Havrylyuk and Makarchuk: Specific Aspects of Life Quality Estimation and Ways of Rehabilitation in Women Who Underwent Uterine Surgery



Problem statement and analysis of the recent research

Recently, it has been noticed a great number of uterine fibroids in women with unrealized reproductive function; moreover, the number of combined forms of hyperplastic processes of the reproductive system in 20-25% of women under 30 years of age and 60% of women over 40 years of age is constantly growing creating a favourable background for cancer [1, 6]. The number of patients who underwent hysterectomy with appendages or without them has been tripled for last 30 years and increased, according to different data, from 6% to 18-25% [7, 9].

The incidence of post-hysterectomy pathological manifestations is 40-60%, pelvic pain syndrome is diagnosed in almost every third patient, the frequency of ovarian function loss (a leading post-hysterectomy syndrome) ranges from 20 to 80%; after hysterectomy in patients with preservation of ovarian function menopause starts 4-5 years earlier than in women who had no surgery; the prevalence of mental disorders and psychological problems after surgery on the uterus is 50-80%, 3-5 years after hysterectomy 40% of patients suffer from urogenital disorders, 25% of patients have problems with sexual function, neuroendocrine and metabolic changes [2, 3, 5, 7, 8].

Despite various theories concerning such changes it is known that due to uterine surgery women suffer from psycho-emotional, vegetative-vascular, neuroendocrine disorders and doctors of different specialties in their daily practice should be careful with choosing appropriate treatment of such patients.

There are scientific reports concerning the increase in the number of psycho-emotional disorders in women with hyperplastic processes both before surgeries and after surgical recovery; many of them are diagnosed with adjustment disorder [1, 4]. As many researches note, the main psychotherapeutic aspects include passive view of life, increased anxiety, tendency to dependent behaviour, rejection of own body, protective behaviour and problems with self-assessment [1, 4, 5].

It should be mentioned that the development of latent hyperprolactinemia that provides a stimulating impact on breasts and causes progressive development of mastalgia, especially in the postoperative period, is often the result of stress situations [1, 4]. One of the promising areas in medicine that gives the exact understanding of the disease, its methods of prevention and rehabilitation in the postoperative period is studying the quality of life; unfortunately this medical aspect is not investigated at all. It is almost impossible to find in modern literature any analytical reports on long-term effects after hysterectomy due to uterine fibroids or endometrial hyperplastic processes with the assessment of the life quality of women, where significantly low life quality before surgical intervention are noted, namely, worsening of sleep, emotional reactions and physical activity, especially on the background of posthemorrhagic anemia [1, 4, 5].

Therefore, due to the existing problem not only the data on neuro-metabolic-endocrine homeostasis should be studied, but also the quality of life of women in the remote postoperative period after hysterectomy with preservation of appendages in reproductive age. It should also be noted that a comprehensive study of clinical and laboratory data and subjective criteria of life quality is essential in assessment of the feasibility of hysterectomy in women of reproductive age, even if they do not plan to bear children in the future.

The objective of the research was to estimate life quality as well as to improve the system of dispensary observation and rehabilitation of women who underwent uterine surgery.

Materials and methods

There was performed a comprehensive examination and surgical treatment of 60 women of reproductive age with uterine fibroid who underwent hysterectomy with preservation of appendages. The control group included 20 somatically healthy women. To verify the diagnosis as well as to develop and monitor the effectiveness of treatment and rehabilitation we carried out a comprehensive examination that included gynaecological, obstetric and medical history, socioeconomic status, general clinical and laboratory methods of examination, bimanual gynaecologic examination, clinical breast screening, cytological and colposcopic examination, modern endocrinological and instrumental techniques. The assessment of the received data was made immediately after surgery, 6 and 2 months, 3 and 5 years after surgery.

The necessity to study life quality of women after surgical treatment of uterine fibroids is explained by the fact that clinical and laboratory parameters do not always make it possible to assess the state of human health. Subjective indicators that reflect the degree of women’s perception of their welfare constitute the concept of life quality that includes the following indicators: subjective feeling of well-being, health and prosperity. Therefore, in 60 women at the age of 28-45 years the main indicators of quality of life after surgical treatment of symptomatic uterine fibroids were evaluated. Quality of life was studied on the basis of a comprehensive assessment using the modified scale of the Nottingham Health Profile (NHP) and the study of such important indicators as energy, sleep, emotional reactions, social isolation, physical activity, pain. All statistical analysis was performed using a standard package “Statistica for Windows – 6.0”.

Results

On the basis of anamnestic data of patients we revealed health deterioration with high rates of liver and gastrointestinal tract disorders, metabolic disturbances (obesity, hypertensive disorders, fibrocystic breast disease), metabolic-endocrine changes and surgery. Reproductive health in women with uterine fibroid was characterized by long establishment of regular menstrual cycle, its breach in the period of puberty, inflammatory diseases of the genital organs, benign ovarian tumours and their surgical removal, inadequate reproductive behaviour with absent or delayed implementation of reproductive function and induced abortion.

In our study we used such instrumental methods as ultrasound examination and Doppler sonography which demonstrated that in the early postoperative period ovarian volume increased by 1.8 times; sonographic study revealed reduced echoicity immediately after surgery; in the early postoperative period ovarian blood flow was low. 6 months after hysterectomy we noticed the improvement of anatomical and functional state of the ovaries (normalization of ovarian volume, formation of normal follicles) which can be explained by the development of collateral blood flow and restoration of blood supply to the ovaries. Normalization of blood circulation was accompanied by a partial reduction in estradiol levels, prevalence of episodes of ovulation and luteal phases in 26.66% of cases. However, 12 months and especially 5 years after surgery there was noticed a progressive deterioration of the ovarian function, which was reflected as the reduction in their volume due to the reduction in the number and size of follicles, deterioration of blood supply to the ovaries, decreased blood flow in the internal iliac artery basin. It should also be noted the progressive hypestrogenism; in addition, there was a clear correlation with the age of the woman, who underwent surgical operation.

When assessing the indicators of quality of life in most cases (up to 86.6%) we noticed their decrease prior to surgery that is basically explained by a symptomatic disease. Within the first three months after surgery almost all women experienced improved indicators of life quality; positive changes in emotional state were observed; no complaints associated with fibroids were recorded. However, in the future, alongside with biochemical, hormonal and neurovegetative disorders we observed a gradual deterioration in quality of life. The results of our research confirmed that the indicators of life quality after hysterectomy depend on the age of a woman. Thus, in women at the age of 40-45 years the indicators of life quality gradually improved, while younger women (under 40 years of age) showed a progressive decrease in social activity and working efficiency.

According to our observations, 61.66% of women of different age groups had stress situations or psychotrauma in the past. Various negative psychological moments, acute exacerbation of chronic diseases, inflammation of the reproductive organs and hepatobiliary zone, abortions and miscarriages, and chronic stress contribute to the manifestation and intensification of the reproductive system disorders.

Changes in life quality of patients with hyperplastic processes of the uterus were manifested in the postoperative period as follows: a decrease in physical activity (43.33% of cases), increased sexual dysfunction (36.66%), inhibition of mental state, conflict-orientated social behaviour, weakening of role functions and subjective deterioration of health and life quality (51.66% of cases).

Discussion

Thus, in women with hyperplastic processes of the uterine both somatic and psychosomatic disorders were detected; their quality of life reduced due to changes in the indicators of general health, physical pain, vitality and emotional functioning. The analysis of our research indicated low indicators of life quality in women with hyperplastic processes of the uterus after surgery. The most pronounced decline was noticed in such indicators as energy, sleep, emotional reactions and physical activity. The greatest decrease in quality of life was observed in patients with posthemorrhagic anemia resulting in limited working capacity, and in women with acyclic uterine bleeding. Up to 5 years after hysterectomy the indicators such as emotional responses and psychological health were most often overwhelmed.

Conclusions

Thus, surgery on uterine fibroids with total or subtotal hysterectomy contributes to interference in a complex neuroendocrine interaction between hypothalamus, pituitary, ovaries, adrenal cortex, thyroid gland and affects the blood supply, innervation, and lymph efflux in the pelvic floor; therefore, postoperative syndromes are polyglandular and polysystemic.

Long-term effects after surgery are accompanied by progressive hypestrogenism, decrease in the ovarian function (the reduction in their volume observed during ultrasound examination), reduction in the number and size of follicles, deterioration of blood supply to the ovaries, low blood supply to the internal iliac artery basin.

Changes in life quality of patients with hyperplastic processes of the uterus were manifested as follows: a decrease in physical activity, increased sexual dysfunction, inhibition of mental state, conflict-orientated social behaviour, weakening of role functions and subjective deterioration of health and life quality.

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Copyright (c) 2017 H. M. Havrylyuk, O. M. Makarchuk

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