Psychiatric illness after hysterectomy.
Authors: M. G. Barker
Journal: BMJ (1968)

It has often been reported that patients with gynaecological complaints are particularly prone to be psychologically unstable and more liable than other women to postoperative psychiatric sequelae. Snaith and Ridley (1948) stated that 46% of their gynaeco logical patients had  psychologically unstable constitutions. Rogers (1950) claimed that half of the women who presented themselves for gynaecological treatment had no gross gynaeco logical disorder, and described their illness as  a psychic con flict sailing under a gynaecological flag. Cohen et al. (1953) found gynaecological operations to be seven times commoner in patients suffering from hysteria than in control subjects. Benson et al. (1959) claimed that 33% of subjects with atypical pelvic pain showed indications of psychosomatic disease. It is perhaps surprising therefore that few studies by gynaecologists mention psychiatric sequelae after hysterectomy. Melody (1962), in his series of 267 patients, found 11 who developed depressive symptoms in the first three months post operatively ; but Howkins and Williams (1963), in their series of 1,000 patients, mentioned only two who developed psychiatric illnesses. Psychiatrists, on the other hand, particularly in the United States, have published many studies on the incidence of psychiatric sequelae after hysterectomy and the possible factors involved in their development. Lindemann (1941), in a study of only 40 women who had undergone surgical operations, found that those who had had a pelvic operation were more likely to have postoperative depressive symptoms than those who had had a cholecystectomy. Stengel et al. (1958) reported on a series of 80 patients with severe postoperative mental disorder, of whom seven had had a hysterectomy, and found that, though the incidence of mental disorder was no higher after gynaecological operations generally than after other abdominal operations, there was a significantly higher incidence of psychosis after hysterectomy. Ackner (1960) reported that 30'S, of his series of 50 patients had  complaints six months after hysterectomy. Others (Patterson et al., 1960; Patterson and Craig, 1963) have reported that, although admis sion to a psychiatric ward was commoner in women who had had a previous hysterectomy than in the general population, no direct relation between the operation and referral could be established in the majority of cases. Also, Bragg (1965), in a survey of 3,000 postoperative patients followed up for an average period of 10 years, found that only 43 had been sub sequently admitted to a psychiatric hospital: there was no significant difference in subsequent admission between the hysterectomy and the cholecystectomy patients. The problem of identifying those liable to develop psychiatric sequelae after hysterectomy has also received considerable attention. The patient's attitude to her uterus and its signi ficance for her in her own self image of womanliness was stressed by Kroger (1957), Drellich and Bieber (1958), and Hollender (1960). A more objective observation was made by Lindemann (1941), Ackner (1960), and Melody (1962), who stated that many of those who experienced  disturbance postoperatively had had psychiatric symptoms preoperatively. Miller (1946) claimed that 330% of hysterectomies were carried out in the absence of pathological findings, and inferred that some wer perf rmned because of the complaints of emotionally disturbed patients. He was followed by other workers who made similar observations. These papers were criticized by D'Esopo (1962), who stated that even when there was no significant finding, as in dysfunctional bleeding, hyster ectomy was still the operation of choice, and advocated that psychiatric advice be sought only in the small proportion of patients with atypical pelvic pain. Ackner (1960), on the other hand, found a higher proportion of subsequent  disorder in those with organic disease at operation as compared with those with functional uterine disturbance. Most of these papers dealt with small numbers and reported percentages and tendencies without submitting the data to statistical analysis. Also, the criteria used for 4etermining psychiatric sequelae ranged from mental hospital admission to   instability, thus allowing no comparison of data. The present study was designed to examine the incidence of psychiatric breakdown after hysterectomy, and to submit the findings to statistical analysis. Referral to a psychiatrist was used as a criterion of breakdown because it was a more objective measure than emotional instability, and included the large number of people now being treated at psychiatric outpatient departments. The incidence of psychiatric referral after hysterectomy was compared with that after another opera tion performed in middle life, cholecystectomy, and also with the expected rate of psychiatric referral in the general popula tion. The hysterectomy patients were divided into two groups according to pelvic pathological findings, and these groups were compared with regard to incidence of referral. The effect of marital state, as being a crude indication of sexual adjustment, was examined for its value in predicting psychiatric referral after hysterectomy.