子宮肌瘤婦女手術前後心理狀態、症狀困擾、生活品質之狀況與關聯：以海扶刀手術及子宮肌瘤切除術為例

A Study on the Relationships among Psychological States, Symptom Distress, and Quality of Life in Uterine Fibroids Women Who Received High-Intensity Focused Ultrasound or Myomectomy

卓曉清(Hio-Cheng Cheok)

指導教授 ： 謝珮玲

中山醫學大學/醫學院/心理學系暨臨床心理學碩士班/碩士(2023年)

https://doi.org/10.6834/csmu202300010

摘要

背景與目的：子宮肌瘤是女性生殖系統最常見的良性腫瘤，患者中25~50%會因生理症狀感到困擾，甚至影響生活品質，以致需尋求手術治療。因子宮對婦女具有重要性，故多數婦女會選擇能治療肌瘤且可保留子宮的海扶刀手術或子宮肌瘤切除術，然而對於國外研究常用來評估子宮肌瘤婦女的症狀困擾和生活品質的子宮肌瘤症狀-生活品質量表，台灣尚未有研究以此為工具，探討這兩種手術對婦女的症狀困擾及生活品質的影響。另外，子宮肌瘤婦女有不同程度的心理困擾，且研究發現負向心理狀態會影響生活的各個層面。此外，有研究發現與子宮肌瘤有類似症狀的子宮內膜異位症之婦女，其負向心理狀態可在症狀困擾預測生活品質上具有中介效果，且其他研究發現負向心理狀態會對症狀困擾和生活品質產生影響，而症狀困擾又會影響生活品質，再加上台灣尚未有研究探討子宮肌瘤婦女之憂鬱、焦慮及壓力等負向心理狀態對症狀困擾和生活品質的影響。因此，本研究以接受海扶刀手術或子宮肌瘤切除術的婦女為研究對象，著重探討婦女的負向心理狀態對症狀困擾及生活品質的影響，旨在瞭解兩組在手術前後之負向心理狀態、症狀困擾和生活品質之狀況及變化情形，以及是否有組間差異，並瞭解橫斷及縱貫之症狀困擾在負向心理狀態預測生活品質上是否具有中介效果。
研究方法：本研究對象為經婦產科醫師確診患有子宮肌瘤並接受海扶刀手術或子宮肌瘤切除術之婦女，且無非處方藥物濫用史及醫療診斷的精神疾病，最後共納入53名婦女。本研究以背景問卷、憂鬱焦慮與壓力量表，以及子宮肌瘤症狀-生活品質量表為工具，並以紙本及網路問卷形式，進行術前、術後一個月、術後三個月和術後六個月的資料收集。研究資料以SPSS25.0統計軟體依據意向分析進行遺漏值填補，並對數據進行描述性統計分析、曼惠特尼U檢定、克洛斯可-瓦力士 H檢定、威爾卡森符號等級檢定、廣義估計方程式分析、皮爾森積差相關分析，以及迴歸分析。
研究結果：海扶刀組手術前後負向心理狀態與症狀困擾嚴重程度皆以「輕度」居多，且手術前後負向心理狀態和症狀困擾皆沒有顯著變化；術前生活品質雖然受影響的程度以「輕度」居多，但術後一個月及六個月受影響的程度則以「中重度」居多，術後一個月生活品質與術前相較有顯著變差，而術後三個月生活品質與術後一個月相較有顯著提升，且改善程度可持續至術後六個月。肌瘤切除術組手術前後負向心理狀態嚴重程度皆以「輕度」居多，其中，術後三個月焦慮程度和術後一個月壓力程度與術前相較皆有顯著減輕；術前症狀困擾嚴重程度以「中重度」居多，術後症狀困擾程度則以「輕度」居多，且術後三個月及六個月的症狀困擾與術前相較也有顯著減少；手術前後生活品質受影響的程度皆以「中重度」居多，術後生活品質與術前相較則未有顯著提升。若以兩組進行比較，發現術前之海扶刀組有「輕度」焦慮和有「輕度」影響的生活品質之婦女多於肌瘤切除術組。比較兩組在主要變項上的變化程度，發現肌瘤切除術組的生活品質在術後的改善程度大於海扶刀組。兩組在主要變項的橫斷關係方面，負向心理狀態直接預測生活品質的情形出現在五種變項組合，症狀困擾直接預測生活品質的情形出現在所有二十四種變項組合，而症狀困擾在負向心理狀態與生活品質之間具有部分或完全中介效果的情形則出現在七種變項組合。兩組在主要變項的縱貫關係方面，唯有海扶刀組有一種變項組合出現負向心理狀態直接預測生活品質的情形，且有兩種變項組合出現症狀困擾在負向心理狀態與生活品質之間具有部分或完全中介效果的情形，肌瘤切除術組則無變項組合出現以上情形。
結論：海扶刀組雖然術後一個月的生活品質有變差，但術後三個月時已提升至與術前無異，而肌瘤切除術組術前的焦慮、壓力及症狀困擾在術後均有減輕。相較於負向心理狀態，症狀困擾對生活品質有更大的直接預測力，其中，在少數情況下的負向心理狀態可直接影響生活品質，而症狀困擾則總是可對生活品質造成影響。另外，負向心理狀態可在一些情況下透過症狀困擾影響生活品質。依據研究結果，若術前便著手減少婦女的負向心理狀態及症狀困擾，對改善其術前、術後的生活品質可能會有助益。建議未來研究以較大樣本數進行，並且進行更為長期的追蹤，以進一步瞭解這兩種手術對婦女的負向心理狀態、症狀困擾及生活品質之影響。

關鍵字

子宮肌瘤 ； 子宮肌瘤切除術 ； 心理狀態 ； 生活品質 ； 海扶刀手術 ； 症狀困擾

並列摘要

Background and purpose: Uterine fibroids (UFs) are the most common benign tumors in the female reproductive system. Twenty-five to fifty percent of women seek for surgical treatment because their quality of life is affected by the physical symptoms. The uterus is important to women so that they choose treatment of High-Intensity Focused Ultrasound (HIFU) or myomectomy, which can treat UFs and preserve the uterus. The Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) was commonly used in foreign studies to evaluate the symptom distress and quality of life of women with UFs. However, there is no study in Taiwan has used UFS-QOL to explore the impact of HIFU and myomectomy on women with UFs. Women with UFs experience varying degrees of psychological distress, and studies indicate that negative psychological states affect all areas of life. In women with endometriosis who have symptoms similar to UFs, a previous study indicated that their negative psychological state can mediate between symptom distress and quality of life. Meanwhile, other studies have found that negative psychological states can affect symptom distress and quality of life, and symptom distress can affect quality of life. Furthermore, there is no study in Taiwan to explore the impact of negative psychological states (depression, anxiety, and stress) on symptom distress and quality of life in women with UFs. Hence, the aims of the present study focused on the impact of women’s negative psychological states on symptom distress and quality of life. First, this study assessed the changes in the negative psychological states, symptom distress, and quality of life of the two groups of patients before and after treatment. Second, it also assessed whether there were differences between the two groups. Third, the mediating role of symptom distress in the relationships between negative psychological states and quality of life was explored.
Methods: A total of 53 women with diagnosis of UFs participated in the present study. They had undergone HIFU or myomectomy, and denied having history of substance abuse and mental illness. All participants completed the personal background information sheet, the Depression Anxiety and Stress Scale-21 (DASS-21), and the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL). Data were collected at baseline and 1, 3, and 6 months after treatment in the form of paper or online questionnaires. Statistical analyses were performed by SPSS 25.0 based on Intention-to-Treat analysis. The statistical strategies of descriptive statistics, Mann-Whitney U Test, Kruskal-Wallis H Test, Wilcoxon Signed-Rank Test, Generalized Estimating Equations, Pearson Product-Moment Correlation Coefficient, and Regression Analysis were conducted.
Results: In the HIFU group, most women had "mild" negative psychological states and symptom distress before and after the treatment. After treatment, there was no significant change in the negative psychological states and symptom distress. In most women, the impact on the baseline quality of life was "mild", but the post-treatment quality of life at 1 month and 6 months were "moderate to severe". The quality of life at 1 month after treatment was significantly lower than baseline level. However, the quality of life at 3 months after treatment was significantly improved compared with the post-treatment level at 1 month. And this improvement could last at 6 months after treatment. In the myomectomy group, the severity of negative psychological states before and after the treatment was "mild" in most women. The anxiety level at 3 months after treatment and the stress level at 1 month after treatment were significantly lower than baseline level. The majority of women had "moderate" baseline symptom distress, and "mild" post-treatment symptom distress. And the symptom distress at 3 and 6 months after treatment was also significantly lessened in contrast with the baseline. The impact on the quality of life before and after treatment was "moderate to severe" in most women, and the quality of life after treatment was not significantly improved in contrast with baseline. More women in the HIFU group had "mild" anxiety and a "mild" degree of influence on the quality of life than the myomectomy group at baseline. Comparing the degree of change in the main variables between the two groups, it was found that the quality of life of the myomectomy group had a greater improvement after treatment than that of the HIFU group. In terms of the cross-sectional relationship of the main variables in the two groups, negative psychological states directly predicted the quality of life in five variable combinations, symptom distress directly predicted life quality in all twenty-four variable combinations, and symptom distress had a partial or total mediating effect between negative psychological states and quality of life in seven variable combinations. In terms of the longitudinal relationship of the main variables in the two groups, only the HIFU group’s negative psychological state directly predicted the quality of life in one variable combination. Meanwhile, only the HIFU group’s symptom distress had a partial or total mediating effect between negative psychological states and quality of life in two variable combinations. In the myomectomy group, there was no mediation effects in any combination of the variables.
Conclusion: The quality of life in the HIFU group deteriorated 1 month after the treatment. However, it improved to the baseline level at 3 months after the treatment. While the baseline anxiety, stress, and symptom distress of the myomectomy group have been lessened after the treatment. Symptom distress is more powerful than negative psychological states in predicting the quality of life. That is, negative psychological states can directly affect the quality of life in some conditions, while symptom distress can always predict the quality of life. With respect to mediation effects, negative psychological states can affect the quality of life through symptom distress in several situations. According to this study result, the author suggests that women's pre-treatment negative psychological states and symptom distress are important to their quality of life after treatment. In order to further understand the impact of these two treatments on women's negative psychological state, symptom distress, and quality of life, future studies should be conducted with a larger sample size and a longer duration of follow-up.

並列關鍵字

Uterine Fibroids ； Myomectomy ； Psychological States ； Quality of Life ； High-Intensity Focused Ultrasound ； Symptom Distress

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