A 1-year follow up of psychological wellbeing after subtotal and total hysterectomy—a randomised study
Dr P Persson, Department of Obstetrics and Gynaecology, University Hospital, 751 85 Uppsala, Sweden. Email firstname.lastname@example.org
Please cite this paper as: Persson P, Brynhildsen J, Kjølhede P on behalf of the Hysterectomy Multicentre Study Group in South-East Sweden. A 1-year follow up of psychological wellbeing after subtotal and total hysterectomy—a randomised study. BJOG 2010;117:479–487.
Objective To compare subtotal abdominal hysterectomy (SH) and total abdominal hysterectomy (TH) regarding influence on postoperative psychological wellbeing and surgical outcome measurements.
Design A prospective, open, randomised multicentre trial.
Setting Seven hospitals and one private clinic in the south-east of Sweden.
Population Two-hundred women scheduled for abdominal hysterectomy for benign conditions were enrolled in the study; 179 women completed the study (94 SH and 85 TH).
Methods Four different psychometric tests were used to measure general wellbeing, depression and anxiety preoperatively, and at 6 and 12 months postoperatively. Statistical analysis of variance and covariance were used.
Main outcome measures Effects of operating method on psychological wellbeing postoperatively. Analysis of demographic, clinical and surgical data, including peri- and postoperative complications and complaints at follow up.
Results No significant differences were observed between the two groups in any of the psychometric tests. Both surgical methods were associated with a significantly higher degree of psychological wellbeing at 6 and 12 months postoperatively, compared with preoperatively. No significant differences were found in the clinical measures including complications. A substantial number of women experienced persistent cyclic vaginal bleedings after SH. Neither minor or major postoperative complications, nor serum concentration of sex hormones, were associated with general psychological wellbeing 12 months after the operation.
Conclusions General psychological wellbeing is equally improved after both SH and TH within 12 months of the operation, and does not seem to be associated with the occurrence of peroperative complications or serum concentration of sex hormones.
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Subtotal hysterectomy (SH) gained popularity among Scandinavian gynaecologists after a Finnish observational study in the 1980s,1,2 which reported a better outcome regarding sexual function in patients undergoing SH compared with total hysterectomy (TH). The method regained interest after the introduction of the laparoscopic technique of supracervical hysterectomy,3 and was followed by a request for randomised studies comparing SH and TH.4–6 A report from the USA showed that although there was a 15% decline in the hysterectomy rates between 1994 and 2003, there was a three-fold increase in SH, and the same trend was seen in other material from the USA and Scandinavia.7–9 The reason for this change was speculated to stem from the belief that SH should have a more positive impact on quality of life (QoL) than TH.
The first randomised comparison of SH and TH that focused on surgical and clinical outcomes was published 2002.10 None of the randomised trials reported in the Cochrane review from 2006 regarding TH and SH have primarily focused on psychological wellbeing.11 A recent randomised study, published in 2008, reported a better outcome regarding QoL in the SH group 1 year postoperatively.12 Gimbel’s meta analysis of TH versus SH was in favour of SH because of the shorter operating times, and reduced peroperative bleeding and postoperative complications, but no difference in recovery time was found, and conclusions regarding QoL outcomes could not be drawn.13 However, a considerable number of women in the SH group had bleeding from the cervical stump 1 year after surgery.
Bilateral salpingo-oophorectomy (BSO) concurrent with hysterectomy may influence psychological wellbeing because of changes in sex hormone levels.14–16 None of the three randomised trials of SH and TH found any significant difference in psychological wellbeing in women undergoing any of the two modes of hysterectomy, but no adjustments were performed for BSO or changes in sex hormone status.10,17,18 No studies have been conducted to primarily investigate the impact of SH and TH on psychological wellbeing adjusted for changes in sex hormone status.
As the perception of patients and physicians seems to be that SH has less of a negative impact on body and organ function, our hypothesis was that SH leads to better general psychological wellbeing than TH. This should be balanced with the occurrence of postoperative complications, such as bleeding from the cervical stump and possible changes in sex hormone levels. The aims of this randomised study were to determine whether psychological wellbeing differed between SH and TH, and to analyse the influence of postoperative complications and sex hormone levels on psychological wellbeing. This study presents the results at the 1-year follow up of the previously described multicentre study of SH and TH.19
This study is a part of a randomised, open, controlled multicentre study of SH and TH performed for benign indications, conducted in the Departments of Obstetrics and Gynaecology at seven hospitals and one private gynaecological clinic in the south-east health region of Sweden. The hospitals consisted of three county hospitals, three central hospitals, and one university hospital. The study was approved by the ethics research committees of Linköping University and Örebro Regional Hospital.
Detailed information about study design, material and methods has been described previously.19 Briefly, patients admitted for abdominal hysterectomy for benign gynaecological conditions between March 1998 and April 2004 were eligible for the study. Medical inclusion criteria were primarily uterine fibroids with bleeding disturbance or mechanical symptoms, but other benign gynaecologic disorders were also included. After the operation at least one ovary should be preserved. Exclusion criteria were genital malignancy, previous or present cervical dysplasia, rapidly growing myomas where malignancy could not be ruled out preoperatively, preoperative treatment with gonadotrophin-releasing hormone analogues, postmenopausal women without hormone therapy (HT), and severe psychiatric disorders.
The study conformed to the Helsinki declaration. The women were randomised to either SH or TH according to a random table, using serially numbered sealed opaque envelopes for the concealment of allocation. The women were assigned approximately 1 week before surgery and were informed of their assignment. The flow chart of the study population has been presented previously.19 Basically the study population for analysis in the previous study19 and this study is identical, except that in the present study the two women from the previous study19 with missing diaries completed their psychometric questionnaires on all occasions, and are therefore included in the present study. One woman had a diagnosis of ovarian cancer 10 months after the hysterectomy, and was thus excluded from this study. In summary, a total of 200 women were randomised in the study. Eight patients withdrew informed consent prior to surgery, nine after surgery before the 5-week postoperative visit and three women were excluded during surgery because of unexpected findings of ovarian tumours or malignant diseases (one benign ovarian cyst, one colon cancer and one uterine sarcoma). One woman was operated upon for ovarian cancer (stage 1A) 10 months after the hysterectomy, and was consequently excluded from this study. Thus, 179 women completed the study and constitute the study group. Ninety-four of these women were allocated to SH and 85 were allocated to TH.
The hysterectomy was performed through a transverse or low midline skin incision, decided by the surgeon based on the size of the uterus or previous surgery. The surgical technique of the hysterectomy was at the surgeon’s discretion. The only prerequisites according to the study protocol were that the uterine cervix was dissected extrafascially, and no peritonealisation was made in either SH or TH. The patients should preferably receive prophylactic antibiotics, with a single dose of 1.5 g cefuroxim and 1 g metronidazol intravenously.
The patient was discharged from the hospital when she was mobile, had sufficient pain relief with oral analgesics and performed spontaneous voiding with sufficient urinary bladder emptying. The research nurse contacted the patient and asked about her general wellbeing after approximately 10 days after discharge, and then weekly until the patient considered she had recovered.
The patient visited the outpatient clinic at 5 weeks, 6 and 12 months postoperatively. Clinical examinations were carried out at the 5-week and 12-month visits, and data on postoperative complications, complaints and present medication were recorded.
Serum levels of follicle stimulating hormone (FSH), testosterone and sex hormone-binding globulin (SHBG) were measured preoperatively and at 12 months postoperatively. The analyses were centralised to one laboratory, using a uniform method during the study period. Venous blood samples measuring haemoglobin (Hb) and erythrocyte volume fraction (EVF) were collected and analysed locally at each hospital preoperatively, and on day 2 postoperatively. If the patient received blood transfusion prior to the second postoperative day, the pre-transfusion value of Hb and EVF was registered.
Psychological functioning was measured at approximately 1 week preoperatively (baseline), and at 6 and 12 months postoperatively, by the following psychometric tests: Psychological General Well-Being (PGWB), Women’s Health Questionnaire (WHQ), State Trait Anxiety Inventory (STAI) and Beck’s Depression Inventory (BDI).20–23 In the context of this trial these instruments have been described previously.19
All analyses were on an intention-to-treat basis. The Student’s t test was used for the analyses of the descriptive and demographic normally distributed data. Yates’ corrected chi-square test and Fisher’s exact test were used for nominal data. Analysis of variance (ANOVA) for repeated measurements was used to compare the results of the psychological measurements between the two groups from baseline to 12 months follow up. Analysis of covariance (ANCOVA) was used to analyse differences in effect variables between the two groups at baseline and at 12 months follow up. Adjustments were carried out for age, smoking habits, nulliparity, sex hormone levels, and use of antidepressants and HT for climacteric symptoms simultaneously. Subsequent post hoc testing was performed with Fisher’s protected least significant difference (PLSD) test. Statistical significance was set at the 5% level.
Missing data in the questionnaire
If there was a missing answer to an item in a questionnaire, the missing score was substituted with the mean value of the rest of the scores in the questionnaire from the same patient.24 The frequency of missing answers was 0.7% for all of the questionnaires.
Inclusion of participants in ANOVA for repeated measures requires individual data for every moment of measurement. If a questionnaire was not completed by one of the women on a single occasion then the mean value of that specific questionnaire for the group at the same occasion was used in order to reduce the drop-outs from the ANOVA analyses. In all, 47 questionnaires were not complete (2.2%).
There were no differences in patient characteristics and indications for surgery between women randomised to TH and SH (Table 1). One hysterectomy, allocated to TH, was peroperatively converted to SH because of technical surgical reasons.
Table 1. Demographic and clinical data
|Age (years)||45.8 ± 5.2||45.8 ± 5.2|
|Gravida (n)||2.8 ± 1.4||2.7 ± 1.4|
|Parity (n)||2.2 ± 1.1||2.0 ± 1.1|
|Nulliparous (no. women)||8 (8.5)||7 (8.2)|
|BMI (kg/m2) preoperatively||25.6 ± 3.6||25.8 ± 4.3|
|BMI < 25 (no. women)||45 (48)||41 (48)|
|BMI ≥ 25 and <30 (no. women)||36 (38)||30 (35)|
|BMI ≥ 30 (no. women)||13 (14)||14 (17)|
|Smokers (no. women)||26 (28)||24 (29)|
|Previous laparotomy in lower abdomen (no. women)||40 (43)||29 (34)|
| Antidepressants (no. women)||2 (2.1)||4 (4.7)|
| Analgesics (no. women)||13 (13.8)||12 (14.1)|
| HT climacterium (no. women)||7 (7.4)||4 (4.7)|
| HT bleeding disturbances (no. women)||7 (7.4)||12 (14.1)|
| Hormonal contraceptives (no. women)||9 (9.6)||12 (14.1)|
|Medication 12 months postoperatively|
| Antidepressants (no. women)||3 (3.3)||4 (4.7)|
| Analgesics (no. women)||14 (15.6)||11 (12.9)|
| HT climacterium (no. women)||9 (9.7)||15 (17.6)|
|Indication of hysterectomy|
| Bleeding disturbances (no. women)||65 (69)||63 (74)|
| Mechanical symptoms (no. women)||21 (22)||15 (18)|
| Dysmenorrhea/endometriosis//pelvic pain (no. women)||8 (9)||7 (8)|
The results of the psychological measures are presented in Table 2. The repeated-measures ANOVA revealed no statistically significant differences in total scores between the two groups in any of the four questionnaires. However, all measures showed a significant change over time (P < 0.0001), reflecting improved psychological wellbeing after 6 months compared with the preoperative score, and this was retained 1 year after the operation. No interaction effects were found. The subanalyses of the different sections of PGWB and WHQ showed no significant differences between the groups in any of the sections (data not shown).
Table 2. Questionnaire scores from women before and after subtotal and total abdominal hysterectomy
|PGWB||Baseline||98.8 (15.6)||98.7 (16.2)|
|6 months||107.7 (12.8)||107.2 (13.3)|
|12 months||105.7 (14.1)||105.0 (16.0)|
|WHQ||Baseline||62.3 (15.0)||63.6 (15.4)|
|6 months||52.0 (12.5)||53.5 (13.3)|
|12 months||53.0 (13.3)||54.0 (13.4)|
|STAI||Baseline||36.0 (9.8)||34.9 (10.0)|
|6 months||33.2 (9.0)||32.5 (8.8)|
|12 months||32.6 (9.1)||32.4 (10.4)|
|BDI||Baseline||6.2 (6.0)||6.7 (6.3)|
|6 months||4.2 (4.8)||4.2 (5.2)|
|12 months||4.0 (5.6)||4.5 (6.1)|
No significant associations were found between mode of hysterectomy and any of the four psychological measures preoperatively or at 12 months in the ANCOVA models when adjusted for age, smoking habits, nulliparity, sex hormone levels, and use of antidepressants and HT for climacteric symptoms simultaneously.
A summary of clinical and surgical data, postoperative complications within 5 weeks and complaints at the 12 months follow up is shown in Tables 3 and 4. The operating time was significantly longer for TH compared with SH. Prophylactic antibiotics were used significantly more often in the TH group than in the SH group. Otherwise, no significant differences in surgical and clinical data were found between the groups. One woman in the SH group had another operation because of a major postoperative bleeding. The postoperative period was uncomplicated in 69 women (73%) in the SH group, which was not significantly different from the 65 women (76%) in the TH group.
Table 3. Surgical, clinical and laboratory data
|Midline (n)||17 (18)||17 (20)|
|Low transverse (n)||77 (82)||68 (80)|
|Operating time (minutes)||70 ± 23||80 ± 28*|
|Uterine weight (g)||451 ± 334||437 ± 300|
|Blood loss (ml)||221 ± 236||242 ± 200|
|Blood loss per time unit (ml/hour)||174 ± 138||173 ± 128|
|Blood transfusion (no. women)||4 (4.3)||3 (3.5)|
|Intravenous fluids per/postoperatively (l)||3.9 ± 1.5||4.0 ± 1.2|
|Prophylactic antibiotics (no. women)||81 (86)||84 (99)**|
|Epidural analgesia (no. women)||25 (27)||25 (29)|
|Duration of hospital stay (days)****||3.4 ± 1.2||3.4 ± 1.1|
|Haemoglobin preoperatively (g/l)||128 ± 13||125 ± 15|
|Haemoglobin postoperatively (g/l)||110 ± 17||108 ± 16|
|ΔHb (g/l)||−18 ± 13||−17 ± 12|
|EVF preoperative (%)||39 ± 4||38 ± 4|
|EVF postoperative (%)||33 ± 5||32 ± 5|
|ΔEVF (%)||−5 ± 4||−6 ± 4|
|FSH preoperatively (U/l)||16.2 ± 21.4||14.0 ± 14.4|
|FSH 12 months postoperatively (U/l)||22.3 ± 24.2||20.3 ± 25.4|
|Testosterone preoperatively (nmol/l)||1.40 ± 0.65||1.20 ± 0.63|
|Testosterone 12 months postoperatively (nmol/l)||1.27 ± 0.68||1.14 ± 0.64|
|SHBG preoperatively (nmol/l)||60.6 ± 29.5||61.7 ± 30.7|
|SHBG 12 months postoperatively (nmol/l)||54.5 ± 25.8||64.8 ± 40.6***|
|Testosterone/SHBG ratio preoperatively||0.030 ± 0.025||0.025 ± 0.022|
|Testosterone/SHBG ratio 12 months postoperatively||0.028 ± 0.020||0.024 ± 0.019|
Table 4. Complications peri- or postoperatively within 5 weeks, and complaints reported at the 12-months follow up
|Complications during hospital stay|
|Peroperative bleeding exceeding 1000 ml (no. women)||3 (3.2)||0 (0)|
|Re-operation, postoperative intra-abdominal bleeding (no. women)||1 (1.1)||0 (0)|
|Postoperative bleeding requiring blood transfusion (no. women)||4 (4.3)||3 (3.5)|
|Postoperative bleeding treated conservatively (no. women)||0 (0)||2 (2.4)|
|Unspecified infections treated with antibiotics (no. women)||2 (2.1)||2 (2.4)|
|Respiratory depression (side effect of opioids) (no. women)||0 (0)||1 (1.2)|
|Complications within 5 weeks of discharge from hospital|
|Wound infection/seroma (no. women)||8 (8.5)||6 (7.1)|
|Vaginal cuff infection/cervicitis (no. women)||1 (1.1)||1 (1.2)|
|Lower urinary tract infection (no. women)||5 (5.3)||3 (3.5)|
|Abdominal/pelvic pain (no. women)||4 (4.3)||3 (3.5)|
|Fatigue (no. women)||2 (2.1)||2 (2.4)|
|Subileus (no. women)||0 (0)||1 (1.2)|
|Other symptoms (no. women)||3 (3.2)||2 (2.4)|
|Complaints at the 12 months follow up||(n = 90)||(n = 85)|
|Regular vaginal bleeding (no. women)||18 (20)||1 (1.2)*|
|Climacteric symptoms (no. women)||4 (4.4)||5 (5.9)|
|Incisional hernia (no. women)||2 (2.2)||1 (1.2)|
|Cervical dysplasia (no. women)||2 (2.2)||0 (0)|
|Loss of libido/sexual dysfunction (no. women)||1 (1.1)||2 (2.3)|
|Abdominal/pelvic pain (no. women)||3 (3.3)||2 (2.3)|
|Genital prolapse/stress urinary incontinence (no. women)||2 (2.2)||2 (2.3)|
|Laparotomy/laparoscopy within the follow-up period (no. women)||2 (2.2)||2 (2.3)|
|Other complaints (no. women)||3 (3.3)||5 (5.9)|
|No complaints reported (no. women)||58 (64)||68 (80)**|
Major complications consisted of: per- or postoperative intra-abdominal bleeding exceeding 1000 ml; blood transfusion; respiratory depression; re-laparotomy and re-admittance for a subileus. Minor complications comprised abdominal wound infection or seroma, vaginal cuff infection, cervicitis, lower urinary tract infection, prolonged period with pain, fatigue, and other conditions occurring in the postoperative period causing substantial, but not severe, discomfort to the patient. Major complications as well as minor complications occurred equally in the two groups. Major complications occurred in six women (6.4%) in the SH group and in four women (4.7%) in the TH group. The corresponding figures for minor complications were 21 (22%) and 18 (21%), respectively.
At the 12 months follow up there were no associations between any of the psychometric measures and occurrence of minor or major complications when adjustments were carried out for age, smoking habits, mode of hysterectomy, sex hormone levels, use of HT and antidepressants. Significantly more women in the SH group reported complaints compared with the TH group (Table 4). The most prevalent complaint was cyclic vaginal bleeding from the cervical stump. Twenty percent (18 women) in the SH group reported blood-stained vaginal discharge or monthly bleeding after 1 year compared with 1% (one woman) in the TH group (caused by a granulation polyp in the vaginal vault) (P < 0.0001). However, the occurrence of blood-stained discharge or monthly bleeding was not associated with any of the psychometric measures (data not shown). Otherwise, no significant difference was found in the occurrence of single categories of complaints between the groups.
We found no difference in psychological wellbeing at 1 year after surgery between women who underwent TH and those undergoing SH. The patients’ psychological wellbeing improved significantly from baseline up to 6 months in both groups, and this was retained at 1 year postoperatively.
We did not perform an analysis of the women that were not enrolled in the study. Randomised trials in general select patients that de facto accept the randomised treatment. In our study this might have led to the selection of a more psychologically stable group of women to participate in the study, but it is also possible that this group was more focused on getting rid of the bother that led to hysterectomy, rather than on the operating method per se. This might help explain our findings that there was no difference in the psychometric measures between the groups. The results of the study can only be generalised to populations of women who are willing to accept any mode of hysterectomy. For women with a wish for a specific and particular mode of hysterectomy, our results may not be applicable.
During the study period another study on hysterectomy types was conducted, and some of the eligible patients were enrolled in that study.25 In the participating hospitals not all of the gynaecologists were active in the recruitment of women to the study, and therefore not all eligible women were asked to participate. Also, while the study was ongoing there was a trend towards performing vaginal hysterectomies that probably led to a slower inclusion of women to our study.26 On the other hand, the majority of the women in our study had an enlarged uterus with fibroids, making them not primarily suitable for vaginal surgery. We also excluded women with ovarian mass in order to preserve at least one ovary and therefore avoid surgical menopause, and this also slowed the inclusion rate. We enrolled 14% of the eligible women in our study. This is comparable with the figures presented in studies by Gimbel and Learman,17,18 whereas the other two randomised studies do not provide information about the inclusion rate.10,12 The length of the study period and the number of included women in the other four randomised trials of SH versus TH vary between 2.5–4 years, and 117–300 women, respectively.10,12,17,18 The fact that the rate of benign hysterectomy in Sweden is relatively low,13 and the inclusion and exclusion criteria were created with the intent of making the patient material homogeneous, restricted the number of women who could participate in the study. Under these circumstances we find our inclusion frame acceptable.
The present study was not blinded. Of all randomised studies of SH versus TH, only the study by Thakar et al.10 was blinded. They stated that the women were highly motivated and compliant in not performing self-examination during the 1-year follow up. However, it seems less likely that the ‘blinding’ will be retained in women who develop cyclic bleeding postoperatively or who are sexually active. With these factors to consider, a complete blinded study does not seem possible to carry out.
Prospective research has demonstrated that hysterectomy in general improves psychological wellbeing for most women.27–31 However, there is some evidence that women scheduled for hysterectomy have a higher degree of psychiatric morbidity,32,33 which may be a bias. We made effort to eliminate this by excluding women with severe psychiatric disorders from the study. Several factors may influence psychological wellbeing after hysterectomy. Women who had concomitant BSO have shown a poorer outcome in this aspect,29,31 but the results are not unanimous,34 probably because of the different designs of the studies and differences in concomitant HT. When looking at the four previously published randomised major studies on SH versus TH addressing psychological wellbeing, none of these made adjustments for bilateral oophorectomy or for sex hormone levels.35,12,17,18 In this study we adjusted the results for known or potential confounding factors of psychological wellbeing, i.e. age, parity, smoking habits, sex hormone levels and use of antidepressants and HT for climacteric symptoms, and all women had at least one ovary preserved after surgery in order to avoid surgical menopause.
Psychological wellbeing is a subjective term that covers a wide span of personal affective states. It is highly individual and therefore difficult to categorise. In scientific settings psychological measures often study variations or changes over time in relation to an intervention. In order to evaluate the psychological wellbeing we used a broad range of psychometric tests with four measures. Two of these (the PGWB and WHQ) give a generic measure of psychological wellbeing, whereas the BDI and the STAI are associated with specific psychological conditions: depression and anxiety. In comparison, the other four randomised trials35,12,17,18 all used generic tests: the Short-Form 36 (SF-36) or EuroQol Group questionnaire (EQ-5D). The British study35 combined SF-36 with a specific test, the General Health Questionnaire (GHQ-28), that is an instrument to detect current psychiatric disorders, and the Italian study12 combined it with a specific test, the body image scale, that measure the patient’s own perceptions of body image. The results of our four tests were unanimous, demonstrating no difference between modes of hysterectomy. We believe that the combination of several generic and specific tests, showing unanimous results, strengthen the conclusion of the present study.
The timing of completing the baseline questionnaires was specified to a fixed time 2 weeks prior to surgery in the Italian study,12 whereas the other three studies either did not describe the timing10 or stated a poorly specified interval.17,18,36 In our study the questionnaires at baseline were completed 1 week prior to surgery. The time between completing the questionnaire and the surgery may influence the woman’s perception of her psychological wellbeing.37 Thus, it seems important to use a fixed time for the measurements in order to correctly evaluate the development in wellbeing after surgery.
Regarding complications, our findings concur with earlier results from randomised trials, except that Thakar et al.10 found a significant increase in postoperative fevers in the TH group. The complication rates overall in the randomised and observational trials vary from 8% to 41%. In our material there was a total complication rate of 27% in the SH group and 24% in the TH group. Besides, there was no difference in the need for a doctor’s consultation, neither at 5 weeks postoperatively nor at 1 year postoperatively.
At 1 year a substantial number of women in the SH group complained about cyclic bleeding or blood-stained vaginal discharge, but this did not seem to influence the general psychological wellbeing, indicating that the large impact on psychological wellbeing is related to the removal of symptoms that led to the operation. In a meta-analysis of SH/TH, bleeding from the cervical stump was reported in 5–22% of cases.13 Although this bleeding does not seem to reduce the benefits for women regarding the effect of the hysterectomy, as shown in our material, we still conclude that information about this risk for bleeding should always be given in the preoperative counselling. The choice of an SH must also include a discussion of the need for continuing cervical smear testing regularly.
Overall we found no differences in psychological wellbeing between women with SH and TH up to 1 year after surgery. Although historically the uterus was believed to have an influence on feelings of attractiveness and vitality,38 we found on average a better psychological wellbeing 1 year after hysterectomy, independent of the mode of hysterectomy.
In conclusion, SH or TH does not influence the outcome in psychological wellbeing among women needing abdominal hysterectomies for benign indications. In general, psychological wellbeing improves after hysterectomy. In our opinion the observed increased use of SH cannot be justified based on the impact of psychological wellbeing.
Disclosure of interests
None of the authors or study group reports any conflict of interest concerning this study.
Contribution to authorship
PP and PK planned the study, and collaborated in the surgical procedures and clinical follow up. PP, PK and JB analysed the data. PP was the primary author of the manuscript. All the authors revised the paper and approved the final version.
Details of ethics approval
The study was approved by the ethics research committees of Linköping University and Örebro Regional Hospital.
The study was supported financially by grants from the Medical Research Council of south-east Sweden, the County Council of Östergötland and Linköping University.
The physicians and research nurses in the multicentre study group are thanked for their invaluable work and support of the study. In addition to the main authors of the manuscript, the Hysterectomy Multicentre Study Group in South-East Sweden includes the following gynaecologists: Drs Raymond Lenrick and Laila Falknäs, Ryhov Central Hospital, Jönköping; Drs Urban Jürgensen and Johan Holmberg, the County Hospital, Eksjö; Dr Christina Gunnervik, the County Hospital, Värnamo; Dr Lisbeth Angelsiöö, the Central Hospital, Kalmar; Dr Kenneth Krohn, Vrinnevi Central Hospital, Norrköping; Drs Leif Hidmark and Anna Saland, the County Hospital, Motala; Drs Fatma Bäckman and Björn Holm, Capio Läkargruppen, Örebro; and Drs Lars Fåhraeus and Mats Hammar, and psychologist Dr Klaas Wijma, the University Hospital, Linköping.