Uterine pathologies could signal the decision for its removal especially when the presenting symptoms have defied either expectant or medical treatment. Sometimes, patients often find it difficult to reconcile their life without their womb, and this makes their decision to consent for surgery challenging. Even after hysterectomy, evidence suggests that women still mourn the permanent loss of their uterus, and they sometimes feel the loss of their femininity.
In this study, the outcome shows a tendency towards increased anxiety related disorders and a reduction of depressive illness following hysterectomy. Though, this observed inference was not statistically significant as a result of small sample size. However, it is arguable from the available data that MIH could occur either before or after hysterectomy. The occurrence of anxiety related disorders and depression among the participants before hysterectomy is in tandem with studies from other settings[12, 13, 23] Suggested reasons for this change include hormonal effects, changes in physical appearances, being married or widowed, history of previous psychiatric disorders and poor sexual performance amongst others[9, 24, 25]. Although these reasons may have accounted for this cohort in this study, it is also probable that the higher anxiety related diagnosis recorded could be due to the general uncertainty that is often associated with the outcome of surgery in our environment. In addition, the non-availability of skilled professionals such as clinical psychologists that could dispel any concerns could be contributory.
Unlike report from elsewhere[14, 26], though we recorded an increase in the proportion of those with anxiety related disorders by about 6.8 percent post- hysterectomy. Notwithstanding, the small sample size and the non-statistical significance of this observed pattern, the result could still offer some explanation in our setting. This finding may not be unconnected with the general lack of hormone replacement therapy among most Nigerian perimenopausal women that may reduce their psychosomatic symptoms such as emotional disturbances, anxiety and hot flushes. The lack is believed to be due to the high cost and non-availability. This peculiar challenge has led some Gynecologists within the country to advocate for ovarian conservation at hysterectomy in perimenopausal women to prevent earlier manifestation of psychosomatic and vasomotor symptoms. Expectedly, there was a significant reduction in the proportion of women with depression by 2.3 percent after hysterectomy. The plausible reason for this result may be due to the disappearance of their distressing preoperative complaints such as menorrhagia, disfiguring abdominal distension or chronic pelvic pain after the definitive care.
The fact that MIH still existed within the study population after the definitive hysterectomy raises concern about the possible association. This may suggest the possibility of a rethink from the opinion that hysterectomy is not associated with psychiatric disorder. In Nigeria, anecdotal evidence suggests that hysterectomised women may suffer emotional disturbance from the possible myth to matrimonial challenge. However, the exploration of the exact reasons from those noted with MIH will provide more insight in future research.
Like in many other previous studies[7, 27], uterine fibroid forms the commonest indication for hysterectomy in this cohort. This finding further reaffirms the high prevalence of leiomyomata among Nigerians. Exploration of the relationship between preoperative clinical diagnosis and post-hysterectomy MIH revealed that those with uterine fibroids and "others" had significant proportion of anxiety related disorders. However, depression was only noticeable among the uterine fibroid subset. The possible reasons for this association may include the presenting symptoms, the myth/misconceptions about the aetiology, and fear of recurrence. It may be difficult to phantom any reason for the two women that had depression among those with fibroid because of their limited number. Genital prolapse is commoner in the elderly. Therefore, women with this diagnosis could have viewed their clinical condition as part of aging process, and thus cope better than others. Likewise, the disappearance of disturbing menorrhagia in those with Dysfunctional uterine bleeding might explain the lack of any significant association with post-hysterectomy MIH.
In conclusion, this study suggests that mental ill health may complicates hysterectomy for benign uterine pathology among Nigerian women, and that anxiety related disorders may increase after operation with the highest proportion in those with clinical diagnosis of uterine fibroid. We advocate preoperative psychological assessment as a preemptive measure, and possibly incorporate clinical psychologist counseling as part of preoperative care to minimize MIH among patients scheduled for hysterectomy. Future research on the peculiar socio-cultural implications, use of larger sample size and effect of hysterectomy will be a significant addition to the available evidence in Nigeria.