Uterine leiomyoma: influence of the method of surgery on a woman's quality of life

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Introduction

Uterine leiomyoma (uterine fibroid) is the most common type of benign tumor in the female reproductive system. Currently, uterine fibroids are diagnosed in 70 % of gynecological patients. The detection rate of uterine fibroids continues to rise, due to the introduction of more advanced and accessible diagnostic methods [1–3].

The main clinical manifestations of the disease include prolonged and/or heavy uterine bleeding, anemia, abdominal pain syndrome, pelvic organ symptoms, and reproductive dysfunction in the form of infertility and miscarriage [4; 5]. These symptoms negatively affect physical activity, psychological well-being, social and intimate relationships, and overall quality of life [6–8].

Surgical interventions such as uterine curettage, hysteroresectoscopy, myomectomy, uterine amputation or extirpation, uterine artery embolization, and focused ultrasound ablation of fibroids [9–11] are used for the diagnosis and treatment of uterine leiomyoma. The most common procedures are hysterectomy and myomectomy. Organ-preserving techniques remain the unconditional choice for patients but do not prevent tumor recurrence [12]. Radical surgery leads to loss of fertility and affects ovarian blood supply, which may accelerate the onset of menopause [13; 14]. Quite often, the result of hysterectomy is not only the elimination of the disease cause but also the development of complications that reduce patients' quality of life. About 30% of patients develop chronic pelvic pain, while others experience intestinal problems, urinary incontinence, vaginal prolapse, as well as emotional and physiological difficulties in marital relationships [15–17]. The option of surgical treatment with cervix preservation remains debatable, as this approach may subsequently increase the risk of precancerous and cancerous cervical conditions [18].

Quality of life also depends on the surgical approach to the abdominal cavity. With the development of minimally invasive techniques, laparoscopic surgery has become the most common method for treating uterine fibroids due to optimal cosmetic results, faster postoperative recovery, and fewer postoperative complications [19].

The objective of the study is to evaluate changes in the quality of life in patients with uterine leiomyoma before and after different surgical treatment.

Materials and Methods

A prospective observational study was conducted from September 2023 to April 2024 at the gynecological department of City Clinical Hospital No. 7 in Yekaterinburg. Patients with uterine leiomyoma admitted for elective surgical treatment were surveyed before surgery and two months after the intervention. Participants were randomized into three groups: Group 1 – women who underwent total hysterectomy (n = 20); Group 2 – women who underwent subtotal hysterectomy (supracervical uterine amputation) (n = 20); Group 3 – women who underwent myomectomy (n = 20). All surgeries were performed via laparoscopic approach with preservation of uterine adnexa. The study utilized the validated SF-36 Quality of Life Questionnaire. Quality of life was assessed across eight domains of the questionnaire.

1) Physical Functioning (PF) was used to assess physical activity. The scale indicator reflected the amount of daily physical activity not limited by health status;

2) Role-Physical Functioning (RP) characterized the impact of physical problems on routine activities, reflecting the degree to which health limitations affected work performance or daily responsibilities;

3) Bodily Pain (BP) scale allowed evaluation of pain intensity and its effect on normal activities during the past month;

4) General Health (GH) showed current health status, expected treatment outcomes, and resistance to illness;

5) Vitality (VT) scale was designed to measure feelings of full strength and energy;

6) Social Functioning (SF) assessed the level of social activity and satisfaction with communication during the past four weeks;

7) Role-Emotional Functioning (RE) illustrated how emotional state affected work performance and daily responsibilities;

8) Mental Health (MH) characterized mood, presence of depression and/or anxiety, as well as the overall indicator of positive emotions.

The survey results were grouped into two indicators: "physical" (PHs) and "mental" health components (MHs). The "Physical" health component (PHs) takes into account the results of the first four sections of the scale. The " Mental " health component (MHs) includes the results of the subsequent four questionnaire sections. For each scale section, the maximum value is 100 points. These scores can range from 0–100, where 100 represents the best possible quality of life and zero indicates the worst one [20].

The analysis of mean values and standard deviations M (SD) was performed for each scale section before surgical treatment and two months after surgery. Statistical significance was calculated for the sample with n = 20, with a critical t-value of 2.093 according to Student's t-test at an acceptable significance level of p = 0.05. The arithmetic mean and standard deviation - M (SD) were calculated. Statistical data processing was performed using MS Excel 2016.

Results and Discussion

According to the clinical guidelines "Uterine Fibroids," the average age at diagnosis of uterine fibroids is 32–34 years, with peak incidence occurring at the onset of menopause. In our study, the mean age of respondents was 43.38 (3.94) years. All patients reported a history of vaginal or surgical delivery, with an average of 1.6 (0.8) deliveries. A desire to plan pregnancy was expressed by 50 % (10) of patients who subsequently underwent myomectomy and 15 % (3) of women from other groups. The most often indications for surgery in the first group were abnormal uterine bleeding, while the second group primarily had a combination of uterine fibroids with other gynecological pathologies, and the third group showed rapid tumor growth and large fibroid size. The diagnosis was first established on an average of 5.06 (1.12) years prior. However, only 15 % (9) of the 60 respondents received conservative treatment before the surgery. At the same time, some publications indicate stabilization of fibroid size and improved quality of life in patients undergoing hormonal and/or symptomatic treatment [21].

Prior to surgery, women who had undergone total hysterectomy reported lower quality of life scores in the following domains: Role-Physical functioning (RP), Bodily Pain (BP), Social Functioning (SF), and Role-Emotional functioning (RE). These findings likely reflect the clinical characteristics of their tumors and the specific indications for surgical intervention.

Two months postoperatively, the total hysterectomy group demonstrated significant improvements in both physical and mental health components compared to preoperative baseline (Table 1). This positive trend was particularly evident in three physical health domains: Physical Functioning (PF), Bodily Pain (BP), and General Health (GH). Similar improvements were observed for three mental health components: Vitality (VT), Social Functioning (SF), and Mental Health (MH), indicating enhanced social engagement. However, the Role-Emotional (RE) domain, which assesses emotional limitations in work and daily activities, showed no significant changes (Table 1).

 

Table 1. SF-36 quality of life assessment results for total hysterectomy

Indicator	Before surgery, points	2 months post-operative, points	t-value	P
ИМТ	26.48 (4.55)	26.48 (4.55)	–	–
PF	84.75 (20.74)	91.5 (17.18)	2.22	0.032*
RP	52.5 (44.35)	70 (41.04)	2.05	0.203
BP	54.45 (30.57)	72.4 (30.1)	2.87	0.049*
GH	61.2 (15.96)	72.9 (14.03)	3.99	0.018*
VT	47.5 (24.09)	59.5 (22.71)	2.66	0.013*
SF	65 (27.98)	79.38 (25.42)	2.67	0.047*
RE	55 (40.86)	70 (38.84)	2.02	0.241
MH	52.8 (21.78)	63.8 (19.83)	2.82	0.024*
PHs	46.97 (8.78)	51.8 (7.69)	2.92	0.031*
MHs	38.82 (11.52)	44.68 (11.73)	2.84	0.028*

Note: *р – statistically significant differences.

 

While total hysterectomy represents a technically more complex procedure with a longer operative period and potentially higher risks of intra- and postoperative complications – factors that might theoretically predict worse health outcomes [22] – our clinical experience suggests that surgical outcomes depend substantially on the gynecological surgeon's skill level. Notably, in our study cohort, total hysterectomy was associated with a greater quality of life improvements according to the mean SF-36 questionnaire scores two months after surgical treatment compared to the subtotal approach. However, the dynamics across different questionnaire domains differed between the total and subtotal hysterectomy (supracervical uterine amputation) groups.

After subtotal hysterectomy, no significant increases were observed in either the physical or mental component scores of the SF-36 (Table 2). Positive changes were only noted in three domains: general health (GH), role-emotional functioning (RE), and mental health (MH).

 

Table 2. SF-36 quality of life assessment results for subtotal hysterectomy

Indicator	Before Surgery, points	2 Months Post-Op, points	t-value	P
ИМТ	25.89 (4.89)	25.89 (4.89)	–	–
PF	81.75 (24.08)	85.25 (21.06)	0.54	0.627
RP	62.5 (44.79)	81.25 (36.16)	0.61	0.153
BP	67.3 (28.1)	74.05 (25.24)	1.13	0.133
GH	60 (16.09)	68.25 (17.92)	2.36	0.042*
VT	45.25 (28.4)	55.5 (30.34)	1.82	0.270
SF	80 (20.84)	83.75 (24.37)	0.77	0.062
RE	68.33 (43.12)	85 (33.29)	2.16	0.036*
MH	52.6 (22.03)	56.4 (28.84)	3.96	0.045*
PHs	48.2 (8.51)	51.42 (5.57)	1.91	0.165
MHs	41.48 (10.49)	44.92 (12.79)	1.33	0.357

Note: *р – Statistically significant differences.

 

Some literature sources report advantages of subtotal hysterectomy over total hysterectomy in terms of lower risk of subsequent prolapse and improved sexual function [23]. It should be noted that subtotal hysterectomy is not indicated in all clinical cases, but only when there are no cervical diseases or deep infiltrative endometriosis. Patients must be counseled about the need for regular follow-up with a gynecologist due to oncological vigilance considerations.

The lack of significant changes in pain scores after subtotal hysterectomy requires additional analysis to refine surgical indications, optimize early and late postoperative management, and improve rehabilitation strategies. The observed differences may be explained by the fact that women undergoing total hysterectomy had tumors that significantly impacted their health status, social and role functioning to such an extent that organ removal was perceived as relief from suffering and a return to a healthy, full-quality life.

Before surgery, patients undergoing myomectomy had the lowest scores in the mental health component (MHs) of quality of life. Two months after surgery, this indicator showed a statistically significant rise along with measures of physical, social, and role functioning. This positive change likely reflects not only the relief from uterine fibroid symptoms but also the resolution of anxiety regarding reproductive plans in this patient group (Table 3).

 

Table 3. SF-36 quality of life assessment results for myomectomy

Indicator	Before Surgery, points	2 Months Post-Op, points	t-value	P
ИМТ	24.28 (4.25)	24.28 (2.89)	–	–
PF	82.25 (22.34)	89.44 (14.81)	2.05	0.562
RP	60.5 (34.32)	84.5 (54.39)	0.75	0.062
BP	80.35 (40.54)	82.3 (26.2)	2.41	0.047*
GH	65.2 (25.36)	68 (46.19)	2.28	0.045*
VT	57.5 (21.09)	60.25 (38.4)	2.33	0.045*
SF	75 (27.98)	80 (20.84)	2.06	0.082
RE	59 (40.86)	68.33 (43.12)	0.66	0.066
MH	52.8 (21.38)	66.6 (42.03)	0.03	0.133
PHs	52.97 (8.78)	57.2 (8.51)	2.61	0.038*
MHs	35.32 (41.52)	44.38 (25.49)	0.83	0.165

Note: *p – Statistically significant differences.

 

Uterine leiomyoma remains one of the most common indications for surgical treatment. The extent and method of surgical intervention should be carefully justified in each individual case. Our results demonstrate improved quality of life scores two months after surgery compared to preoperative values. Following total hysterectomy, quality of life indicators increased by an average of 21.6 % (5.1), after myomectomy by 16.6 % (1.8), and after subtotal hysterectomy by 13.2 % (9.2).

Conclusions

1. Surgical treatment of uterine leiomyoma improves quality of life in women.
2. After total hysterectomy, quality of life indicators are higher than after organ-preserving methods (myomectomy) and subtotal hysterectomy.
3. Myomectomy is the method of choice for patients planning future pregnancy.
4. Subtotal hysterectomy requires more thorough evaluation of postoperative pain syndrome, individualized management of both early and late postoperative periods, and mandatory implementation of rehabilitation measures.

About the authors

T. A. Oboskalova

Ural State Medical University

Email: marinakoval1203@gmail.com
ORCID iD: 0000-0003-0711-7896

DSc (Medicine), Professor, Head of the Department of Obstetrics and Gynecology with a Course in Medical Genetics

Russian Federation, Yekaterinburg

M. V. Koval

Ural State Medical University

Author for correspondence.
Email: marinakoval1203@gmail.com
ORCID iD: 0000-0003-1321-6583

PhD (Medicine), Associate Professor the Department of Obstetrics and Gynecology with a Course in Medical Genetics

Russian Federation, Yekaterinburg

A. M. Bogdanova

Ural State Medical University; Central City Hospital 7, Yekaterinburg

Email: marinakoval1203@gmail.com
ORCID iD: 0009-0006-2819-2659

PhD (Medicine), Assistant of the Department of Topographic Anatomy and Operative Surgery

Russian Federation, Yekaterinburg; Yekaterinburg

O. Yu. Sevostyanova

Ural State Medical University

Email: marinakoval1203@gmail.com
ORCID iD: 0000-0002-0828-0479

DSc (Medicine), Professor of the Department of Obstetrics and Gynecology with a Course in Medical Genetics

Russian Federation, Yekaterinburg

M. G. Askerova

Ural State Medical University

Email: marinakoval1203@gmail.com
ORCID iD: 0000-0002-0705-9748

PhD (Medicine), Associate Professor of the Department of Obstetrics and Gynecology with a Course in Medical Genetics

Russian Federation, Yekaterinburg

References

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