Risk of depressive disorders in women undergoing hysterectomy: A population-based follow-up study
Introduction
Hysterectomy is one of the gynecologic procedures most frequently performed worldwide (Nieboer et al., 2009). Yearly, 5.1 to 5.8 per 1000 women in the United States (Falcone and Walters, 2008), and 2.68 to 3.03 per 1000 women in Taiwan undergo hysterectomy (Wu et al., 2010). It has been reported that over 90% of hysterectomies are performed for benign gynecological conditions (Andryjowicz and Wray, 2011) including dysfunctional uterine bleeding, and uterine fibroids in premenopausal women, and the presence of a prolapsed uterus, or any other pelvic organ in postmenopausal women (Al-Hendy and Salama, 2006).
It has been proposed that women who undergo hysterectomy may suffer from psychological comorbidities (Ewalds-Kvist et al., 2005). For instance, depression, is considered the most common psychiatric risk after hysterectomy (Naughton and McBee, 1997). The term “post-hysterectomy syndrome” was coined by Richards in the 1970s; he reported that 70% of patients who underwent hysterectomy–oophorectomy met the criteria for depression, compared to 30% of women in a surgical control group (Richards, 1974). However, the findings of studies conducted during those years assessing the potential influence of hysterectomy on mood are inconsistent. Two cross-sectional studies suggested that women who undergo hysterectomy, regardless of their oophorectomy status, are more distressed than age-matched peers who do not undergo hysterectomy (Byles et al., 2000, Ceausu et al., 2006). On the other hand, two prospective studies found that women who undergo hysterectomy have a lower risk of depression after surgery, regardless of their oophorectomy status (Farquhar et al., 2006, Gibson et al., 2012). More recently, a meta-analysis conducted by Darwish et al. concludes that hysterectomy for benign conditions, without oophorectomy, is associated with an improvement in depression, compared to the pre-hysterectomy status (Darwish et al., 2014). Therefore, the actual psychological outcomes following hysterectomy are still an unsolved issue. In addition, most of these previous studies were conducted in Western countries, and cultural factors may have an influence on the reactions to hysterectomy in women from different ethnic backgrounds (Lalinec-Michaud and Engelsmann, 1989); therefore, it is essential to conduct studies among people from different cultural backgrounds. Furthermore, only a few of these studies were conducted using a nationwide population dataset, which may limit the generalizability of the results reported (Gibson et al., 2012).
The National Health Insurance program of Taiwan covers most of the population, and most medical institutions (91%) in the country (Chou et al., 2013). The National Health Insurance Research Database (NHIRD) is one of the largest insurance databases in the world. NHIRD contains all the claims from ambulatory and inpatient care, and provides valuable information for many epidemiological studies (Chang et al., 2012, Chen et al., 2014, Huang et al., 2014). The aim of this study was to investigate the risk of depression in women who underwent hysterectomy for non-malignant causes in Taiwan, using a population-based dataset obtained from the NHIRD.
Section snippets
Data source
This study used data from the NHIRD in Taiwan, which is a claims database maintained by the Department of Health and the National Health Research Institutes of Taiwan. The National Health Insurance program (NHI) was launched in March, 1995, and, by the end of 2010, over 23.07 million of Taiwan's 23.16 million residents were enrolled in this health insurance program (Chou et al., 2012). In 1999, under the NHIRD project, the Bureau of the NHI (BNHI) began to release to the public all data on
Clinical characteristics of the study population
Database records from 1689 women who underwent hysterectomy and from 6752 control subjects were included in this study. Patients in the hysterectomy group had a mean age of 45.4 years. Women in the hysterectomy group were more likely to have menopausal and post-menopausal disorders (p < 0.001), while a higher number of women in the control group received hormone therapy (p < 0.05). The median follow-up period for the control group was 10.0 years, which was significantly longer than the 7.3 years
Discussion
The results of this study analyzing the records of the Taiwanese population showed that the incidence of any type of depressive disorder in the hysterectomy group was 11.6 per 1000 person-years, while it was 7.2 per 1000 person-years in the control group. In addition, there was a significantly increased risk of depressive disorder (adjusted HR = 1.78) for women who underwent hysterectomy compared to matched controls during the follow-up period (p < 0.001). To the best of our knowledge, this is
Role of the funding source
This study was supported in part by grants from Taichung Veterans General Hospital, Taiwan (TCVGH-NHRI10407, TCVGH-1047324D, TCVGH-1047312C, TCVGH-104G211, TCVGH-1044002B) and the National Science Council, Taiwan (MOST 103-2314-B-075A-006).
Contributiors
Po-Han Chou designed the study, managed the literature searches, and wrote the first draft of the manuscript. Chin-Heng Lin and Chia-Li Chang performed the statistical analyses. All of the authors interpreted the results, revised the manuscript and approved the final version submitted for publication.
Conflicts of interest
None.
Acknowledgment
1. This study is based in part on data from the National Health Insurance Research Database provided by the National Health Insurance Administration, Ministry of Health and Welfare and managed by National Health Research Institutes (Registered number 101095, 102148). The interpretation and conclusions contained herein do not represent those of National Health Insurance Administration, Ministry of Health and Welfare or National Health Research Institutes.
2. The authors would like to thank the
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