Post-tuba1 Sterilization Syndrome Dona J . Lethbridge

This article presents a review of the literature on post-tuba1 sterilization syndrome. Although studies have shortcomings they suggest the majority of women undergoing tubal sterilization do not experience changes in menstrual patterns after the procedure, but a minority do. Suggestions are made for further research, conducted from a nursing perspective. Implicationsfor practice are suggested, given the tentative information on posttubal sterilization syndrome.

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any women complain of menstrual problems or related disorders after they have undergone tubal s t e M o n (TS). Yet, empirical evidence is mixed as to whether TS actually results in pathophysiological changes that might cause menstrual problems. The term post-tuba1 sterilization syndrome (post-TS syndrome) has been used to refer to a variety of menstrual disorders including irregular cycles, dysmenorrhea, menorrhagia and midcycle bleeding. Nurses are involved with women undergoing TS, during decision-making, throughout the procedure in operating rooms, and during aftercare on surgical floors, outpatient clinics or postpartum units. Many women with a history of TS are clients of nurses for subsequent care. Yet, there is little or no nursing literature on this aspect of tubal sterilization. This article reviews the empirical studies on what has been called post-TS syndrome and suggests implications for nursing research and practice. TS is one of the most prevalent forms of birth control in the world. In the U.S., 28 percent of women between the ages of 15 and 45 have undergone TS, 38 percent of Black women, and 48 percent of women 35 to 44 years of age (Mosher & Pratt, 1990). In Canada, latest statistics show 38 percent of women have undergone TS (Balakrishnan,Krotki & Lapierre-Adamcyk, 1985). The prevalence varies in other countries, ranging from minimal use in areas such as sub-Saharan Africa to 19 percent in Mexico, 23 percent in Thailand, and from 9 percent to 29 percent in the six major subregions of the Peoples Republic of China (Dwyer & Haws, 1990; Mexico National Survey on Fertility and Health, 1990; Poston, 1986; Thailand Demographic and Health Survey, 1989). TS is effected by several methods. Ligation was most prevalent several decades ago, involves removing a segment of the midsection of the oviduct and folding and tying off the severed ends (modified Pomeroy technique). In some cases, the fimbriated ends of the oviducts are removed. Tubal electrocoagulationis occlusion by cauterizationof the midsection of the oviduct. TS is also carried out through application of rings (Yoon or Falope) or spring-loaded clips (Hulka) to the fallopian tubes. Volume 24, Number 1 , Spring 1992

It has been suggested that post-TS menstrual changes may result from disruption of the utero-ovarian blood supply with subsequent disturbance of ovarian function (DeStefano, Perlman, Peterson &Diamond, 1985; Hague, Maier, Schmidt & Randolph, 1987). The ovarian artery and vein run posterior to and closely parallel to the fallopian tube. Procedures that cause more tissue destruction such as tubal ligation or electrocoagulation might be more likely to affect vascularity than application of rings or clips. There seems to have been no study of actual pathophysiological changes in the ovary after TS. However, it can be speculated that an affected arterial blood supply could reduce delivery of follicle stimulating hormone (FSH) and luteinizing hormone (LH) thus reducing estrogen and progesterone production. Over time, reduced estrogen and progesterone levels would then stimulate the production of FSH and LH, establishing a perimenopausal condition. Empirical Studies of Post-TS Syndrome

Several large, multicenter studies of post-TS syndrome suggest that a minority of women experience changes in one or more menstrual parameters. Bhiwandiwala, Mumford and Feldblum (1983) studied menstrual pattern changes in 10,004 women from 64 institutions in 27 countries who had undergone interval or postabortion TS through electrocoagulation or application of clips or rings. They measured change in six menstrual parameters: cycle regularity, cycle length, menstrual flow duration, amount of flow, dysmenorrhea and midcycle bleeding. Standardized forms and similar protocols were used. Menstrual change data were collected pre-TS and at six, twelve and 24 months post-TS through self-report. The majority of women experienced no change. Up to 30 percent, however, experienced either an increase or a decrease in one of the parameters. In this study, previous contraceptive use was taken into account. As might be expected, of the women who experienced change, more women who had used oral contraception prior to their TS reported a decrease in menstrual regularity, and an increase cycle length, flow duration and amount, and dysmenorrhea. Similarly, for those who discontinued use of the IUD pre-TS, more women became regular, and experienced a decrease in flow duration, amount of flow, dysmenonhea, and midcycle bleeding. Those women who had used a barrier method, withdrawal, or tethbridge, RN, PhD, Psi,is Assistant Professor, Department of Parentand Child Nursing, Universityofwashington. The author acknowledges helpful discussions with Dr. Monica Jarrettduringthe writing of this article. Preparation ofthis material was funded byagrantfrom the National Center for Nursing Research, NIH 1, T32 07039. Correspondence to Department of Parent and Child Nursing, SC-74, School of Nursing, University of Washington, Seattle, WA 981 95. Accepted for publication May 16, 1991. Dona J.

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Post-tuba1 Sterilization Svndrome

no contraception prior to their TS had the following experience in the first six months: 1) 3 percent to 10 percent of women experienced menstrual cycles changing from irregular to regular; 5 percent to 10 percent from regular to irregular; 2) 10 percent to 20 percent experienced an increase in cycle length of two or more days, and 10percent to 20 percent a decrease of two or more days; 3) almost 20 percent to 30 percent experienced a change in menstrual flow duration of one or more days, and approximately 17 percent to 30 percent a decrease of one or more days; 4) 10 percent to 20 percent experienced an increase in menstrual flow, and 5 percent to 17 percent a decrease in menstrual flow; 5) 12 percent to 25 percent an increase in dysmenorrhea, and 10percent to 25 percent a decrease; and 6) 2 percent to 8 percent an increase in midcycle bleeding and 2 percent to 10 percent a decrease. Ranges reflect the method of TS, with no pattern apparent over the menstrual change parameters. Prior contraceptive use no longer seemed to affect menstrual pattern 6 to 12 months after discontinuation. It is important to note that a control group was not used in this study. Thus, it is not known how many women might experience such changes within the normal course of events. In this study, menstrual parameters were measured retrospectively through self-report rather than using objective measures such as actual measures of blood loss or prospective measures such as menstrual calendars. The only study to date measuring actual blood loss included 25 women and reported no statistics to support the claim of no difference in blood loss from pre-TS to 6 and 12 month measurements (Kasonde & Bonnar, 1976). Another large international study employing 8,483 post-TS women specifically compared the effects of methods of TS, studying electrocoagulation, rings, or clips in women who were not pregnant and had not used oral contraception or an IUD at least six weeks pre-TS (McCann & Kessel, 1976). They also found that the majority of women reported no change. Of the two possible directions of change, the one considered more disruptive (i.e., a change from regular to irregular cycles, an increase in duration or amount of flow or dysmenorrhea) was statistically similar among all methods of TS. There were significantly more women who reported a change from irregular to regular cycles, decreased dysmenorrhea, or a lessening of the duration and amount of menstrual flow undergoing TS by electrocoagulation than rings or clips. Similarly, another study of 1,555 women who had not used oral contraception or an IUD up to three months pre-TS compared the effect of method of TS on menstrual change up to one year (Fortney, Cole & Kennedy, 1983). A multiple regression analysis and a single additive score of menstrual change comprised of cycle length, regularity, duration of bleeding and dysmenorrhea was used. Pre-TS abnormality in one or more of the menstrual parameters was the best predictor of change, with pre-TS menstrual irregularity the next best predictor. This finding is predictable in that change would be more apparent in conditions of greater variation. For women with less monthly variation preTS, only a change to greater abnormality would be apparent. Both tuba1 rings and clips were found to be associated with less change than electrocoagulation or ligation. The use of an additive menstrual change score is questionable since change in 16

individual parameters may differ in magnitude and should therefore not be added. Also, the assumption that changes in more than one parameter reflect a greater effect of the TS may not be warranted. Another large study compared 2,243 women who had undergone TS to 3,551 women whose husbands had undergone vasectomy. They compared hospital referrals or admissions for gynecological or menstrual disorders up to six years post-TS, a rather crude outcome variable (Vessey, Huggins, Lawless & Yeates, 1983). They found no significant differences. Also using hospital records, Cohen (1987) measured the risk of undergoing hysterectomy up to nine years post-TS for 4,374 women compared to a control group of 6,835 randomly selected women enrolled in the same health insurance plan. At two years, there was no difference in hospitalizations for menstrual or gynecological disorders. Between two and nine years, however, TS increased the probability of hysterectomy 1.6 times after controlling for previous gynecological history, marital status, number of physician visits and hospitalizations. For women aged 30 and over at the time of TS, TS was not a risk factor for subsequent hysterectomy. Since data were obtained through hospital records, information on socio-economic status (SES) was not available. Women of lower SES tend to undergo TS at younger ages and therefore SES may be an intervening variable (Philliber & Philliber, 1985). When the long-term risk of menstrual disturbances post-TS was studied with a control group of non-TS women, an increase in abnormal cycles was revealed after two years (DeStefano, et al., 1985). Comparisons were made at six to 24 months, 25 to 48 months and 49 to 87 months post-TS. A logistic regression model controlled for presterilization status of the menstrual variable being evaluated, age, pre-TS contraception, history of gynecological disorders, gravidity, body mass index, cigarette smoking, education and religion. Among women with normal pre-TS cycles, the prevalence of abnormal cycles did not differ up to 48 months post-TS. At 49 to 87 months, however, the TS group had a significantly increased (i.e., nearly three times more) prevalence of abnormal cycles. Among women with pre-TS abnormal cycles, post-TS abnormal cycles were apparent at 25 to 48 months. At the six to 24 month follow-up interval, the TS group had a significantly increased prevalence of moderate to severe menstrual cramps among women who had no or mild cramps before sterilization. Premenstrual symptoms, including irritability or moodiness, headache or dizziness, and swelling or weight gain did not differ significantly for the two groups over the measurement periods. Since the TS procedures for this study were performed between 1968 and 1972, they were mainly by ligation or electrocoagulation. Thus, findings would not be applicable to TS by clips or rings, both of which are thought to cause less tissue destruction. Studies evaluating luteal phase defects have been inconclusive. Disrupted vascularity could result in abnormal ovarian perfusion and decreased progesterone production. In two studies (Donnez, Wauters & Thomas, 1981; El Mahgoub, El Shounbogy & El Zeniny, et al, 1984), 55 percent of post-TS women were found to have luteal phase defects as revealed by endometrial IMAGE: Journal of Nursing Scholarship

Post-tuba1 Sterilization Syndrome

biopsy. The former study found a higher frequency with tubal ligation and electrocoagulationthan with clip application. However, Hague, et al. (1987) suggest that late luteaI phase biopsies studied in relation to the relevant menstrual cycles are necessary to show abnormally low progesterone levels. They performed late luteal phase biopsies during two consecutive menstrual cycles in 72 women who had undergone TS and found no cases of luteal phase defect. Post-TS abdominal or lower back pain, irregular bleeding or dysmenorrhea may be related to endometriosis. One study found that in 25 cases where TS was by ligation or electrocoagulation resulting in less than 4 cm of remaining proximal tube, 45 percent of the oviducts had tubal fistulas opening into the abdominal cavity and 74 percent showed local though not peritoneal or ovarian endometriosis(Rock, Parmley, King, Laufe & Su, 1981). Of the 13 cases of cautery, regardless of time or length of remaining tube, 66 percent showed endometriosis. Only six cases of TS by ring application were studied, but four of six had endometriosis. In another study of 133 previously sterilized tubes, between 64 percent and 87 percent were dilated to over 600 micrometers (normal, 415.5 +/- 129.3 micrometers) and four were dilated to over 2000 micrometers (Donnez, Casanas-Roux, Ferin & Thomas, 1984). Ten percent of ring applications, 38 percent of ligations, and 33 percent of electrocoagulationsshowed epithelial inclusions into the smooth muscle. Sixteen percent of ligated tubes and 26 percent of those cauterized showed endometriosis. In summary, empirical findings reveal that some women may indeed experience menstrual changes post-TS. Many of the studies have serious short-comings,but it would seem that tubal ligation or electrocoagulationmay increase the risk of accompanying menstrual change. It is also possible that local endometriosis may occur post-TS resulting in menstrual changes occurring over time.

Implications for Further Research on Post-TS Syndrome Studies of post-TS syndrome have been conducted by medical researchers, and intended to investigate the overall safety and consequences of TS. Thus, articles that report that the majority of women experience no menstrual changes post-TS validate the preponderance of benefits over risks of the procedure. However, the profession of nursing also has an interest in the minority of women that may experience menstrual changes. For those who do experience post-TS menstrual changes, what are the nature of those changes? How do women perceive those changes in terms of their overall perception of well-being? Whether or not menstrual changes after TS are verified, what is the meaning of perceived changes to women? It is important that studies of post-TS menstrual change include a control group of women similar to the study group. Several of the studies reported above used pre-TS menstrual cycles as controls for post-TS cycles. However, a design where a nonsterilized group is followed as well would permit observation of menstrual changes that might occur naturally over time. Control group members should be similar in age to control for increased Volume 24, Number 1 , Spring 1992

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Menstrual Calendar Card, Year 1990

THE TREMIN TRUST

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variability in cycle lengths found with women under 25 years and over 40 years of age (Chiazze, Brayer, Macisco, Parker & Duffy, 1968). Groups should also be matched on pre-TS contraception, history of gynecologic disorders, gravidity, body mass index, cigarette smoking, education, religion, socio-economic status, ethnicity, race and any other factors that might possibly affect menstrual functioning and women’s perception of it. Objective measures of menstrual change are needed as well. Retrospective studies rely on memory of the characteristics of menstrual cycles as well as recollections that may be influenced by women’s feelings about and expectations of the TS experience. More objective measures would include prospective studies using a Treloar-type menstrual calendar to document monthly onset, duration, and characteristics of menstrual cycles (Figure 1) (Treloar, Boynton, Behn &Brown, 1967). The World Health Organizationhas recommended a set of symbols that may be used by semi-literate or illiterate women (Belsey & Farley, 1987). More studies of actual menstrual blood loss are also needed, studied through the collection and weight of menstrual pads and tampons. Finally, daily hormonal assays over several cycles preand post-TS in control and experimental groups might reveal luteal phase changes. These studies would necessarily be costly since it has been suggested by the above studies that perhaps 20 percent of women actually experience a post-TS change in menstrual flow. Thus, a large sample size to counter a small effect size would be necessary (Cohen, 1977). Consideration must also be given to the treatment of menstrual cycle data. Data in the studies described above are reported in terms of menstrual cycles. This gives undue weight to data from women with shorter cycles (Burch, Macisco &Parker, 1967). To control for differing cycle lengths, reference periods of a minimum of 90 days are suggested (Belsey, Machin, & d’kcangues, 1986). Then, bleeding and spotting periods may be described in terms of bleedinghpotting episodes, defined as one or more consecutive days in which blood loss has been entered on the record, bounded by bleedinglspotting-free days; bleedingtspot17

Post-tuba1 Sterilization Syndrome

ting-free intervals; and bleeding/spotting segments, defined as one bleedinghpotting episode and the immediately following bleedinghpotting-free interval (Belsey & Farley, 1987). The denotation of spotting as opposed to bleeding presents a problem of interpretation. Spotting is often defined as any bloody vaginal discharge that is not sufficient to require protection (Belsey, et al., 1986). In societies where menstrual protection is not used, the distinction between bleeding and spotting may not be relevant. In addition to quantitative studies of menstrual change, qualitative study of women’s experience of post-TS menstrual change is also necessary. What meaning might menstrual changes have for women experiencing them? In the empirical studies described above, it was generally found that menstrual changes occurred in both directions; i.e., for different women such characteristics as menstrual flow, dysmenorrhea, or cycle regularity both increased or decreased. It should not be assumed, however, that these changes necessarily are viewed positively by the women experiencing them. In two studies of beliefs about the menstrual cycle, women were reported to believe that menstrual flow rids the body of impurities (Scott, 1975; Snow & Johnson, 1977). A decreased or delayed menstrual flow was believed to back up, leaving impurities in the body. There is also the larger question of how women perceive menstrual changes. Might their perception of such changes reflect or be a somatization of their feelings about the TS?

Implications for Nursing Practice Since there is little empirical data that would provide an understanding of post-TS syndrome and direction for nursing intervention, guidelines for care must come from each individual situation. Since menstrual change would be identified after a TS has taken place, it would be difficult to determine objectively the extent of actual change. Nevertheless, women should be encouraged to keep a record of their menstrual cycles, to monitor the parameters discussed above. Bean, Leeper & Wallace, Sherman & Jagger ( 1979) have discussed the difficulty women have in accurately remembering past menstrual cycles. Therefore, this would be done on a calendar or a Treloar-type record. Regardless of the nature of menstrual cycles recorded after a TS, women’s perception of changes should be respected. Since findings in the medical literature stress that a minority of women experience menstrual change, women may have had the experience of being told that menstrual changes after TS do not occur at all. Women’s perception of and feelings about menstrual change should be explored. How much change is acceptable? Women may be able to make a better judgment when actual cycles have been recorded. Further, what do the changes mean to women? For some, increased menstrual flow or shorter cycles may be troublesome; for others, this may not be the case. It is difficult, however, to imagine that any woman would welcome increased dysmenorrhea or midcycle bleeding. Though studies revealed only localized endometriosis after TS, it is not clear that it is also painless or symptom-free. A perceived increase in dysmenorrhea or the onset of midcycle bleeding after TS would warrant referral for diagnosis and further treatment. &ZE& 18

References Bean, J., Leper, J., Wallace, R., Sherman,B. & Jagger, H. (1979).Variations in the reporting of menstrual histories. American Journal of Epidemiology, 109, 181-185. Balakrishnan,T.R,Krotki, K. & Lapierre-Adamcyk,E.(1985).Contraceptive use in Canada, 1984. Family Planning Perspectives, 17,209-215. Belsey, E.M. & Farley, T.M.M. (1987). The analysis of menstrual bleeding patterns:Areview. AppliedStochasticModelsandDataAnalysis,3,129-156 Belsey, E.B., Machin, D. & d’Arcangues, C. (1986). The analysis of vaginal bleeding patterns induced by fertility regulating methods. Contraception,34, 253-260. Bhiwandiwala,P.P.,Mumford,S.D. & Feldblum,PJ. (1983).Menstrualpattem changes following laparoscopic sterilization with different occlusion techniques. American Journal of Obstetrics and Gynecology, 145,684-694. Burch, T.K., Macisco, JJ. & Parker, M.P. (1967). Some methodologic problems in the analysis of menstrual data. InternationalJournal of Fertility, 12, 67-76. Chiazze,L.,Brayer,F.T.,Macisco,JJ.,Parker,M.P. & DuBy,BJ. (1968).The length and variability of the human menstrual cycle. The Journal of the American Medical Association, 203,377-392. Cohen, J. (1977). Sampling techniques. New York: Wiley Press. Cohen, M.M. (1987). Long-term risk of hysterectomy after tubal sterilization. American Journal of Epidemiology, 125,410-419. DeStefano, F., Perlman, J.A., Peterson, H.B. & Diamond, E.L. (1985). Longterm risk of menstrual disturbances after tubal sterilization.American Journal of Obstetrics and Gynecology, 152,835-841. Donnez, J., Casanas-Roux, F., Ferin, J. & Thomas, K. (1984). Tubal polyps, epithelial inclusions, and endometriosis after tubal sterilization. Fertility and Sterility, 41,564-568. Donnez, J., Wauters, M. & Thomas, K. (1981). Luteal function after tubal sterilization. Obstetrics and Gynecology, 57,65-68. Dwyer, J.C. & Haws, J.M. (1990).Is permanent contraceptionacceptablein subSaharan Africa? Studies in Family Planning, 21,322-326. El Mahgoub, S., El Shounbogy, M. & El Zeniny, A. (1984). Long-term luteal changes after tubal sterilization. Contraception, 30,125-131. Fortney,J.A., Cole,L.P. &Kennedy, K.I. (1985). A new approach to measuring menstrual pattern change after sterilization. AmericanJournal of Obstetrics and GYII~COIO~Y, 147,830-836. Hague, W.E., Maier, D.B., Schmidt, C.L. & Randolph, J.F. (1987). An evaluation of late luteal phase endometrium in women requesting reversal of tubal ligation. Obstetrics and Gynecology, 69,926-928. Kasonde, J.M. & Bonnar, J. (1976). Effect of sterilizationon menstrual blood loss. British Journal of Obstetrics and Gynecology, 69,926-928. Mexico National Survey on Fertility and Health. (1990). Mexico 1987: Results from the demographicand health survey.Studies in Family Planning, 21, 181-185. McCann, M.F. & Kessel, E. (1976). International experience with laparoscopic sterilization: follow-up of 8500 women. Advances in Planned Parenthood, 12, 199-211. Mosher, W.D. & Pratt, W.F. (1990). Contraceptive use in the United States, 182.Hyattsville, 1973-1988.Advancedatafromvitalandhealthstatistics,no. Maryland: National Center for Health Statistics. Philliher, S.G. & Philliher, W.W. (1985). Sociological and psychological perspectives on voluntary sterilization: A review. Studies in Family Planning, 16, 1-29. Poston,Jr.,D.L.(1986). Patterns ofcontraceptiveuse inChina. StudiesinFamily Planning, 17,217-227. Rock, J.A.,Parmley,T.H.,King,T.M.,Laufe,L.E.& Su,B.C. (1981). Endometriosis and the development of tuboperitoneal fistulas after tubal ligation. Fertility and Sterility, 35,16-20. Scott, C.S. (1975).The relationshipbetween beliefs about the menstrualcycle and choice of fertility regulatingmethods within five ethnic groups. International Journal of Gynaecology and Obstetrics, 13,105-109. Snow, L.F. 81Johnson, S.M. (1977). Modem day menstrual folklore. Journal of the American Medical Association, 237,2736-2739. Thailand Demographic and Health Survey. (1989). Thailand 1987: Results fmm the Demographic and Health Survey. Studiesin Family pLannin& 20,62-66. Treloar, A., Boynton, R., Behn, B. & Brown, B. (1967).Variation of the human menstrual cycle through reproductive life. InternationalJournal of Fertility, 12,77-126. Vessey, M., Huggins, G., Lawless, M. & Yeate, D. (1983). Tubal sterilization: findings in a large prospective study. British Journal of Obstetrics and Gyn&ology, 90,203-209. IMAGE: Journal of Nursing Scholarship

Post-tubal sterilization syndrome.

This article presents a review of the literature on post-tubal sterilization syndrome. Although studies have shortcomings they suggest the majority of...
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