Psychological Aspects of Gynecologic Surgery

Understanding how we view femininity and the role of women in our culture helps us to appreciate the impact of gynecologic surgery. Many responses to surgery reflect beliefs about human behaviors determined by intact genital organs. For instance, a prevalent attitude is that women cannot be physically attractive, feminine, or sexual without the presence of a uterus. Frequently, following hysterectomy, some women cease sexual contact with their spouses. Interventions by medical staff can be of benefit in aiding recovery even in nonpsychiatric cases.

Accurate information about surgery and expected outcome can help dissuade false cognitions held by both husband and wife. Physicians' own cultural identifications can hinder the communication of unbiased information. One area that falls into this realm is pelvic pain that often defies treatment and for which countless surgeries have been performed. These patients' complaints can be dismissed casually because the physician either is unable to discover an etiology or fails to decode the patient's request for caring.

Often a psychiatric consultation is sought when medical physicians and surgeons are frustrated in identifying an organic cause for the patient's symptoms or because the patient fails to experience relief from recognized therapies. Patients can become hostile because they feel implicitly accused by their doctor of being crazy, and a mutually unsatisfying and antagonistic relationship develops. Such situations are certainly not restricted to the treatment of women. However, women represent the majority of patients and often present with complaints such as menstrual cramps that reflect normal function as well as illness. The gynecologist can be in the uncomfortable position of being asked to treat signs of healthy reproductive function. Patients may demand treatments the physician feels are unnecessary, such as early elective hysterectomy. The gynecologist will justifiably feel tense because often after such a procedure he becomes the target of the patient's anger when emotional factors that may have exacerbated her presurgical symptoms are still unresolved and new complaints develop. A liaison with a psychiatrist can help the gynecologist clarify the developing dread that may occur in anticipation of further contact with such a patient and can aid the physician in feeling less obligated to prescribe medication or further surgery. Instead, the surgeon may become more at ease in beginning to counsel the patient and, at times, enlisting the patient's cooperation in obtaining a psychiatric consultation.

When dealing with uterine or vulvar carcinoma, different difficulties arise. Patients are often initially pleased by the surgeon's skill and concern and are relieved to be rid of an organ that now represents a threat to their life and the integrity of their sense of wholeness and self. The psychologic aftermath of cancer surgery and mutilation of the female genital organs has only recently been studied. Most gynecologists would welcome the elucidation of expected responses and advice on managing the difficult postsurgical course. The fact that there had been little research suggests the possibility that we were avoiding the problems and pain that many of these patients face.

Commonly, medical staff develop avoidant behavior in an attempt to ward off anxiety and negative responses to illness. Gynecologists and urologists become desensitized to genital surgery and its sequelae in an effort to control a variety of distressing reactions to incising psychically invested tissue. Many of our early fears of mutilation are organized during the oedipal phase of psychosexual development and revolve around fears of castration. Genital surgery powerfully revitalizes these imagined terrors and becomes a real injury for patients to endure. These women need to be provided with the proper presurgical and postsurgical counseling to minimize their irrational thoughts and enhance coping responses to support the strengths in their personality makeup. Closer psychiatric-gynecologic liaison can aid the surgeon in developing confidence in communication and counseling skills. The accessibility of patient-oriented psychiatric consultation is imperative in the management and treatment of psychotic patients.

Recent awareness in the last decade of the prevalence of early childhood sexual molestation further complicates predicted outcomes in this group of patients. Commonly, these women have not discussed their incest with anyone and are unlikely to reveal the history of their abuse unless specific inquiries are made. Even then, patients evade and conceal their past out of shame, denial, and pain. Any surgery, but particularly those that affect the breasts and genital region, can precipitate or reactivate a posttraumatic syndrome resulting in a spectrum of responses ranging from “la belle indifference” to atypical psychosis and major depression. Patients with a borderline personality structure may sustain significant ego regression and fragmentation in response to surgery. In both of these groups, self-mutilation and suicidal ideation are possible sequelae in the recuperative phases upon release from the structured and safe environment of the hospital.

Throughout the years, Western civilization has focused on the uterus as a source of physical and emotional illness in women. Hysterectomy derives meaning from the Greek hustera (womb). Early Greek notions were that many female disturbances were caused by a wandering womb. As this organ traveled through the body, it created symptoms at the site of its temporary lodging. Later, the term hysteria was applied to a variety of symptoms, primarily conversion reactions in women, believed by Freud and Charcot to derive from psychopathology stemming from internal sexual conflicts. At that time in Vienna, the symptoms of hysteria were regarded as a deliberate pretense, and patients with such complaints were considered malingerers. This pejorative attitude is probably still with us more than we would like to admit.

Because of the historical and cultural emphasis placed on the reproductive functions of the uterus and its relationship with feminine identity, the study of diseases of the uterus would stimulate interest in students of psychology. However, until the last decade, few well-controlled studies have been designed to detect the psychologic morbidity of hysterectomy. Large numbers of women are available for survey, because recent estimates show that 10% of adult women have undergone hysterectomy and that it ranks second to tonsillectomy for surgical procedures performed in the United States.¹ The following section will briefly review the major contributions in the last several decades.

In 1956, Drellich and associates randomly selected 23 premenopausal women with no previous psychiatric history and attempted to study their responses to hysterectomy.² Of this group, nine had carcinoma. One fourth of the women had delayed seeking treatment for at least 6 weeks, primarily in cases in which the major symptom was painless bleeding. The reasons offered for delay all reflected fears of loss of function, impairment of sexual relationships, or threat of serious illness. Four determinants of apprehension were described as:

1. Fear of surgery, mutilation, death, and pain
   
2. Fear of anesthesia, with loss of consciousness contributing to a fear of helplessness in a threatening situation
   
3. Fear of cancer
   
4. Concerns over the loss of the uterus, reflecting real, as well as symbolic, beliefs
   

Certainly the first three factors are common denominators in all patients undergoing major surgery. It is of particular interest to examine conclusions about the specific loss of the uterus.

Erroneous beliefs can be corrected by surgeons presurgically. Several women had misconceptions about the anatomy and physiology of their reproductive organs. Women expressed the fear that they would lose their interest in sex, as well as their physical strength, and that they required their uterus for a necessary cleansing function. One woman even felt that the uterus provided an internal organization around which she could pattern her life.

In the postoperative phase (3–6 weeks following surgery), the investigators observed that women who showed “complete casualness” prior to surgery tended to develop acute panic states marked by anxiety. Frank depressions were less frequent than agitation. These women had developed an increased sense of vulnerability to injury that required reassurance from the surgeon in order for them to return to their normal level of activity without fear of causing internal injury to themselves.

In 1958, Hollender proposed an interesting theory in an attempt to explain some of the fears women have of physiologic disruption following hysterectomy.³ He felt that observed fears of loss of sexual functioning might be explained by an anatomic model. If women were to compare their invisible organs, uterus and ovaries, with the visible male counterparts, penis and testicles, the conclusion that surgical excision dictates loss of sexual ability would be a logical one. Therefore, we should assume a naiveté in our patients about organ function. An early brief instruction about female anatomy, even in patients who appear highly sophisticated, may help dispel misconceptions and avoid postsurgical difficulties. And, as unaware as women may be about the functioning of their bodies, we can assume that their spouses are even more in the dark. Helping husbands correct their misconceptions may aid women enormously in readjusting to an intimate relationship.

Hollender's study noted agitated depression twice as often in women admitted to a psychiatric hospital following pelvic surgery versus other abdominal operations.³ Surgery for benign disease has more psychologic morbidity than surgery for malignant disease when the affected organ is seen as a threat to survival. Loss of the reproductive organs may have a great impact on some women's sense of completeness and feminine identity. As stated by Hollender, “It might be further assumed that those women who had been least secure in their concept of their own femininity would be most vulnerable to an operation on the genital organs … the more intense will be the need for defensive measures to cope with the threat to the self-image imposed by the symbolic meaning of the removal of pelvic (sexual) organs.”³

Childless women in their early 20s undergoing hysterectomy for nonmalignant illness showed the greatest maladjustment.⁴ We might conclude that maturity adds adaptability and that in the younger age groups, outcome of those women who are developmentally immature is worsened by their reliance on fewer and less flexible coping mechanisms. The less accepting a woman is of herself and less aware of her abilities, the more likely she will be to accentuate appearance in an effort to comply with her cultural stereotypes of femininity. There may also be an overvaluing of her internal organs because productivity is still defined as fecundity. These women have not yet developed the self-image of being economically productive within the culture.

Barglow and associates compared tubal ligation with hysterectomy.⁵ They found a significant relationship between presurgical anxiety and poor prognosis. The group with the worst outcome was the women who underwent hysterectomy. The disruption hysterectomy can cause is not simply a reaction to loss of fertility but rather an attack on a woman's system of beliefs about herself and her ability to interact with her environment.

Other authors have attempted to compare hysterectomy with cholecystectomy in an effort to control for the effects of abdominal surgery. Barker found that the rate of psychiatric referral was 2 1/2 times higher for hysterectomy compared with cholecystectomy, and 3 times higher than that of the general population.⁶ His results supported the findings of early investigators in that there was a marked increase in referral in women without documented surgical pathology. Most patients who presented with depression lacked pelvic disease, experienced marital disharmony, or had previous psychiatric difficulties. These results were upheld by Steiner, who noted a threefold increase in psychopathologic symptoms in women undergoing hysterectomy as compared with cholecystectomy.⁷

A more recent study showed significant postsurgical depression in those women who were shown on self-rating scales to be depressed prior to surgery.⁸ It was also noted that depression was higher in women who were under 35 or who had fewer than 12 years of education, which supports the conclusions of earlier reports.

Lalinec-Michaud, Engelsmann, and Marino discovered that 20% of the 152 women they studied viewed hysterectomy as a threat to their self-concept.⁹ This finding was more likely after emergency surgery (less than 1 month to prepare) than after elective surgery. This group also expressed a fear of cancer more often. However, within a year, the women in the study returned to presurgical levels of sexual functioning.

Other recent surveys indicate that the availability of a supportive confidant provided protection from depression in post-hysterectomy patients.¹⁰ Böös and Schoultz found that women in whom the ovaries were preserved had better sexual adjustment than women with hysterectomy and oophorectomy, despite adequate estrogen replacement.¹¹ Sixteen percent of all cases described sadness, grief, emptiness, and depressive thoughts. Feelings of lowered femininity and equating loss of fecundity with being old were other common themes.

Over the past 40 years we have seen recurrent themes of depression and alteration in the perception of gender role based on the presence or absence of internal sexual organs. Most studies have focused on the effects of surgery. A few authors have looked at interventions, and some of those conclusions will be summarized at the end of the chapter.

If hysterectomy can evoke strong psychologic reactions such as exacerbation of a depressed mood or disorganization of the ego and self-concept, then vulvectomy must be worse. The de-emphasis on female external genitalia is echoed throughout our society. Sex education diagrams for children name the internal female organs but rarely provide even a general term for the external organs. General prohibitions of masturbation in girls have hindered women from familiarizing themselves with their genitalia, resulting in the development of vague concepts of what their genitals look like. The proximity of the anus adds further confusion to the what-and-where of female anatomy for the curious youngster. We need to bear in mind that the women we treat may maintain the anatomic misconceptions they developed in early childhood. Therefore, despite great intellectual ability and success, many women may exhibit disorientation and confusion following vulvectomy because of imprecise perceptions of their anatomy. Their presurgical anxiety, fear, and use of denial hamper the registration of accurate information provided by the surgeon.

Early autoeroticism is focused on the vulva and perineum and is manifested by direct manual stimulation. By age 3, this behavior is organized around the external sex organs and is intentional. Traditional analytic thought is that an avoidance of the vulva occurs later because of the castration anxiety and anatomic inferiority, or penis envy, experienced by girls during the oedipal phase of development (approximately ages 3–6). As mentioned earlier, this is probably a more advanced and focused fear of any injury that threatens the integrity of the body. During latency (age 6 to puberty), it is generally felt that girls practice more indirect means of self-stimulation, such as bicycle riding, sliding down banisters, and rhythmic rocking. This change may reflect a growing awareness in the girl of parental attitudes of unacceptability of masturbation in girls, despite the view that it is normal and appropriate in boys.

With the onset of puberty and vaginal readiness for intercourse, sexual interests are heightened. The adolescent now actively attempts to integrate genital function and self-concept. Sexual fantasies begin to revolve around vaginal penetration, and masturbation may include the exploration of the vagina, with less emphasis on the vulva.¹² The adolescent girl is believed to advance developmentally because she is able to realize her reproductive potential and thus soothe the narcissistic injury inflicted earlier when she realized that she did not possess a penis. Now the girl begins to use mature cognitive abilities to develop a sense of femininity and identification with the mother as a sexual being, and she can begin to use abstract thinking to develop a conceptualization of the uterus. However, it is unclear how much re-evaluation of her primitive concepts of the vulva is occurring. It is possible that surgical excision of the external genitals may have more profound effects than hysterectomy because it results in the loss of one of the earliest autoerogenous zones and may evoke primitive sexual conflicts and fears of punishment and loss of body parts.

The first controlled study to assess the effects of vulvectomy was done in 1980.¹³ The reactions to hysterectomy for carcinoma were compared with reactions to vulvectomy for carcinoma. The subjects were controlled for 5-year survival, cultural group, age, and education. Endometrial carcinoma was chosen because the 5-year survival is comparable, it requires the removal of genital organs, and it can cause mechanical disruption to the introitus similar to that of vulvectomy.

Two thirds of the vulvectomy patients were both clinically depressed and anxious, as determined by test scores, compared with none of the hysterectomy patients. Only two vulvectomy patients, who were approximately 7 years postsurgery, reported any sexual contact, and this consisted of embracing and fondling their partner's genitals. None of the vulvectomy patients were having intercourse, as compared with 81% of the hysterectomy patients.

Another striking difference was the number of women who had difficulty accurately naming the parts excised after vulvectomy (45%), responding with answers such as, “Ask my doctor.” Interviews with respondents in the vulvectomy group confirmed the test scores. One patient who had divorced shortly after her vulvectomy developed a suicidal depression in the 2 years following surgery. On receiving a questionnaire 4 years postsurgery, she told a nurse, “I don't believe I ever had cancer. I don't understand why they did surgery, maybe it had something to do with my masturbation.” Other isolated impairments in reality testing were noted in the vulvectomy patients. One woman no longer would wear slacks because she feared the absence of her vulva would be noticeable. Another woman discovered “something was wrong” and avoided seeking medical advice for 9 months, thinking it was a hemorrhoid. After surgery she felt she couldn't “look anyone in the eye” and avoided looking at herself in the mirror. Her greatest concern was that she felt singled out, that it was God's doing, and that no other woman had ever had this type of surgery. Despite reassurances that other women had the same surgery, she insisted, “No, I'm the only one.”

One woman, not in the study, who was 10 years post-simple vulvectomy, was satisfied with her sexual adjustment. She attributed this to a lifetime of relatively free sexual exploration, previous psychotherapy focused on sexual guilt resulting from a childhood rape, and preservation of the clitoris, which she felt helped her regain the sense that she could still take care of herself. This woman later had a hysterectomy for cancer, which she described as “a breeze … I felt if I could overcome that feeling of being mutilated after the vulvectomy, I could take anything.”

A major concern of women was the fear that their husbands would abandon them. These women acted on the belief that their spouses would find them as sexually unattractive as they felt they were. They seemed to avoid sexual contact and even reported loss of sexual drive. Freud described the intact vulva as a potent evoker of castration anxiety in men:

The terror of (the decapitated head) Medusa is thus a terror of castration that is linked to the sight of something … it occurs when a boy, who has hitherto been unwilling to believe the threat of castration, catches sight of the female genitals, probably those of an adult, surrounded by hair, and essentially those of his mother.¹⁴

If Freud were correct, then a mutilated vulva would arouse marked anxiety and fear of vulnerability in the spouses of vulvectomy patients. No one has carefully studied husbands' reactions to gynecologic surgery, a critical variable in our patients' postsurgical adjustment and reacceptance of themselves as sexual, feminine women.

Another important factor is age. Most patients develop vulvar carcinoma in the menopausal decade when the deterrents to sexual activity, menstruation and pregnancy, are waning. The increased sexual freedom achieved at menopause that compensates for the loss of fertility is not attained by these women and may add to their despair and a conviction that their cancer is a punishment for earlier sexuality. As one patient said, “You look forward to your kids growing up and no unwanted pregnancies, and then this happens. I feel I'm cheating my husband.”

Another factor that may add to the feeling of depressive isolation and decreased ability to test reality is the paucity of words to describe their loss. Often these patients have no knowledge of the anatomy of their genitalia and are unable to comprehend what functions they have lost, but more important, what they have retained. Lerner commented that

Because visible and sensitive aspects of the girl's genitals are not labelled for her, the girl may feel that she does not have “permission” to develop into a sexually responsive and complete woman … penis envy may be a symptom expressing the wish to have one's female sexuality “validated,” but which also serves to block this forbidden wish by inhibiting sexual responsiveness and pride in femininity.¹⁵

Since this first study there have been several other investigators who have examined the aftermath of vulvectomy.

Andersen and colleagues looked at sexual functioning after treatment for in situ vulvar cancer.¹⁶ Specific disruptions in the phases of excitement and resolution, and to a lesser extent, orgasm, were noted. Sexual desire and patterns were maintained. Thirty percent of the sample group remained sexually inactive at the time of follow-up. The study group had a two- to threefold increase in levels of sexual dysfunction. In addition, mood inventory indicated significantly elevated levels of impairment. Women with vulvectomy were reluctant to initiate new relationships because of the genital changes. Very high numbers of controls and study patients requested information on sexual functioning and the inclusion of their partners in sex education.

Weijmar Schultz and colleagues demonstrated a return to pretreatment levels in partner satisfaction after studying a small group of women for 2 years.¹⁷ The ability to induce sexual arousal and orgasm was seriously disturbed at 6 months postsurgery. Half the original sample of 13 couples resumed intercourse at pretreatment levels by 1 year. Positive genital sensations did not appear to return until the second year after surgery. Partner satisfaction and sexual participation remained constant despite significant disruption in physical responsiveness.

In larger studies, Corney noted that half the women reported a deterioration in their sexual relationships.^18,19,20 Fifteen to seventeen percent of the women never resumed sexual relationships. More than two thirds were markedly or severely depressed. Almost two thirds of the women younger than 50 did not resume sexual contact. Ten percent of the women had the irrational fear that the cancer could be sexually transmitted.

As in earlier studies, distress was highest in the younger women. This group rated marital difficulties the highest. All the younger women with partners resumed intercourse, but none of the single or widowed women initiated new relationships.

Indicators of poorer outcome remain consistent throughout studies of hysterectomy and vulvectomy cases. All women can benefit from presurgical and postsurgical support. Those groups that may require additional attention are the following:

1. Women who have not yet passed through the menopause
   
2. Nulliparous women
   
3. Women with less formal education, and particularly those women with less developed knowledge of their reproductive anatomy and physiology
   
4. Women with a prior psychiatric history
   
5. Women depressed or anxious prior to surgery
   
6. Women undergoing emergency surgery, and especially cases with no proven surgical pathology
   
7. Women with carcinoma requiring radical surgery
   
8. Women undergoing radical surgery who are not in significant relationships prior to surgery
   

The presurgical period is probably the most critical. Surgeons should assess for the risk factors listed above. Patients will usually report past depressive episodes and psychiatric hospitalizations and treatment, if asked. Also of use are validated depression, anxiety, hostility, and somatization scales that can be quickly administered and often can reveal affective states that the patient does not verbally report. At least the surgeon can begin to separate out those patients most at risk for marked psychiatric morbidity and can seek assistance in case management. Ideally, the treatment team would include a gynecologist, psychiatrist, and nurse. Unfortunately, this is usually limited to a university hospital setting. However, private physicians might be able to enlist the cooperation of a psychiatrist in the community who would be interested and sympathetic to the needs of the physician and patient.

Traditional medical education has not been designed to train all physicians in developing confidence and skill in interviewing techniques. Most are highly proficient at taking a review of systems and eliciting signs and symptoms of physical illness. However, a great shyness exists in asking personal questions such as satisfaction in one's sexual life, marriage, and career. In many cases, gynecologists refer to psychiatrists, problems that could be managed in their own offices with adequate coaching of empathetic interviewing skills from a psychiatric colleague. Case review would also help identify those patients who should be treated directly by a psychiatrist.

One thing we do know is that patients, out of fear, tend to deny, to varying degrees, the hard facts of illness and treatment. Often, patients questioned after the gynecologist has explicitly and carefully explained their illness and treatment demonstrate enormous gaps in understanding and yet are fearful of asking for clarification. Therefore, procedures should be explained repeatedly with the use of visual aids and vocabulary instruction in anatomic terms to aid communication. The health professional should assess the patient's comprehension in an effort to minimize postsurgical confusion.

Spouses should be included because they may ask questions the patient is hesitant to ask, and approaching surgery as a supportive unit can aid in the solidification of the marital partnership. Both partners need explicit information about what surgery will do and how it may improve or interfere with their sexual relationship. Written material is helpful because it allows the patient to review what has been discussed in an environment less stressful than the physician's office. Some physicians even use tape cassettes of the office discussion for the patient to review. Patients can be instructed to write down questions that arise to be discussed at the next meeting.

An excellent model developed and applied by Dulaney, Crawford, and Turner focused on women undergoing hysterectomy.²¹ Their model can be equally well applied to vulvectomy patients and other treatment groups.

The key components of this model were as follows:

1. Names of patients were obtained presurgically, and these women were contacted by phone. A class was offered that was also publicly marketed. The focus of this early encounter was to allow for discussion of sexual concerns. Male partners were offered a separate class so as not to hamper discussion in the women's group. The presurgical class reviewed the surgical procedure, female reproductive anatomy and physiology, expectations of being in the hospital, and coping with the emotional aspects of the procedure. High-risk patients were offered individual counseling after the class, and their physician was notified for referral if additional counseling was indicated.
   
2. The program coordinator provided continuity of contact by performing the nursing assessment upon admission. Tours of the hospital unit and videotaped educational material were made available to the patient and her significant other.
   
3. A support group was offered monthly after surgery. Women could attend as many meetings as they found helpful.
   

Outcome studies in this group showed that as participation in the presurgical class increased, there was a drop in utilization of the follow-up support group. Patients in the program felt better prepared for surgery. The cost-effectiveness of the program is measurable, and nursing time is saved by providing group orientation.

Wallace also suggested that patient and partner be trained in wound care prior to radical procedures, thereby decreasing discomfort induced by this kind of care.²² She also advised providing a variety of media (books, films, and instruction) on alternate forms of sexual contact, including nongenital stimulation and different positions for intercourse. These suggestions support the consistent interest that study patients have shown in increased information on sexual function and inclusion of partners in the discussion.

Further investigation into the helpfulness of outreach groups is needed. These have been invaluable tools in the treatment of breast cancer. The experience with vulvectomy patients and other patients with severe mutilations demonstrates a strong sense of isolation and differences that may be reduced through contact with patients who have made a good adjustment to such injuries.

If we focus on the needs of our patients, a closer liaison between psychiatry and gynecology will be the natural outgrowth from which both professions will benefit. But ultimately the greatest benefit will be obtained by the women and men who seek out our services.