days’. ‘It was right to
go (home when she did), and I knew then I could have gone straight back in if there was
any problems’.
IB17 (TAH) 2 days ‘I thought I was gonna be in there until Monday (extra 4 days) to be
honest’.
IB8 (TAH) ‘I was in on Wednesday and came out Friday.. I was very pleased to come
out...it was exactly right for me’.
IB21 (LH) ‘Tuesday to Friday, 1 day longer than expected because she had a cold’.
IB06 (LH) ‘You know I wasn’t in hospital lon g. I was only in one night…And I was out,
which I was delighted about cos I was really scarred about my hospital stay.’
IB06 (LH) ‘I bought two nighties for my hospital experience and I should have left the
tags on and taken them back.’
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One participant i n the LH group (IB22) had a prolonged stay which was not associated
with any complications of 3 days, which was similar to the TAH group.
Actual recovery experience
The actual recovery experience and mile stones were more associated with the individual,
their circumstances and complications rather than the surgical route.
TAH Group
IB05 ‘after 3 weeks it was like a bit of bleeding again and I thought oh no, you feel like
your insides are falling out…but I just went to the GP and got some antibiotics. Cleared
up then and just so relieved and so happy to have it done.’
IB05 – ‘It’s slow because you feel really good and then you probably overdo it a bit, I
don’t know just walking round, it’s like the weight kind of collects just at your stomach
and you get this numb, your stomach goes numb. At first you feel as if it’s some kind of a
space hopper or something you know, sort of you know from the inside. But that just gets
less and less.’
IB08- ‘I was out and about 2 days afterwards…I started my exercise regime …on
Saturday which was the day after I came out of hospital I walked round the garden. A nd
on Sunday I did 10 minutes’ walk.’
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IBO8- Mother was ill and had to go on the train to Gloucester herself around 2.5 weeks –
‘I did feel extremely tired afterwards and my stomach felt, did feel swollen and bloated’.
She didn’t feel she was doing herself any harm – ‘I just thought, I would get warnings if I
was doing myself some harm and I didn’t feel that. I just felt very tired from that.’
IBO8- At 8 weeks doing everything – ‘I think I hovered after about 6 weeks.’
IB05 – ‘So now there is very little I couldn’t do’. (3 months).
VH Group
IB03 ‘Very tired the first couple of weeks…Extremely, I was sleeping 16 hours a day.
Don’t know if that’s normal or not. …..Em, had a bit of an infection. Three no two lots of
antibiotics’.
IB03 ‘And I just remember my throat was so sore, so dry, but obviously from that
breathing pipe.’ ‘I didn’t like the catheter’.
IB02 ‘In fact my biggest problem was remembering that I’ve had something done and I
mustn’t lift heavy weights.’ ‘But once I had the drip off and the oxyge n off and all those
tubes out and I just trotted off to the bathroom as I wanted, I was fine.’
IB03 Pain – ‘Fine, I didn’t even take paracetomol. I did as a matter of routine the first
couple of days, but after that.’
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LH Group
IB22 ‘It’s been really good’.
IB22 ‘After the first week or so, I wasn’t in a lot of pain and I kept taking my painkillers,
so I didn’t have much problem at all, and I was able to go up and down the stairs.’
IB22- ‘I went back to work after what 10 weeks’.
IB06 ‘And I never felt ill in myself. I was tender and uncomfortable at times but it wasn’t
really anything to complain about. You know I’ve felt worse when I‘ve had the flu.’
IB06 ‘Well I didn’t really lift anything for weeks and when I first vacuumed after about 6
weeks cos I had to, em it took my breath away.’
IB06 – pushed herself with walking a bit further every day but then felt tender ‘And then
I’d just lie down. I mean it soon got better and then I was angry with myself thinking you
have had major surgery.’
Most participants did not drive until after 6 weeks, regardless of surgical route, however,
there were two participants who drove much sooner. One had a TAH and the other had a
LH.
IB02 (TAH) - Driving for 3 weeks (interview at 8 weeks) seat belt annoying – ‘Because I
am wearing it round the bottom half, it gets quite tight when you are driving .’
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IB06 (LH) Driving after 3 weeks. Work after 8 weeks GP said ‘6 weeks is optimistic.’
Experiences versus expectations
Most participants talked about a b etter experience of recovery as compared to their
expectations in all groups. This was not particularly associated with route of surgery.
TAH group
IB8- ‘My expectations are usually quite realistic I think.. Erm, I suppose it’s from the
information I’ve gathered and em probably past history of surgery’.
IB05 ‘Like just walking, for a long time….and I knew I felt that I could really do some
damage if I kept that up. And so I feel as I needed to lie down cos that pulling and that,
that’s gone on for a long time really; which was to be expected. But I just wasn’t
expecting it’.
Influences from other’s experiences were negative
(IB05) one woman had a hysterectomy around her 40th birthday and was depressed for
10 years and I thought ‘oh I’m gonna feel reall y miserable and, but I didn’t I was just so
relieved that I had it done and so happy’.
The same lady was prepared to have no sex life and was pleasantly surprised
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‘Perfectly alright. That was my main worry’, be depressed and have a ‘horrible scar like
a l adder going up your stomach. And the scar you can’t even see any stitches or
anything, it’s just brilliant’.
IB08- ‘Emotionally ‘no different to usual’
IB17 ‘Recovery was a bit faster than what I expected. I was up and about within sort of 2
weeks. I was pretty much back to normal within 4 weeks as opposed to 6 which they said.
I did have an infection. But I got over that quite quickly.’
This participant (IB17) said she had a positive attitude; ‘Once I have decided something I
go for it with no ends or buts about it I will do it.’
VH group
IB03 – ‘They were saying well you can’t even lift a kettle and things. Well I did….Day
one.’ How was she ‘Fine’. ……’Em after about 2 weeks I mean I went shopping.’
Vacuuming after 2 weeks. IB03 6 weeks off work – right for her.
IB02 – ‘Much better than I expected’. ‘Because someone told me that if you have an
anaesthetic it sometimes knocks off a few brain cells and I haven’t got many to be
knocked off. I can’t afford to lose any and I thought perhaps I am a bit worse. But I don’t
think I am now.’
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IB02 – Felt she could have gone home earlier (stayed 3 days) but it would have been
‘unwise to….Silly to rush things’.
LH group
IB22 ‘What I was worrying about before, I don’t kn ow, it’s all gone. I think I was just
unnecessary worries really’.
IB21 ‘It was plain sailing actually. I have heard that many rumours that you know they
cut through to your bowel…… it can happen can’t it, you get to sign a consent form
saying that if an y of these symptoms happen you know it does happen. But I have had
nothing and I am so grateful for that, you know cos it was a big concern when they go in
blind that they can perforate something.’
IB13- Driving after 3.5 weeks ‘Better than what I thought . I was doing things more of
less straight away. I didn’t really feel like I had had a major operation.’
IB13- ‘I had more pains with my previous problems than what I did with the
hysterectomy.’ At 3.5 weeks was completely back to normal’.
Some participan ts talked about being well prepared and how this has made their
recovery better;
IB22 (LH) ‘Well I think that was why everything went smoothly, because I had you know
good preparation before and I had leaflet that I could go back and read information that
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I couldn’t remember, you know, so I was well prepared, you know mentally and
otherwise.’ Thinks the method used improved her recovery.
Participants talked about listening to their own bodies in all the surgical route
groups;
IB17 (TAH) ‘I have faith in sort of my body will let me know if I am pushing myself too
hard. And then I would have stopped. But cos of how well I could, I just got on with it.’
IB03 (VH) Expectations – surprised because ‘I thought I would literally be bed bound as
such.’ Influenced by what people told her, ‘But the one thing I did do and it always stuck
in my mind. Listen to your body’.
Some participants in all surgical routes had a worse recovery experience than they
had anticipated;
TAH group
IB05 – Was worried about sex life mainly – ‘perfectly alright. That was my main worry’.
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IB02- ‘I was expecting to be back at work within the 12 weeks.’ Struggled with washing
hair over a bath, described her recovery as a ‘rollercoaster’. Uncomfortable go ing up
and down stairs. Post-operative wound infection during first week – ‘I couldn’t even put
me drawers on. Everything was catching. It was really uncomfortable…it was all like
pulling.’ But compared it to her emergency CS 27 years ago and ‘It brought i t all back’.
Remembers her sister helping her wash her hair over the bath then as well.
IB02- ‘it took me a long time to actually start sleeping on my side…Em, about 12 weeks.’
IB02 Did not anticipate that she would need different clothing due to pain and tenderness
‘I’ve managed to find some very elasticated underwear…They come up to my belly button
and there’s no seams.’
VH group
IB03 ‘The only thing I was surprised but I had been warned, the amount of wind that you
get….and the bloated feeling, it’s horrible. I mean that it was really uncomfortable, I
would say it was more uncomfortable than the operation’.
IB03 ‘So, it did get me down for a while, you know, you think oh I am not a woman, not a
proper woman anymore, I can’t have babies.’ ‘It’s not li ke having breasts removed.
Because it’s not physical but mentally it did affect me for a bit. Just a couple of weeks but
no I feel really good.’
IB03 – Kept ovaries and was surprised to get PMT ‘I just thought well I won’t have
periods I won’t get PMT.’
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IB03 – had an infected haematoma ‘And then when I had the bleed..Em…they said they
may need to open me up if the bleeding didn’t stop…Which scared me again. Because I
wasn’t mentally prepared to be opened up.’
IB06 – Wind pain was worse than expected and used a full tin of chocolates to put her
feet on when she was on the toilet to ease the pain. ‘I wish I’d done a swap phone
numbers with one of the ladies who went in on the same day to see how they were
recovering.’
Effect of healthcare professionals
Regardless of surgical route, there was a strong influence of healthcare professionals in
the recovery experience.
IB05 (TAH) ‘I felt like he had really listened to me and done what I wanted
(surgeon)…….‘ I mean they are there, there’s a team there and you k now they were just
brilliant, you felt safe. ‘
IB02 (TAH) ‘Em, went for my 6 week check up with my doctor, just gave me a doctor’s
note and sent me on my way…She wasn’t eh, she didn’t examine me or nothing.’
IB06 (LH) Felt ward staff were very busy and so did not call them post operation when
she had a question about her bleeding. ‘the nurses didn’t seem to be particularly expert,
but you know there was the sister and everyone else seemed to be a student nurse.’
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VH group
OB14- ‘But I am seeing a very good consultant, Mr X, he seems very reassuring’.
IB14- ‘I have listened to what the consultant said and what was said in the hospital and
tried to just focus on that really rather than on other people’s stories because you have to
be careful of that.’
IB14- ‘And if I am told by the doctors don’t do that I won’t. Because I want to, I would
rather get better.’
IB03 ‘The anaesthetist was lovely. Because I was more afraid of not waking….But em, he
reassured me.’
IB03 – Did not meet the consultant surgeon until the operating day ‘Em I mean he was
nice enough, casual laid back sort of thing. Which is great because to me if they are too
formal you get a bit of a barrier don’t you, you are afraid to ask questions.’
IB03 – ‘A night doctor. And he was really reassuring em and explained to me what had
happened and you have had a rough day and I went yeah. He was lovely.’
IB03 – When complication happened consultant ‘To me the way he explained it in plain
English and I knew what he meant…You know not like in the medical terms.’
IB02 ‘I tried to be sensible. And I think I must have succeeded because Mr X was very
pleased with me.’
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IB02 – ‘Well you know my GP…said it is a nice little hospital you know, they will look
after you well and you will be alright there, that encouraged me.’
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What to tell others
Again, there were no particular themes linked to the surgical route and what participants
would tell other women who are having a hysterectomy, the advice seemed to be more
related to the individual, their experience and circumstances. Advice included practical
advice and ways to prepare themselves.
TAH group
IB17 ‘be prepared for the swollen tummy and to make sure they get some clothes that
would fit.’
IB02 ‘There’s, there’s a lot to it, I mean if a woman is suffering you’ve got the choices.’
‘I don’t think you can prepare anybody mentally for it.’ Talked about how she felt it
would be easier to recover if you were slimmer, she felt the stitches pulled on her skin
due to her being ‘big’.
VH group
IB03 ‘Just listen to what you are being, you know listen to them, they know what they are
talking about basically, they are professionals.’
IB02 – ‘Bring sanitary towels and a good supply of clean pants’.
176
LH group
IB21 ‘Get everything sorted at home….so all you’ve gotta do is when you go into hospital
is think about yourself and think how you are gonna recover after.’
IB13 ‘I think mentally you’ve got to be prepared yourself. I knew that getting rid of
everything would solve half my problems. Well it solved them all….I think it’s down to
the individual.’
177
Discussion
Our study shows that there are very little differences between the recovery expectations
and experiences of women who have a hysterectomy regardless of the rout e of surgery.
The laparoscopic hysterectomy group showed a faster recovery period than the
abdominal hysterectomy group and the vaginal hysterectomy group had specific concerns
around their recovery which were associated mostly with a fear of causing damag e to the
stitches by heavy lifting. There are published data around differences in analgesia use and
hospital stay for laparoscopic versus vaginal hysterectomy (110), our study did not
compare analgesia use, however, our data did not show a clear reduction in hospital stay
for the laparoscopic group.
Otherwise, they all had similar fears around the surgery, hospital stay, concerns about
their responsibilities, attitudes around femininity and loss of fertility and sexual function.
I was surprised at the depth and complexity of some of the comments, there were emotive
and powerful words used such as ‘horrendous’ ‘dirty’, ‘grabbed my life’ , I had not
considered previously to enough extent that heavy menstrual bleeding would have such
an impact. There was significant confusion around recovery expectations and difficulty in
talking about sexual feelings. It made me consider whether as a society we have done
enough yet to reduce the taboo around talking about sexuality and sexual emotions. As
gynaecologists and health care providers, I feel this is somewhere we could improve on
as well. Although this study did not aim to look at it, the role of women in this stage of
their lives was highlighted. Women ha ve so many responsibilities which include looking
after children, wider family members as well as working for a living. The time that most
178
women have a hysterectomy for heavy menstrual bleeding is at their prime, when these
responsibilities are paramount. It was evident that a number of women had struggled with
prioritising their other responsibilities over their own health and put off treatment.
Considering how common heavy menstrual bleeding and hysterectomy at this age is, I do
not think that as a societ y we really appreciate the wider impact these medical problems
have on society; nor do I think after this study, we do enough to support such women in
my opinion.
I had not planned to compare how women felt after they had their ovaries removed versus
conservation of ovaries, hence this data was not collected and the groups were not
balanced in terms of those who had or did not have ovaries removed. The interviews did
note some differences particularly in the expectations and feelings of emotion during
recovery. In addition, I had not included any details or questions around whether or not
women were on hormone replacement during recovery, which again could have affected
emotional and physical recovery. These were limitations of the study; although a number
of women did talk about having their ovaries removed and considering hormonal
treatment.
Previous studies have reported that patients see the main advantage of a hysterectomy
being no bleeding, with some women experiencing no pain or bloating after surg ery.
However only 13% reporting feeling strong, healthy and fit and even less (4.8%)
reporting no social handicaps in terms of their life, job and socially and 16% reported
negative attitudes towards hysterectomy including a feeling of loss and diminished
179
femininity (111, 112) . There may be some cultural differences between the attitudes
women have towards hysterectomy, which we did not explore as part of this stud y. In a
Taiwanese qualitative study, women felt that once they had completed their families, the
uterus was ‘useless’, with five themes: release from stress, inescapable fate, positive
support, hoping for peace of mind and sense of trust as reasons for cho osing the
hysterectomy (113). Whereas, in other cultures, there was evidence of a m ore critical
approach with consideration of the pros and cons of hysterectomy and the transition that
occurs in self (114).
Sexual function after a hysterectomy is reported to improve or remain unchanged by
many women (115-118), but a minority of women report a worse sexual function (118) .
Our study found a positive effect in sexual function regardless of route of surgery, which
concurs with the published literature (119), again we did not take into consideration
whether ovaries were removed or hormone replacement was taken.
It is unclear from the published literature how much women value sexual function after a
hysterectomy over physical symptoms such as pain and bleeding and it may be that health
care professionals are still reluctant to give advice freely as part of a routine consultation
and informed consent procedure about sexual function. Better pre -operative information
about what to expect regarding sexual function after a hysterectomy has been shown to
influence satisfaction with hysterectomy (120). Using the Female Sexual Function Index
and a positive and negative checklist of sexual outcomes, this study showed that pre -
operative education about potential negative sexual outcomes was assoc iated with higher
180
positive scores with hysterectomy experience. For the women who received this
information or asked questions about it in our study, we found there was a more positive
experience after the surgery. Some women did not speak about the sensit ive issue of
sexual expectations or felt uncomfortable when they were mentioned. It is known that
there is an effect of the interviewer on whether such topics are disclosed (121). The fact
that the interviewer here was a female and gynaecology doctor may have had an effect on
the responses from the women and need to be considered throughout this part of the
study, both in a positive and negative way. The interviewer may have felt more
comfortable discussing the sensitive issue of sexual expectations and experiences, but this
may have been uncomfortable for some women, whereas other women may have found it
easier to open up to a gynaecologist. The effect of the interviewer may have been even
deeper with women perhaps wanting to ‘say the right thing’ to a doctor. We have tried to
reduce this risk by structuring the interview with a statement around the personal beliefs
and experiences of each women, and that there are no ‘correct’ answers.
Pre-operative education on other hysterectomy outcomes has been shown to p romote
self-care behaviours, encourages post -operative ambulation and reduces post -operative
anxiety and pain (122).
It is likely that more targeted information which women find useful will help in the fears,
expectations and recovery from all types of hysterectomy. In our study, there were both
positive and negative effects of the wide variety of information available, particularly
from the internet which is not managed or signposted. Specific aids such as websites,
apps or videos, which are centred around women, and can be trusted by women should be
181
developed. Furthermore, we know that there is an association with pre -operative
psychological wellbeing and positive recovery (123), which is affected by various
techniques including information and empowerment. Negative recovery in this study was
associated with a poorer pre -surgical psychological wellbeing state and minor
complications post-operatively.
Confounding the issue of psych ological recovery is confusion and conflicting advice
around the recovery timescales and hospital stay with each route of surgery. We know
that there is variation between the beliefs of health care professionals around recovery
and this may explain the inc onsistent messages women receive. A study of healthcare
professionals and patients the in Netherlands has offered a prediction model of prolonged
recovery at 6 weeks which may help with counselling women about their expectations
(124).
Conclusion
It does not appear that the route of surgery had very much effect on the expectations nor
the actual recovery experience of these patients. The only theme that was related to the
surgical ro ute was a lower length of stay in hospital in the LH group. Women’s
experiences were influenced by the information they receive, their individual perceptions
about the surgery and recovery, the advice from health care professionals.
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Chapter 5: V alidated health status questionnaires to women who have had a
hysterectomy
Aim
To study the quality of life before surgery, at 1 and 4 weeks after hysterectomy and at 3
months after hysterectomy in the qualitative group of participants.
Methodology
Three measures o f quality of life questionnaires were given to all the participants in the
qualitative study from chapter 4 at the four time points. These questionnaires were
suggested by my supervisors early on in the study period. The various questionnaires
were chosen to ensure that there was representation of health status, quality of life and
disease specific measures for menorrhagia. The participants were asked to complete the
questionnaires in their own time and post back to the researcher in a self -addressed
envelope.
Measures
SF12 Questionnaire (appendix 14)
The short form (SF) -12 questionnaire was developed from the longer, well established
SF-36 questionnaire as a shorter, more feasible version to assess health related quality of
life (HRQoL). The SF -36 is one of the most widely used questionnaires for this purpose
and it has been validated ag ainst other questionnaires such as the Nottingham Health
Profile and the sickness impact profile for patients with coronary heart disease (125).
The SF -36 was lengthy with 36 items and took a considerable amount of time to
complete. The SF12 was developed by Ware et al reducing
183
the item number to 12, which was subsequently shown to require about one third of the
time of the SF -36 to complete (126). The SF -12 correlated with summary measures for
the SF-36 in a US general population observational study of chronic conditions and HR -
QoL was shown to correlate with the SF -36 in a study of patients with coronary heart
disease with no dif ference in standardized response means (p<0.001) and the study
concluded that the SF -12 was an efficient alternative to the longer SF -36 (127). The
scores are positively correlated with health related quality of life.
EuroQuol 5D (appendix 15)
The EuroQuol 5D (EQ -5D) (euroquol.org) is a standardised measure of health status
which is non -disease specific and can be applied to a range of health conditions and
treatments. It consists of a descriptive profile covering mobility, self -care, usual
activities, pain and discomfort and anxiety or depression, with a single index value for
health status on the day of completion using a visual analogue scale which is positi vely
correlated with health status . The EQ-5D is designed to be completed by the respondent
for postal survey; it is designed in a way which is cognitively undemanding and takes a
few minutes to complete. The instructions to the respondent are contained within the
questionnaire. The EQ5 was developedand validated in 1990 by the EuroQol group (128).
Menorrhagia Outcomes Questionnaire (Short Form) (Appendix 17)
The Lamping Menorrhagia Outcomes Questionnaire is a disease specific questionnaire
for heavy menstrual bleeding. It was developed to evaluate outcomes of hysterectomy
and other procedures for treating menorrhagia. The questionnaire is validated (129) and
184
arose from a longer research questionnaire used in the North West Thames Hysterectomy
Study(130). It was designed to evaluate clinical, quality of life and patient satisfaction
outcomes 3 months after the procedure by a postal survey.
This questionnaire has 26 items to evaluate patient symptoms (2 items), post -surgical
complications (3 items), quality of life (7 items) and patient satisfaction (5 items). As
well as these disease specific questions, it collects data on demographics and 1 item on
the patients’ global evaluation of their bleeding and or pain in the 4 weeks before surgery.
The 17 items related to patient outcomes are scored to create two summary scales:
The Total Outcome scale (17 items) is an estimation of the patient’s overall outcome,
including clinical and quality of life and satisfaction.
The Quality of Life/Satisfaction scale (12 items) includes items on fatigue, irritability,
depression, general health, improvement in symptoms, limitations in daily activities,
sexual functioning, body image, speed of recovery, satisfaction with i nformation about
the operation and with the results of surgery, and willingness to recommend the operation
to a friend with a similar problem. Scores are positively correlated.
The demographic and treatment related questions along with the global evaluatio n of
symptoms before surgery are descriptive and therefore not scored to form summary
scores.
Analysis of variance (ANOVA) was chosen as the statistical test to compare means of
more than 2 groups. In our case, we had 3 groups and multiple time points. Th e ANOVA
gives an F value as its comparison of means and significance of means is tested using a P
value, where significance is P> 0.05. All statistical analysis was undertaken on IBM
SPSS v-16 © by MS.
185
Health status questionnaire results
EQ5
EQ5 scores increased 1 week after surgery and then fell with time during the recovery
period, being lower at 3 months than pre-surgery (table 5.2). Quality of life on the visual
analogue score was lowest (low score is lower quality of life) 1 week after surgery, and
again improved with recovery with a high score. The mean visual analogue scale (VAS)
score was higher 3 months after surgery as compared to pre surgery; however this was
not significant (table 5.3). Table 5.2 number of women who reported problems in EQ5
domains at each time point.
186
Results
Table 5.1 shows the number of women in each route of hysterectomy group. This sample
was the same as the cohort who participated in the interviews in chapter 4.
187
Table 5.1 Participants
Route of hysterectomy Number of participants
Abdominal 7
Vaginal 4
Laparoscopic 9
Table 5.2
Time
period
% (number) of women with problem
Mobility Self-
care
Usual
activity
Pain/discomfort Anxiety/depression Missing
Pre-
surgery
17%
(5)
10%
(3)
34%
(10)
31%
(9)
24%
(7)
0
1 week 28%
(8)
14%
(4)
52%
(15)
52%
(15)
17%
(5)
41%
(12)
4 weeks 7%
(2)
7%
(2)
24%
(7)
24%
(7)
10%
(3)
52%
(15)
12
weeks
7%
(2)
3%
(1)
3%
(1)
10%
(3)
3%
(1)
59%
(17)
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Table 5.3 mean EQ5 scores at each time point.
Time point Pre surgery 1 week 4 weeks 12 weeks
Mean EQ VAS
(SD)
71.37
(25.07)
47.67
(28.01)
81.15
(22.28)
84.81
(19.60)
189
Table 5. Analysis of variance ( Anova) for mean EQ5 VAS scores according to route of
hysterectomy and time point
F Value Sig
Pre-surgery 0.848 0.446
1 week 0.846 0.447
4 weeks 0.133 0.876
12 weeks 0.164 0.850
190
SF12 Results (Fig 5.1-5.48)
The SF12 results are presented to compare responses to each question by the routes of
hysterectomy at the different time points.
SF12 was analysed by route of hysterectomy at the vario us time points. Due to the small
numbers of participants in each group, statistical analysis was not done. There was
missing data for all time points but the proportion of missing data increased with later
time points after surgery.
In the pre surgery questionnaire, there were very little differences in SF12 responses for
the LH and TAH groups. In SF12 question 4, less patients in the VH group reported that
they were limited in their accomplishments as a result of your physical health in the last 4
weeks and no women in the VH group reported that they had accomplished less as a
Result
of their emotional problems in question 7. The VH group reported less interference
with work due to pain in question 8. The VH group reported feeling cal m and peaceful
more of the time as well as having energy more of the time in questions 9 and 10, and
were the only group who reported no effect on their social functioning as a result of their
health or emotional problems.
At 1 week after surgery, there wa s a reduction in quality of life as a result of physical
health in all groups. Again, the VH group reported fewer limitations as a result of their
emotional health than the TAH or LH groups (questions 6, 7and 9), although 3 of the 4
women in the VH group d id report feeling down in the past few weeks in question 11.
The VH group also reported less interference in activities as a result of pain in question 8.
At 2 months after surgery, the TAH group reported more negative answers in all domains,
including questions 2, 3, 4 and 5 in the physical domain and its effect on activity, as well
191
as in the emotional domain for questions 6 and 7. The TAH group had a greater negative
effect on role in questions 8, 11 and 12, and less vitality in question 10.
At 3 months after surgery, apart from question 2, the only group who reported any
negative answers to any of the domains were the TAH group, although the number of
women who had negative effects on quality of life was small.
192
General health subdomain
Figure 5.1
193
Physical Functioning Subdomain
Figure 5.2
194
Figure 5.3
195
Role Functioning (Physical) Subdomain
Figure 5.4
196
Figure 5.5
197
Role Functioning (Emotional) Subdomain
Figure 5.6
198
Figure 5.7
199
Bodily Pain Subdomain
Figure 5.8
200
Mental Health Subdomain
Figure 5.9
201
Vitality Subdomain
Figure 5.10
202
Mental Health Subdomain
Figure 5.11
203
Social Functioning Subdomain
Figure 5.12
204
Figure 5.13
205
Figure 5.14
206
Figure 5.15
207
Figure 5.16
208
Figure 5.17
209
Figure 5.18
210
Figure 5.19
211
Figure 5.20
212
Figure 5.21
213
Figure 5.22
214
Figure 5.23
215
Figure 5.24
216
Figure 5.25
217
Figure 5.26
218
Figure 5.27
219
Figure 5.28
220
Figure 5.29
221
Figure 5.30
222
Figure 5.31
223
Figure 5.32
224
Figure 5.33
225
Figure 5.34
226
Figure 5.35
227
Figure 5.36
228
Figure 5.37
229
Figure 5.38
230
Figure 5.39
231
Figure 5.40
232
Figure 5.41
233
Figure 5.42
234
Figure 5.43
235
Figure 5.44
236
Figure 5.45
237
Figure 5.46
238
Figure 5.47
239
Figure 5.48
240
Menorrhagia Outcomes Questionnaire (Short Form)
There were unfortunately more that 10% missing scores for this questionnaire. In keeping
with the instructions for analysis, the questionnaire results are not valid for statistical
analysis with more than 10% missing values.
I have analysed the scores onl y to learn the statistical methodology. In order to analyse
the menorrhagia questionnaires, the scores need to be converted around a mean of 0
called a Z score. This is then converted into a T score which is the Z score multiplied by
10 plus 50 so that the re is a mean around 50. A standard deviation of the T score is then
60. The T and Z scores are useful to compare means across organisations or populations
and are the standard way of presenting this data. If the T score of a population is above
50 then that population is above average. The results have not been taken into account for
this questionnaire in this study , hence are not to be used in any interpretation . Tables 5.5
and 5 .6 show the total outcome and quality of life/satisfaction scores in Z and sco res.
There was no significant difference in the change of global quality of life score before
and after surgery according to route of surgery (table 5.7), or in the total outcome score at
3 months (table 5.8).
241
Table 5.5
Total Outcome scale scores
Participant Route Mean Z score Mean T score (z
x10) +50
1 TAH Missing
2 VH 2.235 72.35
3 VH Missing
4 TAH 1.823 68.23
5 TAH 1.588 65.88
6 LH 1.353 63.53
7 LH 1.176 61.76
8 TAH 1.118 61.18
9 VH Missing
10 TAH 1.235 62.35
11 LH Missing
12 LH 1.235 62.35
13 LH 1.471 64.71
14 VH 0.765 57.65
15 LH Missing
16 VH Missing
17 TAH Missing
18 TAH Missing
19 LH 1.118 61.18
20 LH 0.941 59.41
242
Table 5.6
Quality of Life/Satisfaction scale scores
Participant Route Mean Z score Mean T score (z
x10) +50
1 TAH Missing
2 VH 2.583 75.83
3 VH Missing
4 TAH 2.583 75.83
5 TAH 2.083 70.83
6 LH 1.583 65.83
7 LH 1.417 64.17
8 TAH 1.5 65
9 VH Missing
10 TAH 1.75 67.50
11 LH Missing
12 LH 1.583 65.83
13 LH 2.083 70.83
14 VH 1.083 60.83
15 LH Missing
16 VH Missing
17 TAH Missing
18 TAH Missing
19 LH 1.083 60.83
20 LH 1.0 60
243
Table 5.7
ANOVA of mean change in global evaluation of symptoms before and after surgery in
route of surgery categories.
F Value Sig
Global evaluation 0.500 0.622
Table 5.8
ANOVA for mean T scores by route of surgery
Summary outcome F Value Sig
Total outcome scale 0.531 0.605
Quality of Life/Satisfaction
scale
1.227 0.338
244
Discussion
The EQ5 questionnaire showed an improvement in health statusfor all groups 3 months
after surgery as compared to before surgery. This is to be expected as we would expect
the negative affect of heavy menstruation to have been relieved by the hysterectomy,
regardless of route.
From the SF12, the VH gro up seemed to have a better quality of life pre surgery both in
the physical and emotional domains. After surgery, again the VH group reported better
quality of life particularly in the emotional domain. This may be because the ovaries are
not usually removed as part of a VH route, whereas they are more often removed during
the TAH and LH routes. We would expect that removal of the ovaries would have a
negative effect on emotional wellbeing due to menopausal symptoms. After surgery, the
TAH group had a lower quality of life at both 2 and 3 months. This may have been due to
prolonged recovery from the larger abdominal incision. However, this study did not
account for the reason for abdominal surgery which may have had an effect on the SF12
responses, such as co–morbidities requiring an abdominal approach like obesity, previous
abdominal surgery or large fibroid uteri. Co -morbidities may have prolonged recovery as
an independent factor to route of surgery.
We did not find a significant difference in the total o utcome scores or global evaluation
before surgery and at 3 months by the Menorrhagia Outcomes Questionnaire, however,
this questionnaire was limited in its analysis due to the proportion of missing values,
making it an unreliable result, and for this reaso n, it has been omitted from the
conclusions. The missing scores may have been due to the long length of this
245
questionnaire and that it was last in the questionnaire pack. By using mean Z-score rather
than total Z -scores, the effect of missing data items ca n be minimised, however, this is
based on 10% or less missing data, this study had more than 10% missing data.
This study was also limited by the small numbers in each of the groups, as well as the
missing data from incomplete or lack of questionnaire res ponses at different time points.
It may have been that only those who were recovered well enough completed the
questionnaires, or conversely, those who were recovered had returned to normal activities
and were too busy to complete the questionnaires. Missi ng values have been reported in
the literature such as the validity study for HR-QoL (127), who reported a high number of
missing values which was similar to an Australian study validating the SF -12 in a heart
and stroke population of 22%. They reported a higher chance of incomplete
questionnaires from females, older people, those who were less educated and those
patients who had stayed in hospital longer or were admitted as an emergency. Moreover,
there was a higher rate of missing values in the health concepts role -emotional and role-
physical items, which was also similar for the SF -36 (131). The instructions for the
Menorrhagia questionnaire were for use with a much older version of SPSS.
Unfortunately, I could not access anyone who could give me upda ted advice and the
author had passed away. I therefore had a protracted analysis where I had to learn how to
change scores into T and Z scores using statistical methodology. Due to the time lapse
between analysing the questionnaire data and collecting the data, there was no
opportunity to collect the missing data from participants. In addition, the ethical approval
did not cover gaining missing data so long after the study (see chapter 8). In addition,
there were a large number of questionnaire items which the participants may have felt
246
was onerous to complete. The Menorrhagia questionnaire was last in the pack and this
may be why it had the most missing values.
Missing data in health status and quality of life questionnaires is a known problem. The
validity study for HR -QoL (127) reported a high number of missing values which was
similar to an Australian study validating the SF -12 in a heart and stroke populat ion of
22%. They reported a higher chance of incomplete questionnaires from females, older
people, those who were less educated and those patients who had stayed in hospital
longer or were admitted as an emergency. Moreover, there was a higher rate of miss ing
values in the health concepts role -emotional and role -physical items, which was also
similar for the SF-36 (127, 131).
247
Conclusion
By the EQ5 and SF12 questionnaires, t he VH group had least effect o n quality of life by
heavy menstrual bleeding pre-surgery and by the surgery post-surgery, particularly in the
emotional domain. Quality of life was reported as lowest for the TA H group at 2 and 3
months post-surgery.
248
Chapter 6
Anxiety and surgery; A validated questionnaire survey to women who had a
hysterectomy
Mechanisms that affect recovery
There are a range of mechanisms by which psychological variables could affect recov ery
after surgery. Variables which have been found to influence the outcome of surgery
include emotional states (fear, depression, stress, a sense of hopelessness), personality
traits (trait anxiety, locus of control, coping), and physiological parameters (132). This
chapter studies the anxiety levels in the women undergoing the three routes of
hysterectomy.
Anxiety
Surgery is associated with significant patient anxiety (86, 133, 134) and behavioural
changes which have been shown to have an effect on recovery (135, 136). It is known
that the majority of pa tients who have been admitted for elective surgery experience pre -
operative anxiety. This is greater in day case patients, particularly in women. Negative
emotions such as anxiety can enhance pain sensations (137), There have been differing
associations of level of anxiety and post-operative recovery. In some studies, low as well
as high levels of anxiety have been found to lead to worse recovery outcomes, with
medium levels o f anxiety being associated with the best recovery (138). Other studies
249
have found a linear relationship with low anxiety associated with a better recovery (132).
All pre-operative anxiety has been found to predict the level of post -operative pain (87).
The State Trait Anxiety Inventory (STAI) is a validated questionnaire to measure anxiety
in adults. It distinguishes between the temporary condition of ‘state anxiety’ and the more
general and longstanding quality of ‘trait anxiet y’ and depression (139). Anxiety
measured by the STAI in patients who had a l aparoscopy for pelvic pain correlated with
the length of time patients felt they were completely cured and free of complaints
independently of the laparoscopy findings (140). A longitudinal study of the impact of
anxiety and depression on pain experi ence over time after major gynaecological surgery
found that pre -operative anxiety was predictive of anxiety on day 2 after surgery.
Moreover, it reported anxiety levels on day 4 in one third of patients reaching psychiatric
proportions (141). Levels of pre-operative psychological morbidity are found to be higher
in women who have a hysterectomy as compared to the general population (142, 143).
Initially, it was shown that there were negative associations between anxiety levels and
endocrine changes in surgical patients (144), however in a more recent study, a
preparatory video showing realistic asp ects of the perioperative period prior to cardiac
surgery did reduce blood cortisol, ACTH, prolactin and noradrenaline levels (145).
Reducing anxiety has been defined as one of the principles of conducting a pre -
anaesthetic consultation (146).
Personality variables of denial, fear and aggressiveness have been shown to be associated
with recovery and responses to pre -operative preparations (147). For example, a high
250
mortality rate has been shown in patients who were depressed before cardi ac surgery
(148). Stress has been linked to the slower healing of wounds through
psychoneuroimmunological mechanisms (88).
251
The STAI (Stait Trait Anxiety) questionnaire (appendix 16)
The stait trait anxiety questionnaire (STAI) is used to measure anxiety. There are three
forms of the questionnaire, X , Y and STAI children. The STAI X was the original
questionnaire to measure anxiety in adults and the current updated version is the STAI Y.
The STAI children is used to measure anxiety in children. The STAI Y requires at sixth
grade reading level and contai ns four -point Likert scales, the scales are positively
correlated with anxiety scored from 20 to 80. The higher the score, the greater the anxiety
(139). The questionnaire is divided into two parts, each with 20 questions. Each part
looks at two types of anxiety; state (S) and trait (T) anxiety and the overall anxiety level.
It is estimated that 10 minutes is required for an adult to complete the questionnaire. It
helps researchers to distinguish between the feelings of transient anxiety from depression
(149). Some questions are reverse scored because they test for the absence of anxiety.
Responses for the S-Anxiety scale assess intensity of current feelings with answer options
of not at all, somewhat, mo derately so and very much so. The T -Anxiety score is that of
general feelings with answer options of almost never, sometimes, often and almost
always. Higher scores mean more anxiety and they are used to compare anxiety trends at
various time points for th e same population or to compare different populations. STAI
does not measure overall anxiety.
Validity
The STAI has been shown to have construct validity against other assessments of anxiety,
such as between Panic Disorder and right-hemisphere brain over activation (150), and the
252
STAI-trait and STAI -state correlated with the Anxiety Sensitivity Index (151) and with
the Conjugate Lateral Eye Movement Test (152).
Concurrent validity with other scales that measure anxiety has been demonstrated with
the Anxiety Scale Questionnaire (ASQ) (153) and Manifest Anxiety Scales (MAS) (154).
Reliability
The test -retest reliability has been demonstrated using 29 male undergraduate students
two weeks before and after a stressful social analogue situation (155) . The state anxiety
increased but the trait remained constant. This correlated with the STAI scores of 0.54
and 0.40 for state and 0.86 and 0.86 for trait.
Feasibility
The STAI is inexpensive and can be used in a multitude of scenarios including research,
psychometric testing such as interviews and clinical scenarios. It can be administered on
mass and has less questions than other measures of anxiety (ASQ has 40 questions and
the MAS has 50). Although the STAI has been adapted into 48 languages, we only used it
for English readers due to financial constraints of translation.
Aim
To study anxiety before a hysterectomy and at 1 month and 3 months of recovery after
surgery.
Methodology
The STAI questionnaire was given to the qualitative hysterectomy group at the interview
before surgery, one week after surgery and then 3 months after surgery. The STAI was in
paper form marked with the participant trial number and handed to the participant to
253
complete in their own time. A self-addressed envelope was provided for the participant to
post the completed questionnaire back.
The data from the questionnaire was inputted manually into a Statistical Package for
Social Sciences, version 16.0 (SPSS, Inc., Chicago, Illinois, USA.) database and analysed
for mean STAI for the state and trait sections at each time point. Due to missing data, we
were not able to compare the mean STAI for participants at each time frame. Analysis
was done using analysis of variance (ANOVA) as the stati stical test in order to measure
the means of more than 2 groups or time points. The ANOVA gives a real effect
comparison means of the groups as a F value and the significance is tested and presented
as a P value; where a P>0.05 is statistically significant.
254
Results
Demographics
The study group comprised of the qualitative group. They were all women who were
having a hysterectomy for benign gynaecology problems via the abdominal, vaginal or
laparoscopic routes.
Table 6.1: Demographics
Route of hysterectomy Number of participants
Abdominal 7
Vaginal 4
Laparoscopic 9
The mean (table 6.2) STAI -state score pre -operatively was 40 (SD 13.53) and mean
STAI-trait score was 41.5 (SD 11.76). At one week after surgery, the mean STAI state
score was 45.6 (SD 14.9) and the mean STAI -trait was 42.7 (SD 13.0). At 3 months after
surgery, the mean STAI-state score had fallen to 31.1 (SD 10.7) and the mean STAI -trait
was 32.7 (SD 11.8).
255
Table 6.2: Mean STAI scores at time points
Time point Mean STAI-state (SD) Mean STAI-trait (SD)
Pre-surgery 40 (13.53) 41.5 (11.76)
1 week post-surgery 45.6 (14.9) 42.7 (13.0)
3 months post-surgery 30.1 (10.7) 32.7 (11.8)
STAI versus route at the different time points
Anxiety levels using STAI were compared by route of hysterectomy using a one way
between groups analysis of variance (ANOVA). Where a significant difference using a
value of 0.05 was seen, multiple comparisons of means after post hoc tests using Welsh
and Brown-Forsythe were used to identify where the difference among the groups lay.
Pre-operative STAI versus route of hysterectomy
Pre-operatively, there was very little difference in the state anxiety scores according to
route of hysterectomy. Question 6 showed a small significance towards the TAH group of
0.375 and question 12 towards the LH group at 0.217. In the trait questions, pre -
operatively there was more anxiety in the LH group in questions 22 at 0.17, question 28
at 0.301 and question 30 at 0.125. The VH had significant values for quest ions 29 at
0.244 and question 32 at 0.182. At 1 week post operation, the state values did not show
any trends between groups apart from the VH group, where there were no significantly
increased state values apart from question 1 at 0.22. Table 6.3 shows the significant stait
values at 1 week post operation.
256
Table 6.3: Significant ANOVA by question and route of hysterectomy for STAIT anxiety
1 week post operation.
Question number ANOVA value Route of hysterectomy
where mean was higher
1 0.22 VH
3 0.242 LH
4 0.062 TAH
5 0.285 LH
6 0.058 TAH
7 0.418 TAH & LH
8 0.136 LH
9 0.023 LH
11 0.392 LH
12 0.484 TAH
13 0.345 LH
14 0.220 LH
17 0.172 LH
18 0.274 LH
20 0.335 TAH
257
Again trait anxiety did not show any trends 1 week post operation wit h route of
hysterectomy (table 6.4) apart from the VH group, who again did not show increased
anxiety in any questions to a significant value.
258
Table 6.4: Significant ANOVA by question and route of hysterectomy for trait anxiety 1
week post operation.
Question number ANOVA value Route of hysterectomy
where mean was higher
21 0.87 TAH
23 0.231 TAH
24 0.345 TAH
25 0.482 TAH AND LAH
26 0.454 LH
27 0.391 LH
28 0.260 TAH
31 0.454 TAH
32 0.371 LH
33 0.417 LH
34 0.193 LH
35 0.294 TAH
36 0.481 LH
38 0.345 LH
39 0.229 LH
40 0.442 TAH
259
At 3 months after hysterectomy, the TAH group showed significantly more anxiety in
both the state and trait questions (table 6.5), particularly in question 19 (I feel steady),
were the significant value was 0.003.
Table 6.5: Significant ANOVA by question and route of hysterectomy for state and trait
anxiety 3 months post operation.
Question number ANOVA value Route of hysterectomy
where mean was higher
STATE ANXIETY
3 0.166 TAH
4 0.145 VH
6 0.228 TAH
8 0.225 TAH
10 0.112 TAH
11 0.315 TAH
12 0.132 TAH
14 0.132 TAH
15 0.012 TAH
16 0.166 TAH
17 0.44 TAH
18 0.228 TAH
19 0.003 TAH
20 0.219 TAH
260
TRAIT ANXIETY
Question number ANOVA value Route of hysterectomy
where mean was higher
22 0.010 TAH
24 0.302 TAH
26 0.494 TAH
28 0.228 TAH
29 0.020 TAH
30 0.494 TAH
31 0.166 TAH
32 0.029 TAH
33 0.382 TAH
34 0.209 TAH
35 0.366 TAH
36 0.191 TAH
37 0.59 TAH
39 0.31 TAH
40 0.283 TAH
261
Discussion
The STAI is positively correlated so the higher the score the more anxiety. In this study,
we found that for both the state and trait sections, the mean scores fell at 3 months post -
surgery from the pre -operative period. The state score was higher in the w eek after
surgery, which is to be expected, although the background trait scores were not changed
much in the week after surgery. Our study aligns with the published literature where the
state anxiety becomes lower as recovery from surgery is achieved (156).
We saw that the total abdominal hysterectomy group had significantly higher stait and
trait anxiety scores 3 months after surgery than then the vaginal or laparoscopic
hysterectomy groups. There is no simple explanation to this and it may be associated with
the increased morbidity associated with an incision through the abdominal wall and
recovery from reduced core strength as a result. This could lead to longer recovery such
as mobility and pain relief. It may have been that women consider an abdominal route as
a more serious or bigger operation due to the visual association with a large scar on the
abdomen. In my experience, women do worry about a large abdominal scar more than
laparoscopic small incisions.
We know as many as 60% of patients undergoing surgery are anxious (157), and females
and depressed patients in pain are particularly susceptible (86). Anxiety is attributed to
uncertainty such as the thought of the unknown, severe pain, n ausea and vomiting or
imminent death as well lack of information (86, 158) . The previous experience and
personality has been shown to influence the style of coping with major life events such as
surgery (159).
262
Trait and existential anxiety are more resistant to psychological interventions such as
information giving or cognitive therapies (160), however procedure specific interventions
have been shown to be influenced by psychological interventions (161).
There are limitations to this study because of the missing data due to which we were not
able to follow each patient through to compare their anxiety scores at each time point.
The percentage of patients where there was missing data was 40% at 3 months, and for
this reason, no conclusions have been formed using the statistical analysis from this part
of the data . In thi s study, we did not study personality types, which we know influence
anxiety and coping mechanisms, however, there were not great differences in the STAI
scores between patients which may suggest differing personality types. The small
numbers in this study is an additional limiting factor, especially to compare the STAI
scores at each time point for the differing routes of surgery.
For this part of the study, we did not perform a power calculation to assess the number
required to show statistical differences in the study question, as it was designed to gain an
understanding of anxiety for the qualitative interview group only.
The pre -operative questionnaires were not taken at a specific time point, so some
participants may have had longer to wait for their surgery and this study cannot assess
whether there is a difference in anxiety scores compared to how close the participant was
to having surgery or how long they have waited on the waiting list. Waiting for surgery
has been shown to be a major stressor (162). The STAI scores are not adjusted for co -
morbidity and we did not take into account the socio-demographics of the participants, all
of which may have influenced the scores (163).
263
Conclusion
The results from this part of the study show that STAI anxiety scores are increased in the
period before surgery and in the immediate post -operative period, but that they drop in
the recovery period after a hysterectomy. When a hysterectomy is p erformed by the
abdominal route, the anxiety scores are higher at 3 months post-surgery as compared with
vaginal or laparoscopic routes.
264
Systematic Review Chapter 7
Psychological Preparation for Recovery from Gynaecological Surgery
Background
There is good evidence that how people think and feel before surgery affects their
recovery, such as anxiety and pain (164, 165) . Negative emotions enhance pain
sensations (137), cognitions and emotions influence behaviour such as return to normal
activities and higher levels of stress are linked to poorer wound healing (88). Analysis of
psychological preparation before surgery in a systematic review by Johnson in 1993
(166) showed that a benefit for negative affect, pain, analgesia use, length of hospital
stay, behavioural recovery, physiological indices and patient satisfaction. Interest in
improving recovery from surgery has continued since this review and more so w ith the
attempt to optimize recovery programmes for maximum efficiency and positive patient
experience. The economic benefits of shorter hospital stays and a quicker return to
normal activity and return to work and also become important outcomes to study r ather
than immediate post-operative outcomes alone.
This systematic review took place once the rest of the studies were completed to inform
us to the types of psychological interventions which can be used to improve them. It will
then form part of a larger Cochrane Systematic Review on The effects of psycho logical
preparation in all elective surgery. For this reason, I will follow the same methodology as
submitted to Cochrane (167). This methodology has had input from all the authors of this
review, however, I have carried out the gynaecology part of the review for this higher
degree independently with supervision from the first author of the Cochr ane Review (Dr
265
R Powell), who was also my MD supervisor. The methods section in this report has been
derived from parts of the submitted Cochrane Protocol (167) appendix 18 with
permission from the authors and under guidan ce from the first author Dr R Powell. This
is to maintain consistency in this systematic review with the larger Cochrane review.
In the real life pragmatic situation, hospital statistics report that women who have
undergone a vaginal hysterectomy, with no abdominal incisions, have an average post -
operative stay of 3.2 days in England (6), which is longer than the laparoscopic approach
and not much different to the stay after the abdominal route despite evidence for a shorter
stay for vaginal and laparoscopic routes (48) . This may indicate that in strictly controlled
experimental designs clinicians are potentially achieving optimum care efficiency
through their beliefs about therapy and through the inadvertent psychological preparation
of all patients. This could be in the form of stringent consent procedu res with increased
access to support mechanisms and follow up. It may be that patients’ and health care
professionals’ beliefs and expectations of recovery play a more significant part in what
actually occurs outside clinical trial settings. Aspects of thi s could be amenable to
psychological intervention to improve recovery outcomes.
Psychological preparation incorporates a range of strategies designed to influence how a
person feels, thinks or acts (emotions, cognitions or behaviours). The benefits of
psychological preparation for surgery have been evaluated in a meta -analysis (166). It
identified many different types of psychological preparation, including procedural
information, sensation information, behavioural instruction, hypnotic and relaxation
training, psychotherapeutic interventions and cognitive behavioural approaches. They
266
were found to be beneficial for a range of outcome variables such as negative affect, pain,
and p ain medication, length of hospital stay, behavioural recovery, clinical recovery,
physiological indices and satisfaction.
Information giving
Patients give high importance to the information given to them by health care
professionals over other sources. It influences behaviours such as when to return to
normal activity and the degree of analgesia use (166). However, there is much variance
in the beliefs and practices of health care professionals in the advice they give to patients
(132). Information giving to patients pre -operatively can be categorised into sensory,
procedural and behavioural. Sensory information describes the experience for example,
what it will feel like and an y other relevant sensations (e.g. taste, smell). Behavioural
instruction consists of telling patients what they should do to facilitate either the
procedure or their recovery from the procedure. For example, instructions about post -
operative breathing exer cises to help prevent respiratory infections. Procedural
information describes the process that the patient will undergo i.e. what will happen,
when it will happen and how it will happen. As a result patients should be more aware of
what to expect which will result in reduced anxiety with reduced pain sensations
(137).
Women undergoing elective gynaecology laparoscopy who were given procedural
information about the su rgery had significantly less analgesic requirements and reported
a more rapid return to full health (132, 137) . In addition, stress has been linked to the
slower healing of wounds through psychoneuroimmunological mechanisms (138) and
267
reducing anxiety has been defined as one of the principles of conducting a pre-anaesthetic
consultation (87). Although pre -operative information is available, consideration should
be given to including those categories of information which improve recovery.
Relaxation
Relaxation techniques can be used before surgery to reduce tension and anxiety. These
include progressive muscle relaxation (where each muscle group is tensed and then
relaxed), simple relaxation (each muscle group is r elaxed in turn), breathing techniques
(e.g. practice of diaphragmatic breathing) and guided imagery (e.g. imagining a pleasant,
relaxing environment). A mixture of relaxation training and sensory and procedural
information giving was used as a pre -operative preparation for patients undergoing a
cholecystectomy. The group who received this preparation reported less pain and higher
levels of activity (87).
Cognitive therapy
Cognitive interventions aim to change how an individual thinks, especially about
negative aspects of the procedure. Information seeking is more common in people who
have an internal locus of control. The locus of control is a psychologi cal term referring to
the extent to which individuals believe they control events that affect them. People can
have a perceived internal or external locus of control. People with external locus of
control will believe strongly in other people, fate and in their destiny, whereas someone
with a strong internal locus of control will believe that they have the ability to influence
their own future. Those with an internal locus of control benefit from knowing more
268
information and are able to reduce their anxiet y levels about forthcoming surgery,
whereas the same information may increase the anxiety levels of someone with an
external locus of control as they may rather not know the details (168). A randomised
trial of procedural information, cognitive coping techniques and general ward
information given to pa tients who had a hysterectomy showed that cognitive coping had
the most effect on recovery (140).
Hypnosis
Hypnosis can be defined as when ‘one person (the subject) is guided by another (the
hypnotist) to respond to suggestions for changes in subjective experience, alterations in
perception, sensation, emotion, thought or behaviour’ (144). Hypnosis may be seen to act
either as a cognitive or a relaxation intervention. There is now evidence from a meta -
analytical review that hypnosis positively affects immune function and may work through
psychoneuroimmunological mechanisms (138).
Emotion-focussed Intervention
Emotion-focussed intervention aims to reduce the nega tive emotions that are predictive
of negative post-surgical outcome. The patient’s coping tendency has also been studied in
relation to the information patients need. People can cope with situations through mainly
problem focused strategies or emotion focu sed strategies. Those who use problem
focused strategies make plans to improve the situation and feel better when these are
followed through. Emotion focused individuals tend to alter their own cognitive
269
interpretation of the situation rather than change i t, for example, ‘looking at the bright
side’ (145).
270
Objectives
To explore the effects of psychological preparation on recovery outcomes after a
hysterectomy. This systematic re view will update the previous meta -analysis (167) and
focus on hysterectomy.
Search Methods
The search included the Cochrane Central Register of Controlled Trials
(cantra) (The Cochrane Library, latest Issue); Medline
(Ovid SP) (1950 to date); Embase (Ovid SP) (1982 to date);
PsycINFO (Ovid SP) (1982 to date); Cinhal (EBSCOhost)
(1980 to date) and Amed (Ovid SP) (1982 to date). The literature search was performed
by MS. The following free text keywords were used:
Search Terms
Hysterectomy
Each psychological preparation term (’psychological preparat*’, education, information,
instruction, cognitive interven*, ’cognitive behavio?ral therapy’, ’cognitive therapy’,
’behavio*ral therapy’, hypnosis, relaxation, guided imagery) AND 1
ALL psychological preparations (link with OR) AND 1
271
Recovery
4 AND 3
No limitations were applied for year of publication, study design or language and
translations were obtained for articles not in English. The reference lists and citations of
included papers were also searched for additional sources. The literat ure search was
completed in 2010. A total of x citations were obtained (figure 1). The full text articles
were assessed for eligibility by their abstracts. Full text was sourced if the abstract was
for a randomized controlled trial.
272
Methods
Selection criteria
Any randomised controlled trial that:
1. uses random or quasi-random allocation and appropriate follow up;
2. compares the positions listed under objectives.
Types of participants
Women undergoing any gynaecological surgical procedure under a general anaesthetic.
Types of Intervention
Outcome measures
Primary outcome measures
1. Postoperative pain
1a. Postoperative pain intensity using the following hierarchy:
i) the pre-specified pain outcome (if given);
ii) a visual analogue scale, from 0 to 100 (or 0 to 10);
iii) McGill Pain Questionnaire (MPQ) intensity rating, Present Pain Intensity;
iv) other MPQ ratings i) Pain Rating Index (weighted or unweighted),
273
ii) Number of Words Counted;
v) other pain intensity scale.
Secondary Outcome measures
1. Negative affect: post intervention and postoperative
2. Resource use
a. Length of stay, in hospital, in post anaesthesia care unit.
b. Postsurgical analgesia use: proportion of patients requiring an
unplanned analgesia intervention in the post anaesthesia care unit,
within 24 hours, at any time in hospital, after discharge.
3. Behavioural recovery (defined as: resumption of performance of tasks and
activities).
Data collection and analysis
Data was collected straight onto Review Manager 5.1. We considered the population,
intervention details and their timing, number of intervention groups, the control group
intervention, adherence to intervention, attrition rate and loss to follow up. For each study
and intervention, we collected data on the study’s primary and secondary recovery
outcome measures. Quality of studies was assessed using the CONSORT tool looking for
data collection, patient enrolment and randomization techniques, sample definiti on,
274
baseline matching of groups, blinding, outcome assessment, follow up and a priori power
calculations.
Each article was assessed by two assessors (MS and MD , a research fellow on Prof JKG
team 2009) and any uncertainty was resolved by discussion with JKG. Analysis was done
using Review Manager 5.1 using a confidence interval (CI) of 95% and significance P
value of below 0.05. Forest plots were used to show pooled effects.
Measures of treatment effect
Dichotomous data
For dichotomous data, we present results as summary risk ratio with 95% confidence
intervals.
Continuous data
For continuous data, we used the mean difference if outcomes are measured in the same
way between trials. We used the standardised mean difference to combine trials that
measure the same outcome, but using different methods.
Unit of analysis issues
Dealing with missing data
For included studies, levels of attrition were noted. The impact of including studies with
high levels of missing data in the overall assessment of treatm ent effect were explored
using sensitivity analysis.
275
For all outcomes analyses were carried out, as far as possible, on an intention -to-treat
basis, i.e. we attempted to include all participants randomised to each group in the
analyses. The denominator for each outcome in each trial was the number randomised
minus any participants whose outcomes are known to be missing.
Assessment of heterogeneity
We used the Chi² statistic to measure heterogeneity among the trials in each analysis. We
regarded the level of heterogeneity as substantial if it was above 50%.
Data synthesis
We carried out statistical analysis using the Review Manager software ( RevMan 2008).
We used fixed-effect inverse variance meta-analysis for combining data where trials were
examining the same intervention, and the trials’ populations and methods were judged
sufficiently similar. Where we suspected clinical or methodological heterogeneity
between studies sufficient to suggest that treatment effects may have differed between
trials we used random-effects meta-analysis.
Publication bias
Publication bias was considered as per the Cochrane Handbook section 8.4.5. This is the
systematic difference between reported and non -reported findings. Those studies which
show a significant difference between the intervention and control are more likely to have
been published than non -significant findings. The Cochrane handbook refers to this type
as bias as substantial.
276
Results
of search
Figure 7.1 Process from initial search to final inclusion for psychological preparation in
gynaecology surgery.
Articles excluded n= 18
- not psychological preparation/incorrect population n= 13
- reviews/ letters/ comments/ editorials n= 1
- Paper/translation unobtainable n= 0
- duplications n= 3
- NOT RCTs of intervention n=3
Primary articles included in systematic review n= 18
Number of women n= 1240
Potentially relevant citations identified from electronic searches to capture
primary articles on psychological preparation for gynaecology surgery
N 161
References
excluded after screening titles and/ or abstracts
n= 124
277
Description of studies
A total of 21 abstracts were eligible. One paper was written in Chinese and translated by
TT. After reviewing the potential papers, 3 were not included in the review as they were
not randomized trials of psychological preparation ( Melzack 1996, Mogan 1985, Moon
1984). The remaining 18 papers were included in the review. All included studies
compared psychological preparations in a randomized controlled trial. Recovery
outcomes were assessed in all trials.
Included studies
There were 18 studies included in this review (Table 7.1). Two of these studies had more
than one psycological preparation method and so were analysed as separate studies
(Laurion GI 2003 and Laurion MU 2003, Nilsson 2001 M&T and Nilsson 2001 Music ).
A total of 1240 women were included in the studies.
278
Table 7.1 Characteristics of included studies
Study Participants Intervention Description of
intervention
Outcomes
Andrzejowski
1996
36 patients ASA grade I
or II for TAH
Acupressure and
acupuncture
At the pericardium 6
point on both wrists
Post-
operative
nausea and
vomiting
Block 1991
109 intervention group,
100 control. Operations
on the fallopian tubes,
total abdominal
hysterectomy, vertical
banding gastroplasty,
cholecystectomy, and
ovarian cystectomy or
myomectomy from
University of Iowa
Hospital and Clinics
Therapeutic
positive
suggestions tape
6 minutes female voice at
a deliberate rate of
speech. Positive
suggestions about
recovery.
Length of
stay, opiod
use, pain,
urine, flatus,
bowel
function and
STAI
Cheung 2003
48 in intervention and
48 in control. Chinese
women who spoke
Cantonese who were
having an elective
abdominal
hysterectomy
Information
booklet with
cognitive
intervention
Cognitive distraction and
reappraisal (Lazarus
1984)
Post-
operative
anxiety, pain,
analgesia use,
patient
satisfaction.
Dudley 2002
42 women having
hysterectomy in a
private clinic in
Virginia. 19 had
massage, 22 controls.
Massage therapy 30 minutes Sweedish
massage from a female
therapist
Length of
stay,
analgesia use
Evans 1998 Total abdominal
hysterectomy patients
at St Thomas’ Hospital
London. 19 in
intervention group, 20
controls.
Positive
suggestion tape
Positive suggestions
under general anaesthetic
Pain, nausea,
defecation
and
flatulence,
length of
stay,
mobilisation
Heye 2002 70 elective
hysterectomy patients
35 in each arm
Foster pain
intervention
24 minute videotape of a
nurse showing breathing
and movement skills with
four post -operative
mobility activities to
improve self-efficacy.
Pain
Laourion GI
2003
Convenience sample of
84 women having
gynaecology
laparoscopic surgery
Guided imagery Listened to Health
Journeys for People
Undergoing Surgery by
Naparstek under general
anaesthesia
Post-
operative
nausea and
vomiting and
pain
Laurion MU Convenience sample of Audiotape of Post-
279
2003 84 women having
gynaecology
laparoscopic surgery
piano music Listened to piano music
with earphones under
general anaesthetic
operative
nausea and
vomiting and
pain
Lobb 1984 30 women Women in
Cleburne Texas fall of
1981 and winter 1982
undergoing
hysterectomy
Relaxation
training and
desensitization
Pre and postoperative.
Desensitization for
surgical trauma included
post-operative stimuli
Length of
post-
operative
hospital stay
Maroof 1997 50 elective
hysterectomy patients
Positive intra -
operative
suggestion tape
Male voice speaking in
the patient 's dialect 15
minutes via headphones
under GA suggesting they
would experience no
sickness.
Emetic
episodes
Nilsson 2001
M&T
90 women ASA I -II
elective hysterectomy
Music with
therapeutic
suggestions
Music - Relaxing and
calming music with sea
waves. Therapeutic
suggestions-Relaxing and
encouraging suggestions
in a male voice by a
person with extensive
experience in
hypnotherapy
Pain, post-
operative
nausea and
vomiting,
bowel
function,
fatigue,
length of
stay, well -
being
Nilsson 2001
Music
90 women A SA I -II
elective hysterectomy
Music alone Music - Relaxing and
calming music with sea
waves.
Pain, post -
operative
nausea
vomiting,
bowel
function,
fatigue,
length of
stay, well -
being
Oetker- Black
2003
108 h ysterectomy
patients Midwest
Teaching Hospital
Self-efficacy
enhancing
teaching
programme
Pre-operative instruction
on mobility, turning, deep
breathing, pain reduction
through relaxation.
Pain on VAS,
SAI,
ambulation,
day 1, length
of stay
Study Participants Intervention Description of
intervention
Outcomes
Perri 1979 26 women for elective
vaginal hysterectomy
Progressive
muscle
relaxation
Two 90 minute individual
sessions pre -operatively
(Bernstein and Borkovec)
Pain
Poolsawal
2003
90 patients for TAH for
cancer Bankok
Universuty Hospital
Relaxation
training
Benson's Respiratory One
Method
Technique
Anxiety by
HADS
280
19/11/1999-29/02/2000
Ridgeway
1982
60 St Georges Hospital
London women
admitted for elective
hysterectomy (10 in
each group)
Information
about surgery,
Cognitive coping
technique
Information - procedural
and sensations
Cognitive coping -
Positive control of how to
view events
Pain, waking
frequency,
nausea,
analgesia use,
mood scale
Taylor 1998 62 p atients having
elective abdominal
hysterectomy
Music Music of their choice on
headphones played in last
30 minutes of surgery and
first hour post op vs
headphones alone.
VAS pain
score,
Graphic pain
intensity
score
Vitale 2006 22 Elective
hysterectomy (10 in
experimental group)
Reiki 3 Reiki Nursing
Interventions 30 minutes
each at timed intervals at
day 1, 24hours and 48
hours post -operation.
Standard Reiki hand
positions, implemented
for hand placement
consistency and each
hand placement was for 3
minutes. Reiki by expert
Reiki Practitioners
minimum level III,
supervised by m aster
Reiki registered nurse.
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Data analyses results
A total of 1240 women were included in all studies. There were 9 studies which assessed
the effect of psychological preparations on pain using a visual analogue score (VAS) and
they did not find a statistically significant effect 0.78 (1.04, -0.52 figure 7.2). Analgesia
requirements by morphine dose was ass essed in 6 studies. I t did not find a significant
pooled effect for the psychological interventions -3.31 (-5.41, -1.22 figure 7.3). Nilsson
2001 compared time to walking, wellbeing at day 1 and fatigue for patients who listened
to music alone and those w ho listened to music with therapeutic solution as compared to
no intervention and did not find any statistically significant difference -0.20 (-5.85, 5.46
figure 7.4), -0.55 ( -1.01, -0.09 figure 7.5) and 0.41 ( -0.78, -0.04 figure 7.6)
respectively. Anx iety as measured by the Stait Anxiety Questionnaire (STAI) was
assessed in two studies ; Vitale 2006 and Block 1991 (figure 7.7). This showed a
significant difference for trait anxiety which was higher in patients who had not had the
psychological intervention [ P <0.00001, mean difference 7.78 (7.19, 10.61) ]. Post-
operative nausea and vomiting was studied in 4 studies. Again, no statistically significant
difference was found in the pooled effect -0.06 (-0.49, 0.38 figure 7.7). Length of hospital
stay post operation was assessed in 4 studies. (figure 7.8). Of all the psychological
preparation techniques, positive suggestion under a general anaesthesia in the Evans 1988
paper was the only one which had a statistically significant effect. It reduced len gth of
post-operative hospital stay -31.00 (-48.35, -13.65), however, this is an older paper and
the mean length of stay was much longer than the newer studies. Pooled length of stay for
the 4 studies was reduced in the group who had any psychological inte rvention [P 0.03,
5.65 (-10 82 to -0.48)].
282
Risk of bias
Figure 7.10 shows the risk of bias as assessed by the criteria of random sequence
generation, allocation concealment, blinding of participants and researchers, blinding of
outcome, incomplete outcome data and selective reporting. Red indicates high risk of bias
and green indicates low risk. Yellow is where the risk was unclear although there was
Reference
to the risk, in some instances, there was no mention of the risk being assessed
so these were left blank. On the whole, there was mainly high or unclear risk of bias
283
Figure 7.2
Pain at 24 hours measured by visual analogue scale
Study or Subgroup
Block 1991
Cheung 2003
Evans 1988
Laurion GI 2003
Laurion MU 2003
Nilsson 2001 M&T
Nilsson 2001 Music
Oetker-Black 2003
Ridgeway 1982
Taylor Music 1998
Vitale 2006
Total (95% CI)
Heterogeneity: Chi² = 25.61, df = 7 (P = 0.0006); I² = 73%
Test for overall effect: Z = 4.21 (P < 0.0001)
Mean
3.7
0
2.4
1.5
1.1
2.3
1.8
0
16.9
5.83
3.8
SD
0.5
0
2
1.5
1.1
1.2
0.7
0
0
1.63
2.4
Total
15
0
19
28
28
28
29
0
20
20
10
197
Mean
3.6
0
2.7
2.4
2.4
2.7
2.7
0
17.4
5.83
5.4
SD
0.4
0
2.5
1.6
1.6
0.8
0.8
0
0
1.9
1.4
Total
17
0
20
28
28
27
27
0
0
20
12
179
Weight
39.9%
2.0%
6.1%
7.7%
13.9%
25.7%
3.3%
1.4%
100.0%
IV, Fixed, 95% CI
0.10 [-0.22, 0.42]
Not estimable
-0.30 [-1.72, 1.12]
-0.90 [-1.71, -0.09]
-1.30 [-2.02, -0.58]
-0.40 [-0.94, 0.14]
-0.90 [-1.29, -0.51]
Not estimable
Not estimable
0.00 [-1.10, 1.10]
-1.60 [-3.29, 0.09]
-0.43 [-0.63, -0.23]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
284
Figure 7.3
Pain measured by morphine use in mg
Study or Subgroup
Andrzejowski 1996
Block 1991
Dudley 2002
Laurion GI 2003
Laurion MU 2003
Nilsson 2001 M&T
Nilsson 2001 Music
Vitale 2006
Total (95% CI)
Heterogeneity: Chi² = 7.05, df = 7 (P = 0.42); I² = 1%
Test for overall effect: Z = 3.10 (P = 0.002)
Mean
54
41
21.4
9.6
7
26.5
22.2
6
SD
26.6
5
28.7
9.4
7.7
17.7
13.5
13
Total
18
15
19
28
28
28
29
10
175
Mean
55.6
44
25.9
9.8
9.8
32.8
32.8
17
SD
29.7
5
28.6
8.2
8.2
17.1
17.1
15
Total
18
17
21
28
28
27
27
12
178
Weight
1.3%
36.4%
1.4%
20.6%
25.3%
5.2%
6.7%
3.2%
100.0%
IV, Fixed, 95% CI
-1.60 [-20.02, 16.82]
-3.00 [-6.47, 0.47]
-4.50 [-22.28, 13.28]
-0.20 [-4.82, 4.42]
-2.80 [-6.97, 1.37]
-6.30 [-15.50, 2.90]
-10.60 [-18.71, -2.49]
-11.00 [-22.70, 0.70]
-3.31 [-5.41, -1.22]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
285
Figure 7.4
Behavioural recovery: time to walking
Study or Subgroup
Nilsson 2001 M&T
Nilsson 2001 Music
Total (95% CI)
Heterogeneity: Chi² = 0.65, df = 1 (P = 0.42); I² = 0%
Test for overall effect: Z = 0.07 (P = 0.95)
Mean
32.8
28.1
SD
12.4
16.3
Total
24
23
47
Mean
31
31
SD
12.7
12.7
Total
20
20
40
Weight
57.5%
42.5%
100.0%
IV, Fixed, 95% CI
1.80 [-5.66, 9.26]
-2.90 [-11.58, 5.78]
-0.20 [-5.85, 5.46]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
286
Figure 7.5
Behavioural recovery: wellbeing day 1 post surgery
Study or Subgroup
Nilsson 2001 M&T
Nilsson 2001 Music
Total (95% CI)
Heterogeneity: Chi² = 0.41, df = 1 (P = 0.52); I² = 0%
Test for overall effect: Z = 2.36 (P = 0.02)
Mean
2.1
1.8
SD
1
0.9
Total
30
30
60
Mean
2.5
2.5
SD
1.5
1.5
Total
28
28
56
Weight
48.6%
51.4%
100.0%
IV, Fixed, 95% CI
-0.40 [-1.06, 0.26]
-0.70 [-1.34, -0.06]
-0.55 [-1.01, -0.09]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
287
Figure 7.6
Behavioural recovery: fatigue day 1
Study or Subgroup
Nilsson 2001 M&T
Nilsson 2001 Music
Total (95% CI)
Heterogeneity: Chi² = 0.60, df = 1 (P = 0.44); I² = 0%
Test for overall effect: Z = 2.20 (P = 0.03)
Mean
3.8
3.5
SD
0.9
1.4
Total
30
30
60
Mean
4.1
4.1
SD
0.9
0.9
Total
28
28
56
Weight
62.8%
37.2%
100.0%
IV, Fixed, 95% CI
-0.30 [-0.76, 0.16]
-0.60 [-1.20, 0.00]
-0.41 [-0.78, -0.04]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
288
Figure 7.7
Negative affect: STAI Trait questionnaire
Study or Subgroup
Vitale 2006
Block 1991
Total (95% CI)
Heterogeneity: Chi² = 29.39, df = 1 (P < 0.00001); I² = 97%
Test for overall effect: Z = 9.17 (P < 0.00001)
Mean
27
43.8
SD
7.05
2.6
Total
10
15
25
Mean
38
34.9
SD
9.64
2.3
Total
12
17
29
Weight
5.7%
94.3%
100.0%
IV, Fixed, 95% CI
-11.00 [-17.99, -4.01]
8.90 [7.19, 10.61]
7.78 [6.11, 9.44]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
289
Figure 7.8
Negative affect: nausea and vomiting day 1
Study or Subgroup
Maroof 1997
Nilsson 2001 M&T
Nilsson 2001 Music
Ridgeway 1982
Total (95% CI)
Heterogeneity: Chi² = 0.46, df = 1 (P = 0.50); I² = 0%
Test for overall effect: Z = 0.25 (P = 0.80)
Mean
1.7
2.1
1.8
0
SD
1.2
1.1
1
0
Total
25
30
30
0
85
Mean
3.1
2
2
0
SD
1.2
1.3
1.3
0
Total
0
28
28
0
56
Weight
48.2%
51.8%
100.0%
IV, Fixed, 95% CI
Not estimable
0.10 [-0.52, 0.72]
-0.20 [-0.80, 0.40]
Not estimable
-0.06 [-0.49, 0.38]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
290
Figure 7.9
Length of stay
Study or Subgroup
Block 1991
Dudley 2002
Evans 1988
Lobb 1984
Oetker-Black 2003
Total (95% CI)
Heterogeneity: Chi² = 11.61, df = 3 (P = 0.009); I² = 74%
Test for overall effect: Z = 2.14 (P = 0.03)
Mean
122
46
170
100
0
SD
9.6
15
24
43.2
0
Total
15
19
19
10
0
63
Mean
122
55
201
112
0
SD
9.6
17
31
15.8
0
Total
17
21
20
1034
0
1092
Weight
60.2%
27.2%
8.9%
3.7%
100.0%
IV, Fixed, 95% CI
0.00 [-6.67, 6.67]
-9.00 [-18.92, 0.92]
-31.00 [-48.35, -13.65]
-12.00 [-38.79, 14.79]
Not estimable
-5.65 [-10.82, -0.48]
Experimental Control Mean Difference Mean Difference
IV, Fixed, 95% CI
-100 -50 0 50 100
Favours experimental Favours control
291
Figure 7.10
Risk of bias summary for
included studies
292
Figure 7.11 Funnel plot Pain
293
Figure 7.12
Funnel plot morphine use in mg
294
Figure 7.13
Funnel plot Time to walking
295
Figure 1.14
Funnel plot Wellbeing day 1
296
Figure 7.15
Funnel plot nausea and vomiting day 1
297
Figure 7.16
Funnel plot Fatigue day 1
298
Figure 17
Funnel plot STAI Trait
299
Figure 7.18
Funnel plot length of stay
300
Discussion
The concept of psychological interventions to improve recovery from hysterectomy was
debated as far back as 1982 when Valerie Ridgway published her research on cognitive
coping and suggested that this was an explanation for the variation in recovery after
surgery (91). In our review however, there was much heterogeneity among studies in
their definition and type of the interventions which makes the comparisons challenging,
however we did see that p sychological interventions could reduce the length of stay after
surgery, particularly suggestion under general anaesthesia as well as trait anxiety. We
rated the quality of most of the evidence for outcomes as ‘low’ and due to the unclear or
high risk of bias of rep orting. This is similar to other reviews of psychological
preparation for surgery (169, 170) . Although we know that psychological states affect
recovery from surgery (105, 171) and that interventions focussed at these could improve
recovery, we need more robust trials to be able to answer the question of which
interventions are effective. Furthermore, there is a variety of recovery outcomes which
were not always presented using robust measures which could be compared in the
analysis and what a favourable outcome might be to clinicians and patients. This review
was undertaken as part of early work towards a larger review, where the authors came to
similar conclusions about psychological interventions from all surgery involving a
general anaesthetic (172). Recovery has many components including measurable clinical
aspects such as vi tal observations, normalising of test parameters, the use of analgesia,
return of physiological function such as passing urine or opening their bowels, number of
days as an inpatient and mobility. From the perspective of the patient, a favourable
outcome m ay be more related to important aspects of their lives such as being able to
301
sleep normally, looking after their families, socialising, feeling emotionally back to
normal or being able to go back to work. There is evidence where psychological
interventions have been shown to improve health and recovery such as from ischaemic
heart disease (173) where a systematic review of intensive relaxation therapy improved
physical recovery such as resting heart rate and exercise tolerance. Psychological
interventions are used as established therapy in many areas of health and w ellbeing such
as with psychotherapy and behavioural medicine where they have been shown to be cost
effective (174). It is likely therefore that there is some merit in psychological
interventions to enhance recovery outcomes.
Conclusion
From this review, psychological interventions such as suggestion under general anaesthetic
could reduce length of stay; and could reduce trait anxiety. Due to the variation between
interventions however, higher quality evidence is needed in order to answer the question of
which psychological interventions work and which recovery outcomes are best affected.
302
Chapter 8: Discussion
Overview of findings
We were not able to find any difference in the time women returned to work according to
their employment status or incapacity benefit type. From this study, we have found that
there is a great deal of variation in the beliefs of UK gynaecologists regarding recovery
from laparoscopic, vaginal and abdominal hysterectomy, particularly in longer term
return to normal activities once discharged from hospital. The difference was not
explained by geography; however there was some explanation by experience and grade of
specialist. This is likely due to the building of personal experience with patients.
Moreover, this variation of advice was seen in the gynaecology nursing staff at
Birmingham Women’s’ Hospital. Health care professionals reported that their advice was
based on personal beliefs rather than on national or local evidence based guidelines such
as NICE. This study on variation in the beliefs of healthcare professionals highlights the
importance of understanding actual recovery experiences of women who have undergone
hysterectomies from each of the surgical routes.
My study of the experiences of women who have had a hysterectomy highlighted that
regardless of route of surgery, the expectations and fears of women were similar before
surgery such as difficulti es making sense of the large amounts of information available,
the influence of friends and family who have previously had this surgery as well as their
own experiences of previous surgery. It is important to remember that women who have a
hysterectomy are likely to have responsibility of dependent children, and the cohort in
this study talked about the concerns they had around childcare and the practical
303
arrangements they had made. Women had tried to improve their health in order to
enhance their recovery and one woman talked about taking time off work and potentially
losing her job. Fears before surgery included the effect on emotions, although some
women felt that the hysterectomy would be a positive influence on their emotions. This
part of the study confirmed how women required guidance from health care professionals
about when to resume activities such as sexual intercourse. Women talked about a variety
of ways to prepare for t heir recovery and some set goals before surgery. The surgical
route of hyste rectomy appeared to be governed by their surgeons and the need to gain
further advice on whether to have their ovaries removed or not. Before surgery, there was
confusion with conflicting advice about length of stay, again correlating with the health
care professionals’ variation in beliefs. Women talked about listening to their own bodies
and interpreted pain as a marker to stop the activity associated with this feeling.
Addressing expectations and concerns before surgery is important as this study has
demonstrated that anxiety levels are increased.
After surgery, there were specific concerns in the group who had had a vaginal
hysterectomy around pain in sitting and opening their bowels, which is expected due the
fact that the incision is in the vagina close to the rectum and perineum.
The laparoscopic hysterectomy group did experience a lower length of stay; however, the
actual recovery milestones were more associated with the individual rather than the
surgical route in general. Women who had an abdomina l hysterectomy had higher
anxiety scores and lower quality of life scores at 3 months than the laparoscopic and
vaginal group. The vaginal hysterectomy group reported the highest quality of life scores
after surgery. Most participants did not drive until a fter 6 weeks, and in general the
304
recovery experience was better than women had expected, particularly in relation to
sexual recovery and effect on their quality of life, again regardless of route of surgery.
This study concurred with the published literat ure on the strong influence of healthcare
professionals in the recovery period.
When considering what psychological interventions may be useful to enhanc e recovery
from hysterectomy, this systematic review concluded that there was variation in
interventions, making comparison s as a whole a challenge , as well as using differing
outcome measures. It may be more useful to compare similar interventions such as music
therapy or relaxation therapy on the same outcome.
Impact for future studies and practice
This study adds to the understanding of recovery from hysterectomy. In particular, it
highlights the variation in advice women receive from their health care professionals, and
the gap in evidence based guidance for recovery outcomes.
It raises the question of developing guidelines for both healthcare professionals and
patients to help with realistic expectations of recovery from hysterectomy and what may
alter it. Furthermore, it shows that despite research showing that recovery is faster from
less invasive surgical approaches, the beliefs and behaviours of both patients and
healthcare professionals do not reflect this. Guidance would support confidence in
enhanced recovery particularly for laparoscopic and vaginal hysterectomy routes.
305
This study highlights the importance of influencing healthcare using a more holistic bio
psychosocial model, paying attention to the ideas, expectations and concerns of women
who have a hysterectomy in order to enhance their recovery and reduce levels of a nxiety.
More patient focussed ways of providing information, addressing concerns and building
confidence are required which address multiple aspects of recovery should be developed
and tested in trials, such as using electronic media, online patient and fa mily resources
such as videos accessible whenever the patient requires them, virtual support networks
and virtual consulting with health care professionals. This will help us to both understand
and support longer term recovery better once the patient has b een discharged from the
hospital.
With limited NHS resources, it is important to empower patients with the tools they
require to aid their own recovery. Further qualitative studies will help us to understand
which recovery outcomes are valued most by wome n recovering from hysterectomy and
how we can work to improve these outcomes.
Reflective critical analysis and learning points
It has taken 8 years to complete this MD which has posed a number of problems,
particularly at the write up stage. The study itse lf was completed within 2 years while I
was in a clinical lecturer post; however the analysis and write up was delayed. This was
due to a number of factors which were disclosed to the University including being
appointed to my first consultant post; for wh ich I requested a one year break in order to
focus on my new role. Subsequently, I experienced a number of major personal issues
which were life changing and I took a break from the MD in order to focus on my
306
personal life. It has taken 3 years to get back into a position to find balance to come back
to my MD. Once I did come back to my MD, I found that I had to re -learn the data and
re-familiarise myself with the literature as well as those chapters I had already written.
Furthermore in this time one of my supervisors moved jobs to Manchester, this made
supervision with her challenging as I was not able to meet with her. My primary
supervisor advised me to continue with him. Once I re -organised my work, I found that I
needed to update my literature search. Unfortunately, in the time which had passed. Even
though my search was saved online, the National Electronic Library for Health database
had been wiped and all saved searched were lost. Therefore, I had to re -run the search
again using the saved search ter ms in 2015. By this time, my librarian advised me to run
the search on the individual databases rather than the collection National library due to
some unreliability in the system. Once the search was completed, again I had to start the
process of collecti ng new abstracts, reviewing the literature for new publications and
applying it to my work, in some cases, having to re -write chapters as a result. Upon
reflection, this process was like starting my MD over again and I had not appreciated the
amount of wo rk and time it would take. With time, the literature around enhanced
recovery had moved on, particularly in gynaecology oncology. Although there were
cohort studies of total abdominal hysterectomy showing reduced length of stay without
an increase in readm ission rates or post -operative complications (11), (175), (176). In
2016, Lena Wijk (11) suggested that outcomes from gynaecology oncology could be
extrapolated to benign gynaecology recovery. Further studies of enhance d recovery in
gynaecology have focused on ovarian cancer such as early re -feeding to improve bowel
function and nutritional status with ERAS guidelines published for gynaecology
307
oncology (12). In benign gynaecology, there have been published studies showing
reduced length of stay, increased cost effectiveness and decreased nursing time in
prolapse and vaginal hysterectomy su rgery with ER protocols (177, 178). Future studies
in ER are now looking at protein loading rather than carbohydrate loading to reduce
length of stay and infection rates after colorectal surgery (179).Once I had updated
myself on the literature, was able to continue with analysing my data. Unfortunately, I
found that I had missing data on the returned postal quality of life questionnaires, and
there was no plan applied for as part of my ethics application to contact participants for
this. The missing data was significant in some questi onnaires and in particular, for the
Menorrhagia Outcomes Disease Specific Questionnaire. Due to the fact that there was
over 10% missing data, the analysis was not reliable according to the instructing
handbook. In order to learn the statistical methodolog y of analysing the questionnaire, in
particular how to deal with Z and T scores, I decided to run the analysis but to disregard
the results. I am pleased that I persevered with this approach as I now have a greater
understanding of this statistical methodo logy which I can use in future analyses and to
understand research which has used these methods. From analysis of my qualitative data,
particularly the quality of life questionnaires, I have learnt that it is important to check
data during the study and to check and run the analyses as you go along to pick up any
data problems early. If I had done this while I was running the study, I could have applied
for an amendment to the ethics application to obtain the missing data. I feel that this was
a missed opportunity which has greatly affected the quality of my study. As a result, any
evaluation programme or audit I have lead since, I have designed it to capture data
308
electronically from the outset with mechanisms to alert me to incomplete data or analysis
problems.
Reading and analysing the qualitative interviews also took much longer than I had
anticipated. In order to really understand the interviews, it was important to read them
multiple times and then think about what the participants had talked about, bef ore being
able to code them into themes. I have realised that the main part of the work for a
qualitative study is in fact in the analysis of the interviews. This was different to other
research I had been involved in where the collection of data or runnin g of the trial or
experiments took most of the time. In the future, I would plan my time differently and
start to familiarise myself and start to analyse the interviews at the same time as
conducting them in order understand them better, and to keep the li nk with the rest of the
study. When I have come across qualitative studies since, I have found people using a
concurrent analysis approach to direct future interviews. On reflection, I also think that I
conducted too many interviews so I was left with a hu ge amount of data. It would have
been a better idea to either run focus groups with the 3 routes of hysterectomy
participants or to select a sample of 2 or 3 women in each hysterectomy route to speak to
at the different time points. The multiple time point s was interesting to track and
understand the evolution of recovery, however again, it left me with a great deal of data.
It may have been more useful to choose a time point after surgery to interview and use
quality of life questionnaires at the other time points alone.
If I were planning this study again, I would think more carefully at the quality of life
questionnaires I used. There are other more relevant questionnaires that I may have
chosen such as the Hospital and Anxiety Depression Score instead o f the STAI. More of
309
the literature I came across had used the HADS score, so it would have been more useful
to compare my findings with other published studies. Thinking from the participant
perspective and in order to understand why there was missing data, I think that there were
too many questionnaires. The EQ5 was easier to complete and gave a good impression of
overall quality of life. I feel that the SF12 and Menorrhagia Outcomes study overlapped
in outcome measures to an extent. In the future, I would stick with the SF12 or updated
similar questionnaire for measures of functioning. I think that the volume of questions
contributed to the missing data as I found that some participants had returned the
questionnaires half completed particularly the Menorrhagia outcomes one.
I have however learnt a great deal by using all these questionnaires in how to code them
and analyse them as well as how to present their results and draw conclusions. With this
study, the aim of using the questionnaires was to triangulate the interview findings; hence
a power calculation was not carried out for rigour of statistical analysis. Now that I am
familiar with the methodology of administration and analysis of these questionnaires, I
feel that I would know how to use them in larger studies if required where I could ensure
the study was powered enough to answer the question.
I have also learnt how to conduct a systematic review using software such as RevMan,
how to critically analyse the literature and how to interpret and pre sent the results in
forest plots. Since starting my MD, I have successfully co -authored a Cochrane
systematic review and a National Guideline as a result of the skills I have learnt during
this MD. Other software I am now familiar and confident in using is SPSS and reference
management software, which I now use as a matter of routine in many aspects of my
work, such as writing reports which require references, conducting literature reviews to
310
inform my clinical practice and evaluating services and therapies using statistical
analyses.
311
Conclusion
Individual psychological wellbeing and any post -operative complications have the most
significant effect on recovery and programmes should be developed to target recovery outcomes
by enhancing education, empowerment and a more positive psychological state. In order to
reduce confusion, there should be a consensus amongst health care workers of recovery
expectations and when to predict variations from normal recovery.
312
Reference
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