psychiatric morbidity) were those with genuine menorrhagia ( 80 mL) and low psychiatric morbidity pre- ... ablation might have several psychological advantages.
BJOG: an International Journal of Obstetrics and Gynaecology April 2003, Vol. 110, pp. 358 –363
Psychiatric morbidity following endometrial ablation and its association with genuine menorrhagia Barry Wrighta,*, Michael J. Gannonb, Maurice Greenbergc, Allan Housed, Tony Rutherforde Objective To explore the relation between pre-operative psychiatric morbidity, menstrual blood loss and psychiatric outcome in women receiving endometrial ablation for heavy periods. Design A prospective cohort study. Setting The menorrhagia clinic at Leeds General Infirmary. Population One hundred and twenty consecutive women referred to the Clinic for endometrial ablation. Methods Psychiatric interview and actual menstrual blood loss measurements at presentation pre-operatively and one year post endometrial ablation. Main outcome measure Psychiatric status using the semi-structured interview, Present State Examination, with measurement of menstrual blood loss. Results Endometrial ablation was performed on 92 women. Of the 87 women evaluated 51 (59%) had clinically significant psychiatric symptoms, mainly depression and anxiety. Psychiatric morbidity fell to 21.8% at one year after endometrial ablation. Women with the best psychiatric outcome (6% post-operative psychiatric morbidity) were those with genuine menorrhagia (80 mL) and low psychiatric morbidity preoperatively. Those who fared worst (39% post-operative psychiatric morbidity) were women with high preoperative psychiatric morbidity and low menstrual blood loss. Of seven women with very low losses [mean 19 mL (SD 17)] who did not proceed to surgery after counselling, six (86%) had significant psychiatric morbidity. Conclusions Pre-operative psychiatric status and menstrual blood loss are predictors of outcome of surgery for women with reported heavy periods. INTRODUCTION There is a reported association between mental health problems and the complaint of heavy periods both in the community1,2 and in gynaecology outpatient clinics3 – 5. Although major surgery such as hysterectomy was at one time considered to be a major cause of psychiatric morbidity6 – 8, there is now a consensus that mental health problems frequently predate hysterectomy and show no post-operative increase9 – 16. A key study by Gath et al.17,18, replicated by Ryan et al.19, demonstrated a reduction in psychiatric morbidity following hysterectomy although not to population levels. Indeed, many women have improved quality of life
a
York and Selby Primary Care Trust, UK Longford/Westmeath General Hospital, Midland Health Board, Southern Ireland c University College London, London, UK d Leeds University, UK e Leeds General Infirmary, UK b
* Correspondence: Dr B. Wright, York and Selby Primary Care Trust, 31, Shipton Road, York, YO30 5RF, UK. D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology doi:10.1016/S1470-0328(03)02999-9
after hysterectomy, and are pleased with the outcome20,21, especially those where heavy periods caused marked disruption to their lives20 or who suffered pain pre-operatively21. Between a quarter and a half of women undergoing hysterectomy experience complications of surgery20,22 – 29 and some complications may have psychological consequences. The context of surgery is also important, as women who have an emergency hysterectomy are more likely to suffer depression post-operatively30. A question arises about how endometrial ablation as an alternative to hysterectomy may fare from a psychological perspective. The permanent destruction of the endometrium has become popular as a method of controlling menorrhagia for women with dysfunctional uterine bleeding31 – 33. Endometrial ablation significantly reduces menstrual blood loss in over 90% women34, and the average reduction in amount of loss is more than 90%35,36. Repeat endometrial ablation is required in approximately 10%37, and between 5% and 15% proceed to hysterectomy37,38, although this can be as high as 35% if organic pathology is not systematically excluded pre-operatively39. The relative simplicity of the procedure of endometrial ablation might have several psychological advantages when compared with hysterectomy. Women prefer it because it avoids major surgery and results in rapid return to www.bjog-elsevier.com
PSYCHIATRIC MORBIDITY AND ENDOMETRIAL ABLATION
normal daily living40. Operating times and hospital stays are shorter, and recovery41 and return to sexual intercourse23 are quicker. It is a relatively safe operation with low levels of morbidity and mortality42. Complications are significantly fewer than hysterectomy when compared in randomised controlled trials23,24,38,41,43. Satisfaction ratings are broadly similar38,43 or in favour of hysterectomy23,44 probably as a result of continued bleeding and dysmenorrhoea in some women after endometrial ablation. However, in contrast to hysterectomy, women receiving endometrial ablation can have it repeated or proceed to hysterectomy. Randomised studies comparing psychological morbidity after hysterectomy or endometrial ablation have not used diagnostic instruments and so have not satisfactorily answered the question of psychological outcome23,24,38,44,45. We set out to assess the psychological morbidity of women before and one year after endometrial ablation for heavy periods, and its relation to menstrual blood loss.
METHODS The study was based in the menorrhagia clinic at the Leeds General Infirmary, which is a large teaching hospital serving Western Leeds and its environs. The hospital has an approximate catchment of 375,000 people. The study had ethical committee approval. A consecutive series of women referred for endometrial ablation by gynaecologists at the hospital were given written and verbal information and consented to participation in the study. Gynaecological assessment included a transvaginal ultrasound scan and outpatient endometrial biopsy. Bloods were tested for full blood count, ferritin, thyroid function tests and follicular stimulating hormone (FSH) level. Women were excluded if they were found to have fibroids of more than 5 cm diameter, endometrial neoplasia, FSH in the menopausal range or hypothyroidism, or if they had moderate to severe learning disabilities. Menstrual blood loss was measured using a simple, twostage, well-validated colorimetric method described by Gannon et al.46. The measurement findings were discussed with each woman. All women with low normal loss (
