Preoperative Evaluation and Preparation of the Gynecologic Patient
Nehama Dresner and Gilla Davis
Table Of Contents
Nehama Dresner, MD
Gilla Davis, MD
UNDERSTANDING THE GYNECOLOGIC PATIENTS FACING SURGERY
THE PHYSICIAN-PATIENT RELATIONSHIP
PSYCHOSOCIAL ASPECTS OF GYNECOLOGIC SURGERIES
THE “DIFFICULT” PATIENT
THE PSYCHIATRIC CONSULTANT
Gynecologic surgery, more than other surgeries, evokes a variety of psychological and emotional issues.1 In addition to the usual concerns surrounding any surgical procedure (pain, disfigurement, debility, outcome), gynecologic surgery carries with it the specter of loss of fertility, femininity, sexuality, and attractiveness.
The Greek word for uterus, hystera, became the root word of a number of medical conditions applied to women, establishing early on the inextricable interplay between psyche and soma, mind and body, and the significance of the female reproductive organs. Galen, the Greek physician of the second century A.D., attributed most of the ills of women to the womb. Thus the word hysteria (“wandering uterus”) developed a negative connection between physical and psychological symptoms because the uterus was believed to be central to diseases in women. The term hystero-neurosis, coined in 1877 by an American gynecologist, traced the source of illness in women to uterine pathology. The wandering uterus was believed to cause somatic symptoms in the body parts it visited, hence the connection between physical symptoms and hysteria.2 Given the historic depiction of the female reproductive tract as the source of physiologic and psychologic distress in women, one can begin to anticipate the layers of issues facing both the physician and the patient for whom gynecologic surgery is indicated.
|UNDERSTANDING THE GYNECOLOGIC PATIENTS FACING SURGERY|
A variety of factors, such as personality and cognitive style, an awareness of psychological issues, and self-concept can help us understand and approach the gynecologic patient facing surgery. Tendencies toward passivity or assertiveness, rationalization or blaming, will predict how a patient will interpret and respond to symptoms and experience her caregivers. For example, a patient who minimizes complaints may be using denial. This defense may facilitate her recovery by allowing her to focus on other issues, or impede it by interfering with compliance to treatment. The patient whose complaints appear excessive in light of physical findings might be somatizing. The unconscious motivation for this behavior might represent either secondary gain (obtaining some gratification from the sick role) or primary gain (the unconscious avoidance of an unconscious conflict). The complaining patient may be depressed, and her focus on physical pain may serve as a way of communicating other (emotional) pain. Of course, it is also possible that the complaints are organic in origin. The possibility of drug reactions or interactions should be considered. In any case, the pain is real and should be dealt with compassionately.
The conspicuous absence of anxiety may indicate inappropriate motivation for the surgery, or it may signal massive denial, which often breaks down after the surgery. Excessive anxiety should always be managed before the surgery. Appealing to the patient's higher-level defenses, such as intellectualization, is often helpful.
A psychiatric interview and the judicious use of psychological testing can be invaluable tools for pinpointing more serious problems, such as agitated depression or incipient psychosis. They may also confirm less severe disturbances, such as medically significant anxiety, which may warrant medication. Once again, treatment of these problems before surgery is optimal and can help prevent serious postsurgical problems.
Ideas, attitudes, and expectations, as well as accurate or erroneous perceptions of the illness or treatment plan, constitute the cognitive element. They influence how a patient processes new information, and create possibilities for distortion and misunderstanding. An appreciation of personality and cognitive style will increase the physician's awareness of possible misconceptions, unrealistic expectations, or counterproductive attitudes and will increase the likelihood that therapeutic efforts will succeed.3
A woman who identifies herself as maternal and nurturing, anticipating motherhood as a vital life role, but who now faces sterilization, or a woman who perceives herself as intact, complete, and desirable because she is healthy, but now faces cancer, may experience surgery as a threat to her identity. Understanding how a patient sees herself and what she values about herself can help us understand more deeply the impact of the proposed surgery.
|THE PHYSICIAN-PATIENT RELATIONSHIP|
Perhaps the most fundamental aspect of the physician-patient relationship is the development of rapport: that is, an understanding between them consisting of trust and mutual respect that facilitates open and empathic communication. The initial approach to the patient by her physician or house officer often sets the tone for the quantity and quality of information that is forthcoming. In addition, in a study of breast cancer patients' psychological adjustment to their cancer, the physician's caring attitude was perceived by patients as the most important factor, outweighing information-giving.4
If the patient has an ongoing relationship with the physician, some rapport has already been established. However, that rapport should not be taken for granted, given the special concerns and stresses brought on by the anticipation of and recovery from gynecologic surgery. Even a patient with whom a physician has a long history may be timid about addressing new concerns, such as risks associated with surgery or postoperative sexual functioning.
If the physician-patient relationship is a new one, assumptions cannot be made about the patient's nature or expectations, and special attention should be given not only to verbal communication, but to body language as well. Liberties such as casual speech or humor should not be taken in a first encounter until a mutual understanding has been established. In meeting with any patient, new or known, sarcasm, joking, and self-revelation can be experienced by the patient as dismissive and self-indulgent. Empathic listening, mixed with restraint, provides a safe and receptive forum for physician-patient communication.
Maintaining appropriate physical distance and respecting a patient's dignity are essential elements in the preoperative evaluation. The initial evaluation should be performed face to face, with the patient fully clothed. Open-ended questions elicit history and medical facts while communicating respect for the patient's perceptions and concerns, and they give the physician valuable insight into the patient's personality and coping style. In addition to the content of the “chief complaint,” the manner in which it is communicated and associated behaviors can be revealing (e.g., patient is jittery or nervous, has poor eye contact, is distant, uses vague terminology, has an impoverished knowledge of reproductive physiology). Such observations provide opportunities for intervention, such as putting an anxious patient at ease (e.g., “You seem nervous. Is there something I can do to make you more comfortable?”) or providing basic facts for patients with a limited fund of knowledge by employing figures or models.
Other specific areas of inquiry may provide valuable information during a preoperative evaluation:
In 1993 a British psychiatrist studied 500 women and found that 20% described the experience of a vaginal examination or colposcopy as being “very distressing” or “terrifying.” Of these women, 30% met the criteria for post-traumatic stress disorder,7 an anxiety disorder generally associated with veterans of war or other severe trauma.
Clearly, not all women experience the gynecologic examination so negatively. A careful history will sensitize the clinician to special concerns, which should be discussed with the patient. For example: “I understand that you've been frightened and uncomfortable during previous examinations. Let me know what I can do to make this easier for you.” Loss of control and a feeling of powerlessness are frequent accompaniments of the pelvic examination. Allowing the patient some area of control, such as enlisting her guidance and participation in the process, can facilitate a less traumatic experience and enhance the rapport between the physician and patient.
In the surgical patient, the added layer of fearfulness about what the examination might reveal compounds an already sensitive situation. Information about the procedure, preparation of instruments (e.g., warming and lubrication), and gentleness are important factors in reducing distress among patients undergoing a gynecologic examination.8 Dignity can also be preserved by avoiding unnecessary exposure and refraining from making inappropriate comments in an attempt to ease the tension.
Mental Status Examination
Any general medical assessment should include a formal mental status examination, which includes 10 basic parts: general appearance, speech, psychomotor state, mood, affect, content of thought (e.g., delusions, hallucinations, suicidality), process of thought (e.g., flight of ideas), insight, judgment, and the cognitive examination (orientation, memory, concentration, abstraction, higher intellectual functioning).
Of specific importance in the gynecologic patient facing surgery is an assessment of depression and anxiety. Sleep and appetite disturbance, loss of motivation and libido, anergia, hopelessness, and suicidal ideation are common symptoms of depression. A feeling of nervousness, tension, irritability, and excessive worry paint a picture of anxiety.9 Incorporating a psychiatric “review of systems” into the general medical history not only provides the clinician with a complete background, but conveys the physician's interest in all aspects of the patient's well-being, as well as his or her openness to addressing these issues as a part of patient care.
An essential part of the preoperative evaluation is an assessment of the patient's ability to understand the nature of the intervention being proposed, the proposed benefits, and the potential risks. A discussion of benefits and risks can enhance the physician-patient relationship and assist the patient in her practical and emotional preparation for surgery.10
Many factors interfere with the communication necessary to obtain informed consent. Psychological factors, such as denial or minimization, and psychiatric illness, such as depression or psychosis, are obvious concerns. Language differences, intellectual capacity, and speech or hearing impairment must also be considered.
Obtaining informed consent consists of the successful communication of, and the patient's subsequent unequivocal agreement to, the following:
There are some circumstances in which the patient may not have the capacity to fully understand the information presented or to make a competent decision based on this information. Psychiatric colleagues can be quite helpful in assessing a patient's capacity to give informed consent. It should be noted, however, that the presence of a psychiatric disorder, even a serious one, does not in itself preclude the ability to give informed consent.
If the physician is concerned about the patient's ability to give informed consent, it would be prudent to secure a psychiatric consultation, especially when sterilization is an issue. In a life-threatening situation, the physician has the authority to proceed with treatment in most situations, but close collaboration with a consulting psychiatrist and hospital legal counsel will be crucial in deciding what actions to take.
Determining competency is a legal decision that cannot be made by the physician. If the patient is ultimately found by a court to be incompetent, a legal guardian will generally be appointed who has the authority to consent to surgery if it is deemed necessary.
CASE REPORT: INFORMED CONSENT.
A 56year-old postmenopausal, single, African-American woman, gravida 5, para 5 presented to the emergency room with vaginal bleeding. She was noted to have a necrotic cervical lesion, which was found to be uterine sarcoma with probable bladder and rectal invasion. The patient refused surgery, and a psychiatric consultation was requested to assess her understanding of her condition and the consequences of her decision to refuse surgery.
Although the patient was “simple” intellectually and uneducated, she did understand that she was bleeding because of a cancer, that surgery and chemotherapy were the recommended treatment, and that the prognosis was poor even with treatment. She had no prior history of psychiatric illness or treatment. She was not depressed, had no delusional beliefs about her illness or the proposed treatment, and was not actively suicidal, although she knew her condition was serious and her decision to refuse surgery might affect her survival. Cognitive examination was intact, other than some deficits in general knowledge and suspicion of below-average intelligence.
Psychological testing was obtained to assess the patient's level of intelligence (full-scale IQ = 76, indicating mild mental retardation) and her ability to understand the consequences of her decision. Based on the results of the psychological and clinical examinations, it was confirmed that although the patient's choice was in conflict with the recommended treatment, and although she had some intellectual deficit, she did have a sufficient understanding of the nature of the medical problem, the nature and purpose of the proposed treatment, and the associated risks and benefits in order to give informed consent. She received chemotherapy but no surgery and was discharged to a nursing home to ensure adequate care between treatments.
|PSYCHOSOCIAL ASPECTS OF GYNECOLOGIC SURGERIES|
The gynecologic surgical patient is subject to all of the stresses generally associated with surgery. Strain and Grossman11 described seven categories of psychological stress affecting the sick, hospitalized patient:
These stressors, coupled with premorbid personality traits, help shape the behavior of the gynecologic patient during her hospitalization and afterward.
The following is a discussion of psychological issues especially related to specific procedures.
Although two recent prospective studies showed that hysterectomy does not in itself lead to depression,1,12 certain premorbid personality traits may lead to hysterectomy. It has been suggested that there is an increased prevalence of hysterectomy in women with panic disorder5 or multiple somatic complaints on the basis of psychiatric rather than gynecologic illness.12 A prior history of depression, age less than 40 years, conflict over childbearing, and lower educational level increase the risk of posthysterectomy depression.
Reports differ on the issue of sexual dysfunction after hysterectomy. A retrospective study of 89 women who had undergone hysterectomy and oophorectomy published in 1977 found that 37% complained of a deterioration in their sexual relationship. Preoperative expectations of sexual alteration were found to be significantly associated with subsequent sexual dysfunction, specifically inhibited sexual desire.13 A more recent prospective study found no significant postoperative changes, except in women with “hysteria,” who reported increased “sexual indifference.”12 A Swedish group reported that women who underwent oophorectomy along with hysterectomy experienced a deteriorated sex life compared to women with preserved ovaries.14
It is fairly common for patients to experience some mild, transient sadness or depression after a hysterectomy. This is particularly true of the nulliparous woman who may be grieving the loss of childbearing. Even if she has children or is menopausal, the loss of this significant organ may trigger a grieving process not unlike that experienced after the death of a loved one. Preparing the patient for this experience of loss may help her integrate the range of postsurgical emotions as a normal process, making her reaction less frightening to her and her partner. Repeated detailed discussions of the acute and long-term impact of the proposed surgery on sexual functioning should be held with patients (and their partners) on more than one occasion, before and after surgery, along with an ongoing openness to questions and concerns.
CASE REPORT: HYSTERECTOMY.
Mrs. E. is a 37-year-old married white woman, gravida 2, para 2 with a 5-year history of migraine headaches that coincide with the luteal phase of her menstrual cycle. Multiple attempts at symptomatic treatment of the headaches were ineffective, and the patient insisted on a hysterectomy to treat her illness. Despite significant misgivings on the part of the physician, a hysterectomy was performed. The patient's headaches disappeared for several months, only to recur sometime later. The patient was angry and felt that she had been mistreated. Psychiatric consultation revealed a woman who was significantly depressed and who had multiple unresolved issues of anger with her mother.
This case demonstrates how psychiatric factors can have an impact on a patient's experience of physical symptoms, and how a review of these factors could influence a clinician's decision to operate. In this case, a psychiatric review of systems, as described earlier, might have brought to light several layers of distress that surgical treatment would have been unlikely to address.
CASE REPORT: MYOMECTOMY/HYSTERECTOMY.
Mrs. G is a 47-year-old nulliparous, single, white woman who presented to the outpatient gynecology clinic with complaints of fatigue, vague abdominal discomfort, and vaginal bleeding. The hematocrit was 12.0, and a diagnosis of uterine myomas was made. The patient was told preoperatively that, although a myomectomy was planned, a hysterectomy might be necessary if findings warranted it. At surgery, a diagnosis of adenomyoma was made and a hysterectomy was performed.
The patient was initially quite angry that the hysterectomy occurred. She felt that the gynecologist had been insensitive in casually remarking that she “no longer needed her uterus.” Psychiatric consultation was requested to help the gynecologist understand and cope with the patient's anger. The patient was subsequently able to mourn the loss of her uterus and acknowledge her sadness at not having had any children. She then was able to understand the intensity of her anger and respond more appropriately to her physician, who may have minimized her distress in his own attempt to cope with her unfortunate circumstances.
In a 1975 retrospective review of the psychiatric effects of sterilization, women often reported psychiatric symptoms, psychosexual disorders, or regrets for having undergone the sterilization. The procedures were performed mostly for medical reasons and in association with pregnancy termination or the postpartum period.15 In a 1981 prospective study of 201 women electing sterilization, however, Cooper and colleagues16 noted that postoperative sexual disturbance was rare (3%), and regret was 2.6% initially but 10.9% 18 months after surgery. Postoperative psychiatric problems correlated most strongly with preoperative problems, which were found to be at the level of the general population (10.4%).
A request for sterilization in the young (under-35) nulliparous woman should be carefully assessed. If the woman has suffered fetal losses and had no subsequent children, the request for sterilization may represent a wish to protect herself from further loss and disappointment. If she is unmarried and fears an unwanted or unplanned pregnancy, sterilization may free her from concerns about birth control. Beliefs about sterilization procedures should be carefully reviewed with any patient, including any possibility of reversing the procedure at a future time, or other means of becoming pregnant down the road (e.g., in vitro fertilization).
If the request for sterilization stems from concerns about medical contraindications to pregnancy, a variety of psychological reactions can be expected. The patient may be angry, depressed, hostile, or withdrawn. Even if childbearing has been completed, the involuntary and fantasied loss of function may be painful or disruptive. Depending on the woman's premorbid history and her support systems, there may be significant psychological stress. Once again, a careful and broad-based preoperative assessment would bring these issues to light and make early intervention (e.g., presurgical counseling) possible.
Mutilative Genital Surgery
The psychological ramifications of mutilative genital surgery are also known. In a 1976 study of 15 patients treated surgically for vulvar cancer, sexual functioning and body image underwent major disruption. Although intercourse remained possible after surgery, women reported levels of sexual arousal at the eighth percentile, and body image at the fourth percentile, at an average interval of 5 years after surgery.17 In pelvic exenteration, there is loss of normal sexual function due to obliteration of the vagina, as well as alteration of excretory function. The major psychological hurdle is the adjustment of the woman's body image. Body image consists of both self-concept and external expectations. Issues such as appearance, body function, and the sociologic aspects of how others perceive the patient, as well as her sense of identity, worth, and competence, must be assessed.18 The patient not only has to deal with her illness, but also with the loss of major body parts. Repeated, thorough, presurgical exploration of psychosocial issues can help prepare the patient and her partner for some of the postsurgical problems.
Interviews with women who have had or who will be undergoing radical pelvic surgery for cancer reveal their concerns about the survival and stability of their family and marital system as well. For some patients, these fears and concerns have led them to refuse surgery. Older women in more lengthy, stable relationships tended to have fewer problems than younger women in shorter relationships.19 This would speak to the need for particular psychosocial intervention in this group.
The patient should be allowed to mourn her losses and be assisted postoperatively in reestablishing a new equilibrium. An attitudinal assessment about sexual frequency, practices, and function is important, as all patients will want to know what readjustments need to be made.
Correction of Congenital Reproductive System Anomalies
Patients who present for correction of congenital anomalies of the reproductive system constitute a small percentage of the gynecologist's surgical practice. The psychological ramifications of such a diagnosis can be diverse and profound. If not discovered at birth or shortly thereafter, a diagnosis is usually made when the adolescent fails to menstruate. This complaint may bring the young woman to the gynecologist for her first gynecologic examination. If there is suspicion of an anatomic malformation, the patient as well as her mother will react to this information.
The patient's mother is likely to respond in much the same fashion as the mother of a newborn with a congenital anomaly. That is, she is likely to experience a sense of shock and disbelief, anger, feelings of guilt, bargaining, and finally resolution. The mother may not be in a position to support her daughter psychologically and may need supportive counseling herself. The patient will often question what ramifications this diagnosis will have on her femininity, sexual functioning, and childbearing potential.
The criteria of sexuality depend on several variables. These include chromosomal patterns, sex chromatin, gonadal structures, differentiation of genital ducts, external genitalia, hormonal status, sex of rearing, and gender role. Disruption in any of these spheres (e.g., a congenital sexual anomaly) may seriously interfere with the patient's perception of self and psychosexual development. It is often helpful for the patient to develop a presurgical relationship with a psychiatric consultant, who can then continue to provide support and guidance through the operative and postoperative periods. In addition, openness and availability on the part of her gynecologist can foster trust and increase comfort in that relationship.
CASE REPORT: VAGINAL DYSGENESIS AND RUDIMENTARY UTERUS.
An attractive, single, 17-year-old girl presented to the gynecologist with a complaint of primary amenorrhea. Secondary sex characteristics were grossly within normal limits. Gynecologic examination revealed vaginal dysgenesis, and ultrasound showed a rudimentary uterus. Surgical reconstruction was undertaken, and although the patient seemed to do well psychologically, her mother was noted to be quite distraught.
It was noted that the mother began to discuss her pregnancy in great detail with her daughter. Revealing guilty feelings, the mother elaborately reviewed each event that she thought might have contributed to her daughter's problem. Allowing the mother to ventilate these feelings to the consulting psychiatrist and nurses helped her to reestablish a much-needed supportive role with her daughter.
In summary, there are numerous areas of concern that one can anticipate for the gynecologic patient. These include future sexual functioning, attractiveness and femininity, and fear of pain and death, with special prognostic considerations when a malignancy is suspected or found. An understanding of these concerns and a careful psychosocial assessment endow the treating physician with greatly needed insight into his or her multifaceted patient and her perioperative needs.
Emotional Preparation for Surgery
The effects of emotional preparation on surgery can be multiple. Egbert and colleagues20 found that a supportive and informative visit by a physician before surgery was associated with a stronger postsurgical recovery. A review of the literature supports the conclusion that preparing patients by informing them about what will happen or how to cope improves recovery.
Wilson21 compared two populations of surgical patients, those with elective cholecystectomy and those with abdominal hysterectomy. The following are some of his findings:
Muscle-relaxation training reduced the hospital stay and pain-medication
requirements and increased strength, energy, and postoperative epinephrine
The author also suggested that information about expected sensations may benefit patients either by prompting a therapeutic catharsis or by moderating a hyperaggressive response to surgery.
Reading22 studied a group of 59 women undergoing elective laparoscopy. Patients were placed into three groups: (1) preoperative preparation, (2) no preoperative preparation, and (3) placebo. The women were assessed regarding pain, anxiety, and attitudes 3 weeks after surgery. Results showed similar levels of pain for all groups, although fewer prepared patients requested postoperative analgesia. Follow-up showed no difference in pain reports, but did demonstrate a trend toward prepared patients reporting a more rapid return to health.
Ridgeway and Mathews23 studied the different effect of information giving versus cognitive coping in a group of 60 hysterectomy patients. Cognitive coping (the choice to dwell on the more positive aspects of an event, which, in turn, may control how the event is viewed) seemed to have the most effective influence on analgesia use, reported days of pain after discharge, and belief in the usefulness of intervention methods. They suggested that psychological influences could lead to changes in recovery-promoting behavior or might act directly on physiological or immunologic function.
Egbert and colleagues20 noted that preoperative encouragement and instruction of patients undergoing elective intra-abdominal operations reduced the postoperative narcotic requirement by half. They also found that patients who were encouraged during the immediate postoperative period by their anesthetists were ready for discharge 2.7 days before the control patients.
Thus, consistent data support the concept of preoperative preparation, both educational and emotional. Such efforts can range from preoperative teaching (i.e., discussing the surgery and what the patient can expect before, during, and after surgery), to cognitive-skill acquisition (e.g., reinforcement of positive intellectual focus), to behavioral techniques (e.g., relaxation, stress management). The nursing staff can and should play an important role in such preparations.
Teaching can be on a one-to-one basis or in a class format. Because new information is often difficult for patients to assimilate while under stress, the presentation of written explanations and materials or models to the patient, or allowing the patient to tape the material presented, can be invaluable. This allows the patient to refer back to the information, which will help avoid unnecessary concerns and inappropriate expectations. In this way, the patient's partner can also participate if he is unable to be present at the time the information is presented.
|THE “DIFFICULT” PATIENT|
Occasionally, the physician encounters a patient who, by a variety of behaviors, stimulates negative feelings in the staff. Termed “hateful patients” by Groves,24 they fall into four categories:
The “dependent clinger”: A profoundly needy patient whose repeated cries for reassurance and caretaking trigger emotional exhaustion and a desire to be free of the patient.
The “entitled demander”: An extremely needy patient who intimidates and devalues the caretaker, provoking feelings of rage.
The “manipulative help-rejecter”: An emotionally needy patient whose pessimism and negativism seem to increase in direct proportion to the physician's efforts. The “gain” to the patient is to remain in a relationship that persists as long as symptoms do.
The “self-destructive denier”: A dependent patient who does not use denial in a healthy fashion, but rather seems to derive pleasure from defeating those trying to help. Often, the physician wishes to abandon such a patient.
The physician's awareness of his own feelings and reactions are invaluable because they can provide important clues about the psychopathology of the patient. An honest acceptance of one's own feelings about such patients will help ensure their appropriate care and diminish the risk of litigation.
|THE PSYCHIATRIC CONSULTANT|
The consultation-liaison psychiatrist can be invaluable to the gynecologist in many of the situations listed above. A preoperative psychiatric consultation is useful if there is concern about the psychological ramifications of the surgery, if a past psychiatric diagnosis exists, if there is a question regarding informed consent, or if primary or secondary gain is a concern. The psychiatrist can help clarify issues that will inform caretakers and smooth the perioperative course.
The physician should make certain that the patient is prepared for the consultant's visit. More than 80% of the patients interviewed by Schwabb responded favorably to the idea of a consultation.25 The reason for consultation should be presented clearly and nondefensively, and the consultant introduced as a member of the health-care team. Many physicians, however, resist the idea of a psychiatric consultation because they believe it might create serious complications, or because they do not recognize the relevance of psychiatric symptomatology to the presenting illness.26 These countertransference issues are important to acknowledge because they may prevent the patient from receiving an appropriate assessment.
The consultant can also assist staff in dealing with a difficult patient. He or she can provide support to staff who are dealing with a dying or angry patient or can act as a reservoir for the patient's feelings, thus allowing the patient to be more appropriate with the treating staff.
11. Strain JT, Grossman S: Psychological reactions to medical illness and hospitalization. In Strain JT (ed): Psychological care of the medically ill: A primer in liaison psychiatry, Chap 3. New York, Appleton-Century-Crofts, 1975