Preoperative quality of life at time of gynecologic surgery: considerations for postoperative management.

Survey results were analyzed from 154 participants: 102 with benign conditions and 52 with endometrial cancer. Response rates varied between surveys, including demographics (n=154), global health (n=139), perceived stress (n=131), gastrointestinal health (n=125 for gas and bloating and n=112 for diarrhea, respectively), sexual health characteristics (n=114), as well as vaginal and vulvar symptoms (n=102). Demographic differences between patients with benign and cancerous conditions are presented in Table 1 . The mean age was significantly greater in women with cancer (60.06 years) than in women with benign conditions (45.07 years; P <.0001). Average BMI was significantly higher in patients with endometrial cancer (39.57 kg/m 2 ) than in patients with benign conditions (30.06 kg/m 2 ; P <.0001), even after adjusting for age as a continuous variable ( P <.0001). The benign group had a significantly greater income ( P =.0001), were more likely to have a history of CPP ( P =.0005) and were more often premenopausal ( P <.0001), when compared with the endometrial cancer group. Table 1 The association of demographics with disease status Table 1 Demographic All (n=154) Benign (n=102) EMC (n=52) P value Age, mean (SD) 50.13 (12.54) 45.07 (9.70) 60.06 (11.55) <.0001 Race  American Indian/Alaskan 13 (8.44) 5 (4.90) 8 (15.38) .01  Asian/Far East/South East 4 (2.60) 4 (3.92) 0 (0.00)  Asian/Indian 0 (0.00) 0 (0.00) 0 (0.00)  Native Hawaiian/Pacific Islander 1 (0.65) 0 (0.00) 1 (1.92)  White 110 (71.43) 74 (72.55) 36 (69.23)  Black or African American 12 (7.79) 11 (1078) 1 (1.92)  Middle Eastern/North African 1 (0.65) 0 (0.00) 1 (1.92)  Mixed or multiracial 9 (5.84) 7 (6.86) 2 (3.85)  Not specified, other 4 (2.60) 1 (0.98) 3 (5.77) Ethnicity  Non-Hispanic 115 (74.68) 72 (70.59) 43 (82.69) .10  Hispanic 39 (25.32) 30 (29.41) 9 (17.31) Education (n=151)  Less than high school 6 (3.97) 3 (2.94) 3 (6.12) .73  High school diploma or GED 31 (20.53) 20 (19.61) 11 (22.45)  Some college 36 (23.84) 23 (22.55) 13 (26.53)  Associate degree/technical certification 32 (21.19) 21 (20.59) 11 (22.45)  Bachelor's degree 29 (19.21) 22 (21.57) 7 (14.29)  Master/doctoral degree 17 (11.26) 13 ((12.75) 4 (8.16) Income ($) (n=144)  <10,000 8 (5.56) 3 (3.13) 5 (10.42) .0004  10,000–25,000 17 (11.81) 10 (10.42) 7 (14.58)  25,000–50,000 31 (21.53) 12 (12.50) 19 (39.58)  50,000–75,000 30 (20.83) 23 (23.96) 7 (14.58)  75,000–100,000 15 (10.42) 14 (14.58) 1 (2.08)  >100,000 27 (18.75) 23 (23.96) 4 (8.33)  Do not know/refused 16 (11.11) 11 (11.46) 5 (10.42) pH, n (%)  ≤4.5 91 (59.09) 77 (75.49) 14 (26.92) 4.5 63 (40.91) 25 (24.51) 38 (73.08) BMI (mean [SD]) 33.27 (9.72) 30.06 (7.23) 39.57 (10.89) <.0001 BMI  <25 28 (18.18) 23 (22.55) 5 (9.62) <.0001  25–29 43 (27.92) 38 (37.25) 5 (9.62)  30–34 27 (17.53) 18 (17.650) 9 (17.31)  ≥35 56 (36.36) 23 (22.55) 33 (63.46) Menopausal status  Premenopausal 102 (66.23) 88 (86.27) 10 (19.23) <.0001  Postmenopausal 52 (33.77) 14 (13.73) 42 (80.77) BMI , body mass index; EMC , endometrial cancer; SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. The association of demographics with disease status BMI , body mass index; EMC , endometrial cancer; SD , standard deviation. There was often more than 1 benign preoperative indication for hysterectomy recorded in the medical records. The most common benign reason for hysterectomy was irregular bleeding (43.3%), followed by pelvic pain and dysmenorrhea (23.17%), enlarged uterus and fibroids (22.68%), pelvic organ prolapse (5.15%), other causes (3.09%), and cancer prophylaxis (2.06%). Postoperative diagnoses included fibroids (34.5%), adenomyosis (23.6%), other (23.6%), endometriosis (10.8%), endometrial hyperplasia/dysplasia (5.4%), abnormal uterine bleeding not otherwise specified (0.9%), BRCA positive status (0.5%), and pelvic organ prolapse (0.5%). When comparing global health T-scores in univariate analysis, there were no significant differences in mental health, general health, and social activity between benign and cancerous conditions ( Table 2 ), although the benign group had a greater but not significantly different score. The physical health score for the benign group was marginally significantly greater than that of the cancer group ( P =.05). There were no significant differences in these T-scores in univariate analysis related to menopausal status. Table 2 The association of the global health (T-score) with disease status Table 2 All (n=139) Benign (n=90) EMC (n=49) P value Physical health Mean (SD) 43.69 (8.06) 44.63 (8.44) 41.96 (7.06) .05 Median 44.20 44.30 41.60 Mental health Mean (SD) 48.89 (7.88) 49.72 (8.10) 47.36 (7.30) .17 Median 48.80 49.80 46.70 General health Mean (SD) 3.19 (0.94) 3.28 (0.91) 3.04 (0.99) .12 Median 3.00 3.00 3.00 Carry out social activities Mean (SD) 3.72 (0.93) 3.82 (0.93) 3.54 (0.92) .10 Median 4.00 4.00 4.00 EMC , endometrial cancer; SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. The association of the global health (T-score) with disease status EMC , endometrial cancer; SD , standard deviation. There were no differences in self-reported overall stress ( Table 3 ) between the 2 groups. When evaluating individual stress symptoms, the cancer group felt less able to control the important things in their lives ( P =.02) and became upset from unexpected events more often ( P =.04) compared with the benign group. Perceived stress did not differ by menopausal status ( P =.47). Table 3 Association of PSS-10 T-score with disease status Table 3 All (n=131) Benign (n=86) EMC (n=45) P value Mean (SD) 52.66 (8.68) 50.63 (8.81) 52.64 (8.15) .05 Median 51.00 49.00 53.00 EMC , endometrial cancer; PSS-10 , Perceived Stress Scale; SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Association of PSS-10 T-score with disease status EMC , endometrial cancer; PSS-10 , Perceived Stress Scale; SD , standard deviation. Gastrointestinal, vulvar and vaginal symptoms, and sexual function were explored in these groups. In univariate analysis diarrhea T-scores did not significantly differ between the benign and cancer groups overall, or by menopausal status or postsurgery diagnosis in benign patients ( Table 4 , Table 5 , Table 6 ). However, individual symptoms did differ between groups; patients with cancer more often felt the need to empty their bowels ( P =.04) and were more bothered by loose stools ( P =.02) but had less gastrointestinal gas and bloating ( P =.001) than patients with benign conditions ( Table 7 , Table 8 ). Table 4 Association of gastrointestinal diarrhea T-score with disease status Table 4 All (n=112) Benign (n=80) EMC (n=32) P value Mean (SD) 47.98 (7.93) 47.13 (7.03) 50.05 (9.65) .29 Median 44.40 44.40 52.25 EMC , endometrial cancer; SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Table 5 Association of gastrointestinal diarrhea T-score with menopausal status in benign patients Table 5 All (n=80) Premenopausal (n=69) Postmenopausal (n=11) P value Mean (SD) 47.13 (7.03) 46.43 (7.61) 47.24 (6.98) .70 Median 44.40 44.40 44.40 SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Table 6 Association of gastrointestinal diarrhea score with postoperative diagnosis in benign patients Table 6 Postoperative diagnosis n Mean (SD) P value Abnormal uterine bleeding Yes 1 39.90 .25 No 79 47.22 (7.02) Endometriosis Yes 12 45.70 (5.61) .59 No 68 47.38 (7.26) Adenomyosis Yes 28 47.22 (6.51) .91 No 52 47.08 (7.35) Fibroids Yes 48 46.02 (6.70) .12 No 32 48.81 (7.28) SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Table 7 Association of gastrointestinal gas and bloating T-score with disease status Table 7 All (n=125) Benign (n=84) EMC (n=41) P value Mean (SD) 56.29 (9.43) 58.35 (8.67) 52.07 (9.61) .001 Median 56.90 58.90 52.20 EMC , endometrial cancer; SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Table 8 Association of gastrointestinal gas and bloating T-score with menopause status in benign patients Table 8 All (n=84) Premenopause (n=72) Postmenopause (n=12) P value Mean (SD) 58.35 (8.67) 59.23 (7.99) 53.11 (10.95) .04 Median 58.90 59.45 55.30 SD , standard deviation. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Association of gastrointestinal diarrhea T-score with disease status EMC , endometrial cancer; SD , standard deviation. Association of gastrointestinal diarrhea T-score with menopausal status in benign patients SD , standard deviation. Association of gastrointestinal diarrhea score with postoperative diagnosis in benign patients SD , standard deviation. Association of gastrointestinal gas and bloating T-score with disease status EMC , endometrial cancer; SD , standard deviation. Association of gastrointestinal gas and bloating T-score with menopause status in benign patients SD , standard deviation. Sexual health characteristics significantly differed between the disease groups ( Table 9 ). Patients with benign conditions had more sexual activity ( P <.0001), sexual activity interest ( P <.0001), and desire ( P <.0001) than patients with endometrial cancer. In benign patients who were sexually active, there was significantly more dyspareunia than in patients with cancer ( P =.045), although they had higher sexual satisfaction T-score than patients with cancer ( P =.006). Table 9 Association of sexual function characteristics with disease status Table 9 All (n=114) Benign (n=80) EMC (n=34) P value Sexual activity interest (past 30 d)  Not at all 42 (38.53) 17 (22.08) 25 (78.13) <.0001  A little bit 20 (18.35) 16 (20.78) 4 (12.50)  Somewhat 26 (23.65) 25 (32.47) 1 (3.13)  Quite a bit 13 (11.93) 12 (15.58) 1 (3.13)  Very 8 (7.34) 7 (9.09) 1 (3.13) Want to have sexual activity (past 30 d)  Never 24 (22.64) 9 (11.69) 15 (51.72) .0001  Rarely 27 (25.47) 21 (27.27) 6 (20.69)  Sometimes 32 (30.19) 26 (33.77) 6 (20.69)  Often 21 (19.81) 20 (25.97) 1 (3.45)  Always 2 (1.89) 1 (1.30) 1 (3.45) Any sexual activity (past 30 d)  Yes 57 (56.44) 52 (72.22) 5 (17.24) <.0001  No 44 (43.56) 20 (27.78) 24 (82.76) If NO to sexual activity in past 30 d Reasons for no sexual activity (past 30 d)  No interest in sexual activity 21 (47.73) 10 (50.00) 11 (45.83) .99  Vagina dryness or pain 4 (9.09) 4 (0.00) 0 (0.00) .03  Difficulties with orgasm 2 (4.55) 1 (5.00) 1 (4.17) .99  Not enjoy sexual activity 1 (2.27) 0 (0.00) 1 (4.17) .99  No partner 13 (29.55) 2 10.00) 11 (45.83) .02  Partner was away 5 (11.36) 4 (20.00) 1 (4.17) .16  Partner was not interested in sexual activity 3 (6.82) 1 (5.00) 2 (8.33) .99 If YES to sexual activity in past 30 d Lubricated during sexual activity  Almost always 25 (45.45) 22 (44.00) 3 (60.00) .76  Most times 12 (21.82) 10 (20.00) 2 (40.00)  Sometimes 10 (18.18) 10 (20.00) 0 (0.00)  A few times 5 (9.09) 5 (10.00) 0 (0.00)  Almost never 3 (5.45) 3 (6.00) 0 (0.00) Difficult to maintain lubrication  Extremely difficult 0 (0.00) 0 (0.00) 0 (0.00) .17  Very difficult 5 (9.09) 5 (10.00) 0 (0.00)  Difficult 5 (9.09) 5 (10.00) 0 (0.00)  Slightly difficult 19 (34.55) 19 (38.00) 0 (0.00)  Not difficult 26 (47.27) 21 (42.00) 5 (100.00) Discomfort felt inside your vagina  None 17 (32.08) 14 (29.17) 3 (60.00) .50  A little bit 12 (22.64) 10 (20.83) 2 (40.00)  Some 7 (13.21) 7 (14.58) 0 (0.00)  Quite a bit 10 (18.87) 10 (20.83) 0 (0.00)  A lot 7 (13.21) 7 (14.58) 0 (0.00) Pain felt inside your vagina  None 19 (35.85) 14 (29.17) 5 (100.00) .08  A little bit 12 (22.64) 12 (25.00) 0 (0.00)  Some 9 (16.98) 9 (18.75) 0 (0.00)  Quite a bit 8 (15.09) 8 (16.67) 0 (0.00)  A lot 5 (9.43) 5 (10.42) 0 (0.00) Discomfort in your labia  None 38 (71.70) 33 (68.75) 5 (100.00) .82  A little bit 7 (13.21) 7 (14.58) 0 (0.00)  Some 4 (7.55) 4 (8.33) 0 (0.00)  Quite a bit 3 (5.66) 3 (6.25) 0 (0.00)  A lot 1 (1.89) 1 (2.08) 0 (0.00) Discomfort in your clitoris  None 38 (71.70) 33 (68.75) 5 (100.00) .74  A little bit 10 (18.87) 10 (20.83) 0 (0.00)  Some 3 (5.66) 3 (6.25) 0 (0.00)  Quite a bit 2 (3.77) 2 (4.17) 0 (0.00)  A lot 0 (0.00) 0 (0.00) 0 (0.00) Been able to have an orgasm/climax  Have not tried 0 (0.00) 0 (0.00) 0 (0.00) .50  Never 4 (7.41) 4 (8.16) 0 (0.00)  Rarely 3 (5.56) 3 (6.12) 0 (0.00)  Sometimes 24 (44.44) 23 (46.94) 1 (20.00)  Often 12 (22.22) 10 (20.41) 2 (40.00)  Always 11 (20.37) 9 (18.37) 2 (40.00) Satisfying orgasms/climax  Not had an orgasm/climax 2 (3.70) 2 (4.08) 0 (0.00) .99  Not at all 4 (7.41) 4 (8.16) 0 (0.00)  A little bit 6 (11.11) 6 (12.24) 0 (0.00)  Somewhat 11 (20.37) 10 (20.41) 1 (20.00)  Quite a bit 20 (37.04) 17 (34.69) 2 (60.00)  Very 11 (20.37) 10 (20.14) 1 (20.00) Satisfied with your sex life  Not at all 7 (12.73) 6 (12.00) 1 (20.00) .89  A little bit 8 (14.55) 8 (16.00) 0 (0.00)  Somewhat 15 (27.27) 13 (26.00) 2 (40.00)  Quite a bit 11 (20.00) 10 (20.00) 1 (20.00)  Very 14 (25.45) 13 (26.00) 1 (20.00) Pleasure your sex life has given you  None 3 (5.45) 3 (6.00) 0 (0.00) .99  A little bit 10 (18.18) 9 (18.00) 1 (20.00)  Some 18 (32.73) 16 (32.00) 2 (40.00)  Quite a bit 13 (23.64) 12 (24.00) 1 (20.00) EMC , endometrial cancer. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Association of sexual function characteristics with disease status EMC , endometrial cancer. Patients with benign conditions had significantly higher VAS scores than patients with cancer ( P =.03, Table 10 ), indicating that patients with benign conditions had more vaginal dryness, soreness, irritation, and dyspareunia overall. At an individual symptom level, the benign group had more dyspareunia ( P =.03) and more vaginal dryness ( P =.01) compared with the endometrial cancer group. There was not a significant difference in VuAS scores between the disease groups. There were also no significant differences in vaginal or vulvar symptoms by menopausal status or type of benign condition. Table 10 Association of Vaginal Assessment Scale and Vulvar Assessment Scale with disease status Table 10 All (n=102) Benign (n=74) EMC (n=28) P value Vaginal Assessment Scale a Mean (SD) 2.14 (2.27) 2.43 (2.35) 1.35 (1.85) .03 Median 1.00 2.00 1.00 Vulvar Assessment Scale b Mean (SD) 1.23 (1.84) 1.37 (1.88) 0.85 (1.72) .16 Median 0.00 0.00 0.00 EMC , endometrial cancer; SD, standard deviation. a Vaginal Assessment Scale=sum of responses for vaginal dryness, vaginal soreness, vaginal irritation, and dyspareunia b Vulvar Assessment Scale=sum of responses for vulvar dryness, vulvar soreness, vulvar irritation, and painful to touch. Chase. Preoperative quality of life in gynecologic surgery. Am J Obstet Gynecol Glob Rep 2023. Association of Vaginal Assessment Scale and Vulvar Assessment Scale with disease status EMC , endometrial cancer; SD, standard deviation. Vaginal Assessment Scale=sum of responses for vaginal dryness, vaginal soreness, vaginal irritation, and dyspareunia Vulvar Assessment Scale=sum of responses for vulvar dryness, vulvar soreness, vulvar irritation, and painful to touch. To better understand these preoperative differences in the patient cohorts, we examined the effect of age, BMI, and comorbidities (hypertension and diabetes) on patient-reported outcomes in multivariate analysis. When adjusting for age in the model, the differences in global health scores (physical, mental, general, and social) became significant between the groups, because of the older age of patients in the endometrial cancer group ( P <.05) However, if BMI and comorbidities were also included in the model, the difference in the groups was not significant ( Supplemental Table 1 ). This was also true for gas/bloating, diarrhea, and perceived stress ( P >.05, Supplemental Tables 2–4 ). Differences in VAS scores became less statistically significant ( P >.05), but differences in VuAS scores became statistically significant ( P <.05) after adjustment ( Supplemental Table 5 ). Sexual interest was decreased in the patients with endometrial cancer both in the unadjusted and adjusted models ( P <.05), and vulvar complaints became significantly different between the groups when controlling for BMI, age, and comorbidities ( P <.05; Supplemental Table 6 ).

This study was approved by the University of Arizona Institutional Review Board (UA IRB #1708726047). Patients were recruited, consented, and administered the surveys before hysterectomy. Patients with endometrial cancer were compared with patients with benign conditions. Patients self-reported relevant medical history as well as demographic and socioeconomic information. Charts were reviewed for operative reports and obstetrical and gynecologic history. The surveys included 4 Patient Reported Outcome Measurement System (PROMIS) surveys: National Institutes of Health Toolbox Global Health v1.2, Gastrointestinal: Gas and Bloating v1.1 13a, Gastrointestinal: Diarrhea v1.0 6a, and Sexual Function and Satisfaction Brief Profile (Female) v2.0. The Perceived Stress Scale (PSS-10), developed by Cohen et al. 15 and the Vaginal Assessment Scale (VAS) and Vulvar Assessment Scale (VuAS) were also included. Final scores were expressed as T-scores, which were calibrated with item response theory. A question was inadvertently omitted from the PSS-10; however, a final score was obtained using item response theory to adjust for the omission. The clinical notes and operative reports were retrospectively reviewed for each patient with benign conditions to determine the priority indication for hysterectomy. Data were deidentified before analysis. All individual questions as well as aggregate T-scores were compared across the 2 groups: patients with benign gynecologic conditions and patients with endometrial cancer. Comparisons between groups were performed using the Kruskal-Wallis test. Multivariate analysis was performed using linear regression to adjust the comparisons for potential differences in age, body mass index (BMI), and comorbidities (diabetes and hypertension). All statistical analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC). Tests were considered to be significant at a P value of .05.

Preoperative QOL may differ among patients depending on not only indication for surgery but perhaps more importantly on age, BMI, and preexisting conditions. Depending on the realm of QOL explored, global QOL vs gastrointestinal complaints, pain, or sexual function, patient factors may have a varied impact on QOL score. To date, studies have focused on QOL following cancer treatment, 11 , 16 , 17 , 18 , 19 within particular benign conditions, such as endometriosis 6 , 20 , 21 , 22 CPP 23 , 24 , 25 , 26 and fibroids, 7 as well as between different benign conditions. 1 , 3 To add to the literature, our survey results examine QOL in a heterogeneous patient population in an urban setting undergoing hysterectomy, which is typical of a large center for gynecologic care. The opportunity to enhance postoperative care and better understand baseline preoperative QOL is useful. Challenges with mental health have been documented for patients with benign conditions, including endometriosis, 20 , 21 , 23 , 27 CPP, 23 , 25 , 28 and fibroids; 7 nevertheless, our study took into consideration potential confounders such as BMI, age, and comorbidities (hypertension and diabetes mellitus). It has been shown that the existence of pain, even when comparing within the same benign gynecologic condition, can contribute to worsened mental health 21 , 25 , 27 and worsened QOL. 1 Given that stress levels were similar between the benign and cancer groups, similar mental health levels could be expected. Because multidimensional QOL factors have been previously shown to influence one another, 14 , 21 , 29 , 30 , 31 it is possible that the physical and mental-emotional QOL factors measured in this study also interrelate. It is compelling that patients with benign and cancerous conditions in this sample report similar mental health and general stress levels before hysterectomy. In our study, when controlling for age, patients with endometrial cancer reported greater stress than patients with benign conditions. However, the effect of including BMI and comorbidities diminished these differences. Moreover, our study illustrates that patients with cancer may feel less able to cope with stress; patients with cancer reported that they felt less able to control important things and became more upset from unexpected events, 2 measures of coping. Our study highlights the gastrointestinal symptomatology in the benign group and supports the literature in demonstrating that gas and bloating symptoms may be common among benign and malignant gynecologic conditions. 32 , 33 Studies demonstrate that patients with CPP have a higher prevalence of fibromyalgia and irritable bowel syndrome than the general population, 33 and that patients with endometriosis experience gas and bloating. 32 Endometriosis often causes bowel obstruction, 34 intraabdominal adhesions, 35 and pelvic pain. 36 , 37 Specifically, this pelvic pain can be associated with stretching movements or organ distension. 38 Notably, it has been shown that gas and bloating symptoms vary with menstruation regardless of irritable bowel syndrome presence, 39 illustrating that the reproductive and gastrointestinal systems may, in fact, be linked. However, the impact of BMI, age, and comorbidities on gastrointestinal symptoms may be more impactful than the diagnosis driving hysterectomy. Surprisingly, patients with benign conditions had significantly more vaginal pain, vaginal dryness, and dyspareunia, and yet reported more sexual activity, satisfaction, and interest than patients with cancer. This became more significant when controlling for age, BMI, and comorbidities, indicating that patients undergoing hysterectomy for benign reasons should be screened for vaginal symptoms preoperatively and follow-up should be documented on recovery. The differences in vaginal pain can be explained by the symptomatology of benign conditions and endometrial cancer. Benign conditions are often associated with pelvic pain 20 , 40 and dyspareunia, 41 whereas pelvic pain does not typically present with endometrial cancer until late stages. 42 It is known that benign gynecologic conditions are associated with dyspareunia either because of the inflammatory nature of conditions such as endometriosis and adenomyosis, 25 or the mass effect of conditions such as uterine fibroids. 43 Although it might be assumed that differences in sexual interest between groups can be explained by age, because the benign group tended to be younger than the cancer group, the differences between groups remained after adjusting for age. Therefore, there may be disease-related factors driving this difference. Despite increased pain at baseline with intercourse, women with benign conditions in our study were more satisfied with their sexual activity; however, this difference was not significant when controlling for age, BMI, and comorbidities. Previous findings have indicated that women with endometriosis and CPP experienced reduced sexual activity and sexual satisfaction, 3 when compared with healthy controls, and this could be confounded by BMI, age, and/or comorbidities. Finally, greater sexual well-being has been shown to correlate with better psychological well-being for patients with endometrial cancer, 14 illustrating the multifactorial aspects of QOL. The focus of this study was to describe patient-reported QOL in a preoperative setting to better understand areas to focus on during postoperative care. Given that surgical interventions are considered a “teaching point” in a patient's life, this critical event is an opportunity to improve the future health of the patient and to impact not only physical but also social, functional, and emotional health. In perioperative care, there may be a link between patient-reported QOL and patient satisfaction. 47 , 48 , 49 If the needs and expectations of the patient are met with the surgical experience, this could contribute to higher levels of satisfaction. Satisfaction may influence overall well-being and perceived QOL. However, if a patient is dissatisfied with their surgical care, this may negatively affect their QOL by causing distress, anxiety, or physical discomfort. Our results have illuminated the morbid symptomatology of patients with benign and malignant conditions, and therefore should encourage improvements in timely diagnosis, clinical interventions, and quality of care for these patients. Given the recent push for mental health reform and awareness, 44 this study reveals that clinical considerations could be made preoperatively and addressed postoperatively. 20 , 45 At the same time, preexisting factors such as BMI and comorbidities may impact QOL regardless of the diagnosis driving the decision for hysterectomy. The association of patient satisfaction with QOL in perioperative care could be explored in future studies. The strengths of our study include the use of validated survey tools that assess a broad range of QOL characteristics. In addition, given our diverse population, this study has large potential for generalizability and thus clinical application to larger populations. Limitations include a small sample size for some benign conditions, which reduces generalizability within specific benign gynecologic conditions. In addition, because of the use of surveys in this study, self-reporting bias 46 could also be present. Finally, postoperative QOL was not collected and therefore QOL change over time cannot be assessed.

According to the results of our preoperative surveys, women who underwent a hysterectomy for benign and malignant reasons have preoperative QOL changes that could be more related to BMI, age, and comorbidities than the actual diagnosis calling for hysterectomy. The impact of these factors on postoperative recovery is also likely to be strong in both benign and malignant groups. Therefore, gynecologists have a potentially influential impact on the future physical, emotional, and social health of their patients at the time of hysterectomy. A comprehensive approach to treating patients with benign conditions and cancer is warranted, given the reduced QOL that both groups experience in physical and mental-emotional health.

Gynecologic surgeries, benign and malignant, are some of the most commonly performed surgeries in the United States. Previous reports have shown that half of all women of reproductive-age suffer from benign gynecologic conditions 1 , 2 such as uterine fibroids, abnormal uterine bleeding, chronic pelvic pain (CPP), pelvic organ prolapse, and endometriosis; and all of these conditions have deleterious effects on quality of life (QOL). For example, CPP is one of the most frequently reported symptoms in women of reproductive-age and its effects extend into their social, marital, and professional lives. 3 Abnormal uterine bleeding has been shown to affect up to a third of women of reproductive-age. 4 , 5 , 6 , 7 “Benign” conditions are detrimental to the well-being of women and have been repeatedly shown to pose a significant economic and healthcare burden. 8 Endometrial cancer is one of few cancers that is increasing in the United States, with 66,200 new cases anticipated in 2023 (American Cancer Society). Longitudinal studies have demonstrated that after diagnosis, patients with endometrial cancer have been shown to experience a reduction in physical activity, 9 pelvic floor dysfunction 10 and worsened mental health. 9 , 11 , 12 , 13 , 14 However, the well-being of these patients at the time of hysterectomy remains largely understudied. The benefit of understanding QOL preoperatively in patients undergoing gynecologic surgery is a strategy to drive improvements in postoperative care and follow-up. Without understanding the baseline QOL status in these patients, we will not be able to adequately understand the quality and impact of the care we give. This exploratory analysis examines QOL and the factors that may influence this in patients with benign and malignant gynecologic conditions at the time of hysterectomy.