Quality of Life in Thai Women after Hysterectomy

Hysterectomy is the standard treatment and most common procedure for the Women with gynecological problem both benign and malignant tumor. The American Congress of Obstetricians and Gynecologists [1] reported that overall hysterectomy rates were highest among women ages 40-44 and 45-49 at 9.6 and 9.7 per 1,000 women respectively in 2008. The rate among women ages 35-39 was 6.5 and 5.6 for women ages 50-54 [1]. The Centers for Disease Control and Prevention Website reported 10.6% of women 40-44 years of age who have ever had a hysterectomy in 2011-2015 [2] in the United States. This information is also similar in Thailand, especially in the university hospital, where reported 800-1,200 cases [3] of women underwent hysterectomy per years.

Hysterectomy is the significant operation to reduce the suffering from gynecological signs and symptoms such as pain, abnormal uterine bleeding, dyspareunia, dysmenorrhea, hypermenorrhea, pelvic mass. In addition, previous studies reported that this operation could reduce those symptoms suffering and also increase the quality of life among these women [4-7]. However, the uterus is the main organ for female identification. Women might perceive the loss of feminist when they have a hysterectomy. These might affect body image, self- esteem, and marital adjustment including sexual dysfunction [8,9]. In some women have depression after surgery. On the other hand, these will cause low health status both physical and psychological status, including social relationships, and environment after surgery. Thus; it may affect the quality of life in women after hysterectomy.

“Quality of Life” (QOL) is an important outcome in health care system. World Health Organization (WHO) defines Quality of Life as “Individuals’ perception of their position in life in the context of the culture and value systems in which they live and concerning their goals, expectations, standards, and concerns”. WHO-QOL consists of 4 domains; physical health, mental status, social relationships, and environment. Women who had hysterectomy may affect directly to four domains of their quality of life [10-12].

From literature reviews, supported that quality of life may relate to reproductive age. Hysterectomy can affect infertility, sexual dysfunction and other symptoms more than women postreproductive age. Besides, women who had a partner may have an excellent support or trouble from their partner. On the other hand, women with high education level may manage their resources to solve their problems [8,9] that will affect the quality of life. Age, marital status, and educational level of these women may have different quality of life. Thus, the purposes of this research were to examine the quality of life and compare the quality of life in different age group, partner status, and education level of Thai women after hysterectomy in a university hospital. Results from this study will provide evidence to promote the quality of life in further women after hysterectomy.

Purposes of this study were

A. To examine the quality of life of Thai women after a hysterectomy.

B. To compare the quality of life in different age group, partner status, and educational level of Thai women after hysterectomy.

This descriptive comparative study was conducted in a university hospital. Data were collected during January-June 2016. Convenient participants were women after hysterectomy 3-36 months. Sample sizes were calculated by using the compare means sample size from the University of California at San Francisco Training in Clinical Research (TICR) Program access from [13] http://www.sample-size.net/sample-size-means/. Then, the power .80, alpha .05, with moderate effect size (.5), with the standard deviation of the outcome in the population is equal to 1. Then calculate the sample sizes is equal to 132 participants.

Instruments

There were three instruments used as follows:

A. The personal data

B. World Health Organization quality of life-Thai version (WHOQOL-BREF-THAI) developed by WHO.

The details of these instruments are following described: Personal data were developed by the principal investigator and colleagues. Data information was personal data, such as age, educational level, marital status, occupation, income, financial status, treatment paid, and time after the operation.

World Health Organization quality of life-Thai version (WHOQOL-BREF-THAI) was developed by WHO. World Health Organization quality of life (WHOQOL) was initially been developed 100 questionnaires, and then it was selected 24 item-scales to be in short version (WHOQOL-BREF). The WHOQOL group defined the quality of life as perceptions of persons on their life position in the circumstance of their culture and value system, including regarding their goals, anticipations, principles, and concerns. WHOQOL-BREF later was translated into Thai by Mahudnirunkul and colleague (B.E. 2540).

The content validity was tested and CVI was .65 as well as its reliability was tested with Cronbach’s alpha coefficient equaled to .84. It has consisted of four domains; physical health, mental status, social relationships, and environment. There are 24 items with a 5-level Likert-scale. The score in each item ranged from 1 (not agree at all) to 5 (most agree). There are 21 positive items and three negative items. The summed score is achieved through the interpretation of each domain. High scores meant high quality of life. The reliability of the instrument with Cronbach’s Alpha Coefficient for this study was 0.88.

Protection of human rights

This study was approved by the committees on human subjects from the faculty of medicine Ramathibodi Hospital, Mahidol University, Thailand. This was done to ensure the protection of human rights. After it was approved the IRB from the committees, then the data collection process started. Researchers followed the procedures of the Helsinki Declaration of 1975, as a revised in 2000, ID 04-57-01, with number MURA 2014/195/S1-2PS2.

Data were analyzed by statistical methods as follows:

A. The descriptive statistic analyzed the personal information data in Thai women after hysterectomy.

B. The overall and four dimensions of quality of life including physical health, psychological status, social relationships, and environment domain analyzed by mean, standard deviation, minimum and maximum value of the possible and actual range.

C. The comparative of quality of life in different age group, partner status, and educational level of Thai women after a hysterectomy, were analyzed by Independent T-Test, with a significant level at .05.

Results demonstrated that the average age of Thai women after hysterectomy was 50.74 years (SD=9.49), which varied from 21-76 years. The mean time after hysterectomy was 24.33 months (SD=8.30), which varied from 3-36 years. Majority of them had a bachelor’s degree and above 76.70% married 56.10% Buddhist 93.90%. The majority occupation of participants was government official 66.70% income more than 20,000 baht/month (around 645-650 US$), enough financial status 89.40% treatment paid by claiming from government 72.70%. More information has been shown in (Table 1).

Table 1:Characteristic of Thai women after hysterectomy (n=132).

Results from Table 2 & 3 showed the mean of overall quality of life was 88.18 (SD=12.10), varied from 63-118. The majority level of quality of life both overall and 3 domains of quality of life were in moderate level as follows; physical health domain (53%) social relationships domain (66.70%) and environment domain (62.10%). On the other hand, the majority level of quality of life both overall and the psychological status domain were in high level (57.60%) (Table 2 & 3).

Table 2:Descriptive data of health status and quality of life in Thai women after hysterectomy (n=132).

Table 3:Descriptive data of health status and quality of life in Thai women after hysterectomy (n=132).

Table 4:Comparison the quality of life between age group in Thai women after hysterectomy (n=132).

Table 5:Comparison the quality of life between marital status group in Thai women after hysterectomy (n=132).

Table 6:Comparison the quality of life between educational level in Thai women after hysterectomy (n=132).

Results in Table 4-6 reported the comparison the quality of life between age group, marital status, and education level in Thai women after hysterectomy. It was found that there was significant difference of QOL between age group in overall QOL (p=.005), physical health domain (p=.003), and environment domain (p=.003). It was also found that there was a significant difference of QOL between educational level in social relationships domain of quality of life (p=.012), but there was not significant difference of QOL between marital status (Table 4-6).

Results from this study demonstrated that the quality of life of the participants was in the moderate and high level which was congruent with previous studies [4-7]. It could explained that hysterectomy can correct the physical problem such as chronic pelvic pain, dyspareunia, hypermenorrhea or abnormal uterine bleeding. When women’s physical health improved, another three domains of their psychological status, social relationships, and environmental domains also improved. These reasons pointed to increase women’s quality of life. Then the majority of the participants’ quality of life was in a moderate and high level in this study.

When comparing the quality of life different between reproductive and post-reproductive age group, results showed that the quality of life in women with reproductive age is higher than post reproductive age especially in overall QOL, and two domains of physical health and environmental domain. This result is congruent with the study of Bahri [9]. They found a positive correlation between age and depression following a hysterectomy. This can be implied that women with post-reproductive age had lower QOL than reproductive age. It can be explained from the results of this study that younger women still had better physical health and environment than older women. They perceived of their excellent physical strength, psychological status, social relationships, and environment after their operation.

When considering the quality of life in between marital status group, found that there was no a significant difference between women with have or have not partnered. This result is not congruent with previous studies [4,14]. This can explain that women had well support in both groups. It might be that all participants may have an excellent support from the nature of Thai culture. On the other hand, women who had no partner may feel free. They do not have a concern about sexual dysfunction with their partner. In women with a partner, they may have a low quality of female sexual function after a hysterectomy [15]. However, women with a partner they have excellent support; they may concern about sexual dysfunction with their partner. Then both groups of women with and no partner may have the same quantity of QOL.

In the other point, when considering the quality of life in women with different level of education, it was found that there was only one domain of QOL had a significant difference between women with different level of education. This result is not congruent with the previous study of factors affecting sexual satisfaction in Korean women who have undergone a hysterectomy [14]. However, women with a high educational level tend to have higher QOL than women with a low educational level. People who have a higher educational level can use their resources and search for more information to care for themselves than women with a lower educational level. This is because education is a valuable asset. It can provide people to adapt themselves to any situation they experience. High education is associated with occupation and higher income. Then it can be seen from the result of this study that women with higher education level also had a higher quality of life. From this reason, Health care providers must assess the women with lower education level to provide their information need and solve their concern.

Prospective study research should be recommended to follow the quality of life in women after hysterectomy. To know the quality of life in each point of treatment from pre to at least six months post operation may provide complete information for health care providers improve the quality of care in these women. A qualitative research study should be implemented to explore the essences of the quality of life appropriate with culture in Thai Women after hysterectomy.

It can be summarized that the quality of life in Thai women after hysterectomy was quite moderate to a high level. It was different between reproductive age and posted reproductive age. It was higher in younger than older women. Women with a higher educational level tend to have more QOL than women who had a lower educational level. Health care providers should focus on women with older age and low educational level.

This research studied in small sample size even though it passed the sample size calculation process. It could not use random sampling during data collection because of not available participants.

The authors gratefully thank Faculty of Medicine Ramathibodi Hospital, Mahidol University for funding support and all participants who participated in this study.

1. Women’s Health Stats and Facts (2011) The American Congress of Obstetricians and Gynecologists, USA.
2. Key Statistics from the National Survey of Family Growth. Centers for Disease Control and Prevention.
3. Medical Statistics Center (2013) Ramathibodi Hospital Faculty of Medicine, Ramathibodi Hospital, Mahidol Unibversity, Thailand.
4. Bayram GO, Begi NK (2010) Psychosocial adaptation and quality of life after hysterectomy. Sexuality and Disability 28(1): 3-13.
5. Nieboer TE, Hendriks JCM, Bongers MY, Vierhout ME, Kluivers KB (2012) Quality of life after laparoscopic and abdominal hysterectomy. Obstet Gynecol 119(1): 85-91.
6. Lee CF, Wen FH, Lin SS, Lin HM (2009) Changing quality of life in hysterectomized women. J Formos Med Assoc 108(5): 414-422.
7. Reitsma ML, Vandenkerkhof EG, Johnston SL, Hopman WM (2011) Does health-related quality of life improve in women following gynecological surgery? J Obstet Gynaecol Can 33(12): 1241-1247.
8. Chou PH, Lin CH, Cheng C, Chang CL, Tsai CJ, et al. (2015) Risk of depressive disorders in women undergoing hysterectomy: A populationbased follow-up study. J Psychiatr Res 68: 186-191.
9. Bahri N, Tohidinik HR, Najafi TF, Larki M, Amini T, et al. (2016) Depression following hysterectomy and the influencing factors. Iran Red Crescent Med J 18(1): e30493.
10. WHOQOL: Measuring quality of life.
11. Mahudnirunkul S, Silapakit P, Poompaisalchai W (1997) Comparison between WHO-Quality of Life (100 items) and WHO-Quality of Life (26 items) in Thai People. Saun Prung Hospital, Thailand.
12. Mahudnirunkul S, Silapakit P, Poompaisalchai W (1998) Quality of Life in Thai People during critical economic period. Saun Prung Hospital, Thailand.
13. Hulley SB, Cummings SR, Browner WS, Grady D, Newman TB (2013) Designing clinical research: An epidemiologic approach. (4th edn), Lippincott Williams & Wilkins, Philadelphia, USA, p. 79. Sample size calculation from the UCSF Training in Clinical Research (TICR) Program Access.
14. Sung MH, Lim YM (2015) Factors affecting sexual satisfaction in Korean women who have undergone a hysterectomy. Australian Journal of Advanced Nursing 27(2): 46-54.
15. Bredite I, Ancane G, Rogovska I, Lietuviete N (2014) Quality of female sexual function after conventional abdominal hysterectomy-three months’ observation. Acta Chirurgica Latviensis 14(1): 26-31.