1. Introduction

Gynecologic surgery involves a wide range of surgical procedures (^{Falandry et al., 2022}). Although it is a rich field of clinical-medical research, not much has been written about the related clinical-psychological aspects (^{Carter et al., 2010}; ^{Maksimovi´c et al., 2009}; ^{Öztürk et al., 2018}; ^{Pellegrini et al., 2017}; ^{Salehi et al., 2018}). Furthermore, the opinions among researchers are also conflicting (^{Birsen et al., 2018}; ^{Ferrandina et al., 2020}; ^{Frumovitz et al., 2020}; ^{Hartmann et al., 2004}; ^{Helström & Nilsson, 2005}; ^{Mann et al., 2020}). Some studies have suggested that hysterectomy could reduce symptoms of depression and anxiety, increase general well-being (^{Aziz et al., 2005}; ^{Mattsson et al., 2020}; ^{Persson et al., 2010}), and improve their interpersonal functioning in terms of a better perception of the body image and sexual functioning (^{Klock et al., 2021}; ^{Pauls, 2010}). However, other researchers found evidence of a decrease in well-being and in the quality of life (^{Darwish et al., 2014}; ^{Khastgir et al., 2000}; ^{McPherson et al., 2005}).

Recently, the attention of the researchers started to focus specifically on the period just before the surgery to highlight the cognitive attitude and the illness behavior related to it. A study of ^{Amorim and colleagues (2018)} underlined that in the moment of reading the informed consent, the most widespread emotion is the fear of the risks of the procedure, followed by indifference and resignation. According to these researchers, both attitudes, however, are accompanied by the motivation to undergo surgery in order to eliminate pain and restore the wellbeing prevented by the disease. Also, other authors have emphasized the psychological value of the moment of signing informed consent (^{Bonadies et al., 2011}; ^{Brain et al., 2004}; ^{Tiller et al., 2005}). For instance, in women with gynecological cancer, it was found that patients use the moment of communication of diagnosis to gain as much information as possible on risk management options. If a surgical intervention were the best option, detailed information was on the potential effects on quality of life after surgery (^{Etchegary et al., 2018}).

Other studies even wanted to highlight psychological factors that predict depression and well-being in the post-operative period. The results of a study with women undergoing hysterectomy for benign indication showed that baseline levels of pre-operative depression, energy, and positive well-being predict their respective levels after surgery (^{Theunissen et al., 2017}).

One of the points that accords all the researchers is the fact that there are many factors capable of influencing post-operative recovery and peri-operative symptoms. The current research continues to pay attention to the inter-individual variability, and a growing field of studies has identified a subgroup of women reporting substantial negative psychological outcomes (^{Flory et al., 2005}). It appears that the emotions and psychological factors most involved are pre-operative pain and trait anxiety (^{Carr et al., 2005}; ^{Vandyk et al., 2011}), as well as perceived social support (^{Thornton et al., 1997}). Currently, the role of biological explanations that emphasize hormonal influences on mood (^{Schwartz et al., 2002}) is given less weight and it is considered together with other factors such as a history of a psychiatric disorder that was repeatedly confirmed as the major predictor of the psycho-physical recovery after surgical interventions (^{Cooper & Gath, 1983}; ^{Khastgir et al., 2000}; Oates & Gath, 1989; ^{Yen et al., 2008}).

Although it is difficult to understand the interplay between all these factors, it is important for the gynecologist to be familiar with the psychiatric/psychological history of the patient. In the scientific field, however, there is a need to deepen this line of studies and to indicate the most useful information to consider for the patients’ health and recovery after surgery. Thus, our study fits within the line of studies that identify clinical variables (both medical and psychological) that can influence the peri-operative symptoms. The authors focused on a variety of clinical-medical variables and included an analysis on clinical-psychological variables as well. In this research, the assessment of psychopathological symptoms and a description of the illness behavior are included.

2. Materials and Methods

3. Results

By considering the large standardized Cohen’s effect size (d = .5), a type I error of 5% (α = .05) and a type II error of 5% (β = .05; power =95%), an a-priori power calculation using GPower 3.1 (^{Faul et al., 2009}), revealed that 66 participants were required. Although the subjects recruited in the actual research is less than 66, a post-hoc power analysis revealed that a sufficient power of 0.83 was achieved with the current sample size of 58. Considering the socio-demographic characteristics of the sample, all the women were employed, married, or partnered, and 72% of them (n = 42) had at least one child. The distribution of women according to their educational level (middle school, high school diploma, or University degree) was equal. The clinical-medical data of the sample are reported in Table 1.

The average values and the standard deviation of the obtained scores from the entire sample at SQ scales and sub-scales confirm that the psychopathological symptoms course in the peri-operative period (from 15 days before the intervention to the discharge day) is characterized by an important inter-individual variability (see Table 2).

From a descriptive point of view (see Figure 1), the anxious hyper activation trend confirms the hypothesis and shows a decreasing trend with values higher than the clinical cut-off (=4) in the period prior to the intervention and lower values at the discharge. On the contrary, depressive symptoms tend to stay constant and near the threshold level before the operation, with an increase in post-operative period as expected. Moreover, the Somatization scale shows elevated values in the operative period, with significant decrease in the day before the intervention. Finally, hostility shows a decreasing trend but with all values being under the clinical cut-off (=4).

Looking at the average values of the IBQ, the same inter-individual variability emerges as well (see Table 3). However, no noteworthy clinical aspects emerged.

However, interesting aspects emerged considering the impact of the different clinical-medical and clinical-psychological variables on the psychopathological symptoms assessed through the SQ and the illness behavior described with the IBQ. Therefore, the statistical analyses conducted confirmed the hypotheses that drove this research and highlighted other aspects related to the specific moment of administration (T0, T1, and T2).

3.3 Positive vs Negative Anamnesis for Prior Surgical Interventions, Prior Pregnancies, Abortion and/or Voluntary Termination of Pregnancy (VTP)

The psychopathological symptoms assessed at T0 of the women that underwent other (gynecological or not) surgical interventions in the past (N = 48) were compared with those of the women that had never undergone any operations (N = 10). The experienced group reported higher levels of anxiety (U = 126.5; p < .05) and greater difficulty of feeling content (U = 128.5; p < .05), while the second group reported lower levels of hostility (assessed through the SQ) and irritability (assessed through the IBQ) (U = 127; p < .05 and U = 131; p < .05) after the intervention (T2).

Furthermore, the Mann-Whitney U test revealed that having had prior pregnancies (N = 34) is associated with higher levels of reported hostility (U = 277; p < .05 and U = 283.5; p < .05). However, lower levels of anxiety (U = 265; p < .05 and U = 267.5; p < .05) and greater ability to relax (U = 279.5; p < .05 and U = 282.5; p < .05) emerge during the pre-operative period (both at T0 and at T1).

Figure 1 

No significant differences between the group of subjects with positive anamnesis for VTP (N = 7) and the group with positive anamnesis for spontaneous and/or therapeutic abortion (N = 7) were found with the MannWhitney U test. As a result, these sub-groups were considered jointly. In fact, it appears that both groups of women (N = 14) reported greater ability to relax (U = 198; p < .05) and to feel content (U = 147.5; p < .01) at T1. After the surgery (T2), they reported lighter symptoms of depression (U = 149; p < .01), greater relaxation (U = 172; p < .05), and a minor impact on physical wellbeing (U = 189; p < .05).

4. Discussions

As for the descriptive analyzes conducted on the psychopathological symptoms, interesting aspects emerged. First, high levels of anxiety and somatizations highlighted the anxious hyper activation that characterizes the pre-operative period. Furthermore, a slight decline in mood was also noted. In fact, it is possible to hypothesize that the preparation for the intervention generates fears and concerns and that this condition remains substantially stable for the two weeks considered, from T0 to T1. Even though on a qualitative level, an opposite trend emerged by observing the scores of the last administration. At the time of discharge, the anxious hyper activation is replaced by a notable increase in symptoms of depression and somatizations. Understandably, the somatic symptoms increase within the outcome of surgery and, in addition, they are accompanied by a noticeable change in mood. Hence, it is possible to hypothesize that the mood is affected by the presence of painful symptoms that are annoying. Moreover, the limitations resulting from the surgical operation and the medical indications that are usually provided (remain at rest, do not make efforts, etc.) can also generate sadness and perception of disability that can be debilitating it selves.

Moreover, the results obtained by the present study confirm the great inter-individual variability that characterized the subjective experience associated with gynecological surgical interventions. In this research specific, clinical medical and psychological variables were described as potential factors responsible for such variance. For instance, confirming previous studies in the literature, psychological impact in the post-operative period is greater for women who underwent interventions, compatibly with the outcomes of the more invasive intervention. These women reported higher levels of anxiety, inability to relax, and sense of general malaise compared to the women that underwent hysterectomy (^{Darwish et al., 2014}; ^{Khastgir et al., 2000}; ^{McPherson et al., 2005}). Regarding the indications for the intervention, 15 days before it, women with uterine pathologies complained more about intense depressive symptoms, while women affected by adnexal pathologies experienced greater symptoms of anxiety and depression the day before surgery. The same tendency is revealed regarding the methods of the intervention. For instance, two weeks before the subjects underwent laparotomy, they reported greatest levels of anxiety, depression, and somatic symptoms, while in the proximity of the intervention, higher levels of anxiety and depression are experienced by women that underwent laparoscopy surgery. Considering these latter aspects, it is possible to hypothesize that the more invasive interventions generate anxious activation and worries at least two weeks before the surgery. However, even women who have to undergo laparotomy or an intervention aimed at treating adnexal pathologies and prolapse feel fear the day before. Conversely, the slightest psychological impact is associated with gynecological interventions for prolapse and vaginal procedure.

These data suggest that different levels of psychological distress can be attributed to indications, methods, typology of intervention as well as the type of given information. In fact, even in the cases of surgical operations of laparoscopy and in the presence of adnexal pathologies, the possibility of non-conservative uterine interventions or of consequent necessity of laparotomy operation is not excluded. Such possibility is also clearly specified in informed consent signed by the patient. Therefore, it seems that the impact on psychophysical wellbeing can be partially attributed to this state of great uncertainty. In fact, different pieces of given information and the following expectations seem to significantly influence perioperative symptomatology course and emotional psychological consequences for women.

In addition, in this research specific data regarding the psychological aspect were collected. Confirming the literature (^{Cooper & Gath, 1983}; ^{Khastgir et al., 2000}; ^{Oates & Gath, 1989}; ^{Yen et al., 2008}), a previous history of psychological disorders seems to modulate the psychopathological symptoms and the distress of these women already vulnerable to stress and emotionally fragile. Nevertheless, also the patient’s type of pain perception and the fears and expectations concerning the intervention must be considered before a surgical gynecological intervention. These aspects, strictly related to the “psyche” of the patients, can influence the period of convalescence and physical recovery. Furthermore, the administration after the intervention of the questionnaire that investigates the illness questionnaire allowed highlighting some noteworthy aspects. More specifically, it seems that the presence of emotional instability and difficulty in managing emotions, especially the negative ones, differentiate a psychiatric group from a mentally balanced group.

Nonetheless, an innovative result emerged taking into account the individual history in terms of previous pregnancies and the desire to have children in the future. In particular, the desire for maternity also creates a higher level of tension towards the intervention, probably due to the expectations associated with it, while prior pregnancies are associated with a decrease in anxiety and ability to relax. To our knowledge, the desire for maternity emerged for the first time as a risk factor towards psychopathological suffering. Indeed, women who wish to become pregnant experienced more intense levels of fear related to the surgery and are, understandably, and consistently with our hypotheses, more concerned about its outcomes.

In summary, the psychopathological symptom that emerges most frequently is anxious activation. However, it is also interesting to note that this symptom has a physiological trend because it decreases after the stressful event. It is important to note that anxious activation is part of everyday life: it is an index of adaptation of the body since it promotes the mobilization of useful resources to deal with certain stressful situations. However, if prolonged over time, this activation can become useless and even harmful (^{Cosentino et al., 2018}; ^{De Vincenzo et al., 2022}; ^{Selye, 1936}). It is fundamental to emphasized that the monitoring of anxious states is necessary. A certain degree of activation is frequent in patients who must undergo surgery, but its trend must be monitored specifically after the surgery in order to be ready to intervene if a return to baseline levels is not observed.

Another point to consider is the influence of emotional-psychophysiological states on some physical aspects, such as the perception of pain. The presence of depressive symptoms after the operation (e.g., low mood, dysfunctional thoughts, withdrawal and isolation, and poor social involvement) can modulate the attentional focus and, therefore, accentuate the perception of pain and somatic symptoms. From a clinical point of view, physicians and psychologists already know that even the mental representation of pain constitutes a stressful stimulus. For instance, the individuals that are unable to “mentalize” pain tend to deny the physical symptoms. These cases are considered risk factors for the psycho-physical post-operative recovery. On the other hand, other subjects, only by imagining their pain, are considered to be activated from an emotional-psychophysiological point of view and can carry out denial thoughts and avoidance behaviors which are so dangerous to human health (^{Pruneti & Guidotti, 2020}). In other words, the perception of fear, when protracted and no longer connected to the event that triggered it, can favor maladaptive thought processes and the adoption of risk behaviors for health.

In conclusion, this study highlighted several factors that health professionals need to pay attention to. Unfortunately, due to the observational nature of this study, it was possible to describe only with preliminary analyzes the clinical variables capable of modulating the psychological suffering in the days preceding surgery and the emotional experience at the time of discharge. For this reason, further studies with larger sample sizes are needed. Involving a large number of women would make it possible to create more numerous sub-groups and, in this way, more sophisticated and advanced statistical analyzes. More specifically, it would be useful to compute a linear regression in order to highlight the weight of the specific variables taken into consideration and, possibly, also the interactions between them.

Furthermore, other psychological measures could be considered. For instance, further studies could highlight the role of specific behaviors at risk for the development of stress-related symptoms and disorders. Moreover, considering that women with previous mental disorders suffer the most before and after surgery, vulnerability to stress and specific personality traits could highlight high levels of trait anxiety (which predispose to the full-blown anxiety disorders) and introversion (which, instead, is typical of depressive disorders). The P Stress Questionnaire and the 16-Personality Factors Questionnaire could be added to the questionnaire that detects psychopathological symptoms in order to better describe the suffering of these women in its complexity.

Lastly, considering the importance of monitoring the psychological distress, it would be useful to re-assess these women during a follow-up. In fact, the study could be replicated by monitoring the course of post-operative psychological symptoms possibly through administering the questionnaire even one month after surgery. Paying attention to the post-operative convalescence period would allow assessing long-term psychophysical recovery and, likely, intervening with psychological programs.

5. Conclusion

The results of this research allow to underline the clinical variables that influence the well-being of a group of women undergoing gynecological surgery. Some data already existing in the scientific literature have been confirmed, while other aspects seem to emerge for the first time. For instance, more invasive interventions are certainly more worrying. However, less invasive interventions are probably initially underestimated, but then they can generate fear and anxiety just the day before the surgical intervention. Furthermore, on a psychological level, not having had pregnancies and the desire to have them in the future seem to be prominent risk factors for the development of further psychopathological symptoms. To conclude, paying attention to these variables would be helpful in order to guarantee a better experiencing of the surgery and, at the same time, facilitate psychophysical recovery. Hopefully, this line of research currently lacking in literature will become enhanced and it will encourage the adoption of good practices for the clinicians and interdisciplinary teams. Nevertheless, despite the rich literature regarding the interconnection between mind and body, this concept is not always adequately considered and the medicine units that benefit from the presence of clinical psychologist and counseling services are still few in the western countries. An integrated approach would surely allow for a multidisciplinary discussion between various health professionals to pursue the better management of the patients care and their disease.

6. Institutional Review Board Statement

This study was conducted in accordance with the recommendations of the local ethic committee at the Hospital of Carpi (Modena, Italy). In Italy, until 2018, no ethical approval was required for observational nature studies, since they were not defined as medical/clinical research, according to the Italian law No. 211/2003. The study was conducted before 2018 and included nonclinical surveys which used non-invasive measures. Furthermore, this study complies with the Declaration of Helsinki and with Italian privacy law (Legislative decree No. 196/2003). No treatments or false feedback were given, and no potentially harmful evaluation methods were used. Participation was voluntary, and participants could drop out at any time without any negative consequences. All data were stored only by using an anonymous ID for each participant.

7. Informed Consent Statement

All data were handled in accordance with the ethical standards established in the 1964 Helsinki Declaration. Subjects’ anonymity was preserved, and the data obtained were used solely for scientific purposes.

8. Data Availability Statement

The data presented in this study are available upon reasonable request from the corresponding author.