Original article
Hysterectomy and loss of fertility: Implications for women's mental health

https://doi.org/10.1016/j.jpsychores.2007.03.018Get rights and content

Abstract

Objective

The objective of this study was to assess the percentage of women scheduled for hysterectomy who would have liked to have had a child or more children and associated factors.

Methods

The study sample included 1140 premenopausal women having hysterectomy for benign indications who were interviewed before and after their surgery over the course of a 2-year follow-up period. The main outcome measures for this study were desire for a (or another) child measured preoperatively; concurrent measures of psychological distress, including anxiety, depression, anger, and confusion, and seeking of professional help for emotional problems; and psychological distress measured 12 and 24 months postoperatively.

Results

Of the sample, 10.5% (n=120) answered yes to the question, “Before you were told you needed a hysterectomy, would you have wanted a (or another) child?” As compared with those who did not, those who desired a (another) child were younger; more likely to be nulliparous; waited longer before having surgery; were more likely to have an indication of endometriosis; had higher levels of depression, anxiety, anger, and confusion; and were more than twice as likely to have seen a mental health professional for anxiety or depression in the 3 months before their surgery. These differences in psychological distress persisted over the course of the 2-year follow-up period.

Conclusions

The issue of loss of fertility should be discussed candidly with women considering hysterectomy, and those who express ambivalence, sadness, or regret at the loss of future childbearing options may benefit from further exploration of fertility-sparing treatments.

Introduction

Hysterectomy is one of the most commonly performed operative procedures in the industrialized world and occurs most frequently during the childbearing years [1], [2]. Because hysterectomy is usually an elective procedure performed as treatment for symptoms associated with benign gynecologic disorders, it is generally assumed that premenopausal women having hysterectomy have completed childbearing and are reconciled to the loss of fertility that hysterectomy entails. However, in a recent 3-year prospective study, 6% of premenopausal women having hysterectomy for benign indications indicated regret at their loss of fertility before surgery that increased after surgery, reaching a peak of 30% 2 years after hysterectomy [3]. Unfortunately, we know very little about the psychological impact of regret at loss of fertility as a result of this surgical procedure. In contrast, there are numerous studies on women's sadness and regret at the loss of fertility after bilateral tubal ligation [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. These two life situations are not identical as one involves a conscious decision on the part of the woman and her partner to limit childbearing, whereas the other involves sterility that is the consequence of treatment for a disease. In addition, unlike tubal sterilization, hysterectomy is irreversible. Several studies found that hysterectomy improves quality of life and decreases psychiatric symptoms among women overall [16], [17], [18], [19]. However, those studies did not specifically address the issue of psychological repercussions of loss of fertility. Thus, physicians and their patients cannot rely on information obtained from studies on sadness and regret after tubal ligation or on quality-of-life studies after hysterectomy as a guide for assessing the emotional impact of the loss of fertility as a result of hysterectomy on an individual woman and her family. Despite the frequency of hysterectomy in the United States and in countries throughout the world, we know little about the psychological correlates of regret of loss of fertility among premenopausal women having hysterectomy or how such regret may affect long-term psychological functioning after surgery.

As part of a large-scale, longitudinal, and prospective study on the outcomes and effectiveness of hysterectomy, we asked women about their childbearing desires before surgery and measured psychological functioning before and after surgery over the course of a 2-year follow-up period. This provided a unique opportunity to measure desire for further childbearing among premenopausal women having hysterectomy for benign indications and to assess the concurrent and long-term psychological correlates of this desire.

Section snippets

Methods

We analyzed the responses of more than 1000 premenopausal women to specific questions pertaining to their desire for a (another) child. Women were interviewed in person in their homes shortly before undergoing hysterectomy. Responses were analyzed in relation to a variety of factors such as age, race, and number of children, education, income, and measures of mental health as measured by the Profile of Mood States (POMS) [20]. The objectives of our analysis were to determine the variables most

Results

In response to the question, “Before you were told that you needed a hysterectomy, would you have wanted a (another) child?,” 120 women (10.5%) responded yes, 980 (86.0%) responded no, 40 (3.5%) responded maybe, and 11 women said they did not know (counted as missing data).

The women who answered yes and maybe in response to the question, “Before you were told that you needed a hysterectomy, would you have wanted a (another) child?,” were younger than those who said no, as shown in Table 1.

Discussion

In this study, we found that among women of childbearing age having hysterectomy, 14% indicated that they either definitely or perhaps would have liked to have had a child or more children. In addition, these women were significantly younger and more likely to be nulliparous and psychologically distressed at the time of hysterectomy as compared with those who were certain that they did not want a child or more children. These results are consistent with those of research publications that

Acknowledgments

This research was supported by grant HS0685 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD, USA, and the Intramural Research Program of the Reproductive and Biology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.

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