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Severity of Menopausal Symptoms in Women Posthysterectomy at a Tertiary Care Hospital, Tamil Nadu, India: A Cross-sectional Study
Correspondence Address :
Dr. Vijayalakshmi Kandasamy,
Professor, Department of Obstetrics and Gynaecology, Chettinad Hospital and Research Institute, Rajiv Gandhi Salai, Kelambakkam-603103, Tamil Nadu, India.
E-mail: viji_kands@yahoo.co.in
Introduction: Menopause, a natural occurrence in women’s lives, is characterised by a drop in ovarian hormones, oestrogen, and progesterone levels. Sudden hypoestrogenic state, that is caused by hysterectomy leads to the development of menopausal symptoms.
Aim: To assess the occurrence and severity of menopausal symptoms in women, who underwent hysterectomy for benign gynaecologic conditions.
Materials and Methods: A hospital-based cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India, over a period of three months. The study included 100 women in the age group of 35-55 years who had undergone hysterectomy for benign conditions were invited to participate in the study. Those who agreed to the study and completed the questionnaire after six weeks and three months postoperatively were included in the present study. Menopausal symptoms and severity were assessed using modified Menopause Rating Scale (MRS) scale. Posthysterectomy menopausal symptoms at six weeks and three months, were compared using Chi-square test.
Results: The mean age of the study participants was 45.85±6.24 years. Most of them, 52 (52%) had heavy menstrual bleeding, 28 (28%) of the study participants had no associated co-morbidities. A total of 54 (54%) of the women of this study was diagnosed as Abnormal Uterine Bleeding-Leiomyomas (AUB-L). Majority 76 (76%) of them had undergone total abdominal hysterectomy with or without bilateral salphingoopherectomy. Mean duration of hospital stay 7.48±2.02 days. Postoperative diet of these women included calcium containing foods 57 (57%), iron containing foods 68 (68%). There was a statistically significant difference in majority of menopausal symptoms like hot flushes, palpitations, night sweats, reduced duration of sleep, anxiety, lack of interest in sex, forgetfulness and joint and muscle pains between six weeks and three months postoperatively.
Conclusion: The present study concluded that the symptoms of hot flushes, difficulty in urinating, anxiety, joint and muscle pain was significantly higher at six weeks when compared to three months.
Hot flushes, Hypoestrogenic state, Hysterectomy, Surgical menopause
Menopause, a natural occurrence in women’s lives, is characterised by a drop in ovarian hormones, oestrogen, and progesterone levels (1),(2),(3). Hot flushes, irregular menstrual cycles, psychological changes, urogenital disturbances, loss of libido, muscle and joint pains are some of the menopausal symptoms experienced by women (2),(3),(4). In the period leading upto menopause, these symptoms are felt by more than 80% of women over the age of 45 years. Common symptoms include psychological issues, somatic symptoms, urogenital symptoms, and sexual dysfunction (5),(6),(7),(8),(9). Hysterectomy is the surgical removal of the uterus with or without ovaries leading to surgical menopause. The majority of hysterectomies are done for benign gynaecologic conditions (10). The most common indications for hysterectomy are leiomyomas, Abnormal Uterine Bleeding (AUB), and persistent pelvic pain (11). Hysterectomy for various benign conditions leads to many positive outcomes such as cessation of AUB, relief from monthly menstrual symptoms, endometriosis-related pelvic discomfort, fibroid-related pressure symptoms, and urinary disturbances (12). Sadness and anxiety are also some symptoms that get better. Some women may develop new issues like weight gain, changes in self-image, social and home disruptions, prolonged healing duration, and wound discomfort that can last for upto a year in many women after surgery (13). Women frequently experience more severe menopausal symptoms as a result of the sudden menopause caused by hysterectomy than they would if menopause occurred naturally (14).
The MRS is a widely used tool in evaluating the health-related quality of life of women going through the menopausal transition (15). Hysterectomy is the most commonly performed surgery in women for various gynaecological conditions (16). There are not many studies in literature which has assessed the time of occurrence and severity of menopausal symptoms in women who experienced surgical menopause as a result of hysterectomy. Studies such as Zhang JP et al., found that the majority of menopausal symptoms were mild to moderate in severity, with fewer being severe (17). Benshushan A et al., which showed that surgical menopause when compared to natural menopause, was associated with more severe psychological symptoms like anxiety, lack of sleep, urogenital symptoms like urinary disturbances and somatic symptoms like hot flushes (18). But these studies has not assessed the time of occurrence and severity of menopausal symptoms in posthysterectomy women. Hence, the present study was undertaken on 100 women who had undergone hysterectomy and developed surgical menopause. The present study was conducted to assess the various menopausal symptoms in the women at two different time points of six weeks and three months posthysterectomy, to see the type of symptoms that are predominant.
This was a hospital-based cross-sectional study conducted in the Department of Obstetrics and Gynaecology at Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India. The study was conducted over a period of three months from April 2022 to July 2022. The present study included women in the age group of 35-55 years who had undergone hysterectomy for benign conditions and were invited to participate in the study. A convenient sample of 100 women who agreed to the study and completed the questionnaire administered at six weeks and three months posthysterectomy were included in the present study. Ethical principles such as patient respect, beneficence, and justice were strictly followed. Before beginning the study, an Institutional Human Ethical Committee approval was obtained (Ethical Committee approval no.: IHEC-I/0972/22). All study participants provided written informed consent. The study participants’ confidentiality was maintained throughout the study.
Inclusion criteria: Patients who got operated at Chettinad Hospital and Research Institute for benign conditions such as fibroids, AUB, endometriosis, prolapse during the study period were included in the present study.
Exclusion criteria: Patients who were on antipsychotic or antidepressant medications and patients who had undergone hysterectomy for malignant conditions were excluded from the present study.
Study Procedure
Informed consent was taken before collecting the data. The data collection was done by a structured questionnaire which included patient’s name, age, symptoms, co-morbidities, diagnosis, procedure done, postoperative diet and exercise. Menopausal symptoms like hot flushes, palpitations, night sweats, reduced duration of sleep, anxiety, feeling depressed, dryness of vagina, lack of interest in sex, burning micturition, recurrent Urinary Tract Infection (UTI), difficulty in urinating, forgetfulness and joint and muscle pains was ascertained at six weeks and three months posthysterectomy. For assessment of the menopausal symptoms, modified MRS, was used (19). MRS is an 11-item questionnaire comprising three independent dimensions: Psychological, somatic, and urogenital subscale. The urogenital subscale was modified by authors, adding two more additional urinary symptoms. Recurrent urinary tract infection and difficulty in urinating were the two symptoms added. The scale was prevalidated using cronbach’s alpha test in the score, 0.76- which was acceptable.
Each of the 13 symptoms in modified MRS was classified into four categories based on the number of episodes per month.
1. Frequently-Symptoms occur 4-5 episodes per month
2. Sometimes-Symptoms occur 2-3 episodes per month
3. Occasionally-Symptoms occur 1-2 episodes per month
4. Rarely-Symptoms occur 1-2 episodes in 2 months.
Statistical Analysis
The data has been entered and analysed with the Epi info version 7.1. Before analysing the data each variable was acquired to check for missing values, blank values and typing errors. The corresponding case numbers were used to trace the questionnaires and the information was rechecked and entered. Quantitative variables like age were expressed as mean and Standard Deviation (SD). Description of categorical variables like age category symptoms, co-morbidities, diagnosis, procedure done, postoperative diet, postoperative exercise, postoperative symptoms of menopause like hot flushes, palpitations, night sweats, reduced duration of sleep, anxiety, feeling depressed, dryness of vagina, lack of interest in sex, burning micturition, recurrent UTI, difficulty in urinating, forgetfulness and joint and muscle pain were expressed as frequency and proportion. Postoperative menopause symptoms at six weeks and three months were compared using Chi-square test.
The mean age of the study participants is 45.85±6.24 years. Out of 100 participants, 30 (30%) were between the ages of 51-55 years. Among 100 participants, majority of them had heavy menstrual bleeding as the presenting symptoms which was 52 (52%).
Regarding co-morbidities, about 28 (28%) participants did not have any co-morbidities, 27 (27%) had type 2 diabetes mellitus (Table/Fig 1).
(Table/Fig 2) describes the indications for hysterectomy and type of procedures performed. The most common indication was leiomyoma 54 (54%), 18 (18%) had AUB-adenomyosis. The highest number of procedures performed were total abdominal hysterectomy with bilateral salphingoopherectomy in 46 (46%) women. Mean duration of hospital stay was 7.48±2.02 days (Table/Fig 2).
The study found that women in the postoperative period had taken diet consisting of calcium containing food 57 (57%), phytoestrogens containing food 38 (38%) and iron containing food taken by 68 (68%) women. Around 54 (54%) of women did regular walking for 30 minutes per day and 8 (8%) of participants practiced yoga (Table/Fig 3).
(Table/Fig 4) describes the menopausal symptoms women experienced at six weeks and three months, posthysterectomy. Nearly 48 patients experienced hot flushes occasionally at six weeks and 54 patients experienced hot flushes occasionally at three months posthysterectomy. The symptoms of hot flushes occurring 2-3 episodes per month was significantly higher at six weeks when compared to three months (p-value <0.05). At six weeks posthysterectomy, palpitations occurred rarely in 53 patients and 81 patients had palpitations rarely at three months posthysterectomy. The postoperative symptoms of palpitation had significantly decreased in three months, when compared to six weeks (p-value <0.05). Postoperative hysterectomy symptoms like feeling depressed and dryness of vagina was seen equally at six weeks and three months. Other symptoms like lack of interest in sex, burning micturition, recurrent UTI, difficulty in urinating, forgetfulness, joint and muscle pain was significantly higher in three months after posthysterectomy, when compared to six weeks of posthysterectomy (Table/Fig 4).
In the present study, mean age of the study participants was 45.85±6.24 years which was much lower when compared with the findings of the study by Mahajan N et al., where the mean age was 54.4±6 years (20). Most of them (52%) had heavy menstrual bleeding, whereas 20% had abdominal pain during menstrual cycle and 9% of them had mass per abdomen, as symptoms. Zhang JP et al., found that the majority of menopausal symptoms were mild to moderate in severity, with fewer being severe (17).
Fifty four (54%) of the women of the present study were diagnosed as AUB-L and 18% as AUB-Adenomyosis (AUB-2A). Majority (46%) of them had undergone total abdominal hysterectomy with bilateral salpingo-opherectomy. Mean duration of hospital stay was 7.48±2.02 days. These findings are consistent with the findings of Wright JD et al., (21).
In present study, 57% of the women had followed a postoperative diet of calcium containing foods and 68% of them had a practice of eating iron containing foods. A 54% of them were found to follow postoperative exercise of walking for 30 minutes daily and 8% practised yoga for 30 minutes to one hour. Diet rich in calcium and iron helps to maintain the bone mineral density for these women (22). It also reduces the incidence of muscle and joint pain, that women may experience after hysterectomy. Iron rich diet further helps in maintaining optimal level of haemoglobin, which prevents them from becoming anaemic, thus alleviating symptoms like palpitations and insomnia (22).
On comparing the symptoms of study participants between six weeks and three months posthysterectomy, present study showed a highly statistically significant difference in hot flushes between the two groups (48% and 54%, p=0.001). There was a significant change between the postoperative symptoms of palpitations (p=0.005) also. There was also very high significant change in postoperative symptoms of night sweats, reduced duration of sleep, anxiety, lack of interest in sex, burning micturition, difficulty in urinating, forgetfulness and joint and muscle pain (p=0.001). It is worth mentioning that, the frequencies of disturbed sleep, night sweats, palpitations, hot flushes, depression, recurrent UTI, difficulty in urinating were less frequent in both the groups. These results are found to be in concordance with the study of Benshushan A et al., which showed that surgical menopause when compared to natural menopause, was associated with more severe psychological symptoms like anxiety, lack of sleep, urogenital symptoms like urinary disturbances and somatic symptoms like hot flushes (p-value <0.001) (18).
In a study by Pal A et al., the prevalence of physical and mental exhaustion was found to be much higher (86%) (23). The urogenital problems like sexual problems (20%) and dryness of vagina were found to be less prevalent and if present then the symptoms were mild. In present study, urogenital symptoms like dryness of vagina, lack of interest in sex, burning micturition was mostly seen in three months posthysterectomy women. A study done in Turkey by Yanikkerem E et al., claimed that women mostly complained of vasomotor symptoms, especially hot flushes (79.6%), in present study hot flushes, palpitations, night sweats were predominantly seen in six weeks, when compared to three months posthysterectomy (24).
Limitation(s)
The present study assessed a small sample size of 100 women only. Further research is needed on larger number of subjects to assess the severity of various menopausal symptoms, that women experience posthysterectomy.
The present study concluded that women begin to experience menopausal symptoms as early as six weeks postoperatively itself. The predominant symptoms like hot flushes, night sweats, anxiety, sleep disturbances are experienced by the women at six weeks posthysterectomy and dryness of vagina, forgetfulness, burning micturition, joint and muscle pains at three months posthysterectomy.
The present research highlights the need for further studies on a larger number of women, undergoing hysterectomy to assess their menopausal symptoms. The present research will help the healthcare professionals to provide counselling and to manage the menopausal symptoms, appropriately.
DOI: 10.7860/JCDR/2022/59639.17269
Date of Submission: Aug 12, 2022
Date of Peer Review: Sep 08, 2022
Date of Acceptance: Nov 15, 2022
Date of Publishing: Dec 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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