JOGNN IN FOCUS

Sleep and Fatigue Symptoms in Women

Before and 6 Weeks After Hysterectomy
Kimberly H. Kim and Kathryn A. Lee

Correspondence
Kimberly H. Kim, RN, PhD,
Department of Nursing and
Health Sciences, California
State University, East Bay,
25800 Carlos Bee Blvd
Hayward, CA 94542.
kimberly.kim@csueastbay.
edu
ABSTRACT
Objective: To compare sleep and fatigue experiences of women before hysterectomy and at 3 and 6 weeks after
surgery, to compare symptoms by type of surgical procedure, and to examine the biopsychosocial contextual factors
related to symptoms.
Design: A descriptive repeated measures study assessed sleep and fatigue using questionnaires and objective wrist
actigraphy monitoring for sleep.
Setting: Data were collected in women’s homes at least 2 days before surgery, and at 3 and 6 weeks postoperatively.

Keywords Participants: A convenience sample of 25 women scheduled for hysterectomy.

symptoms Results: There was significantly higher self-reported sleep disturbance 3 weeks after surgery compared with base-
sleep
line. Women who had vaginal hysterectomy continued to experience sleep disturbance and fatigue 6 weeks after
fatigue
hysterectomy surgery, while those who had abdominal hysterectomy reported better sleep and less fatigue at 6 weeks compared
with baseline. The number of awakenings recorded with actigraphy increased postoperatively for both groups, and
younger women experienced more wake time during the night than older women. Level of education was positively
related to preoperative fatigue severity.
Conclusions: Findings suggested poor sleep and fatigue during the postoperative period should be evaluated in light
of women’s ages, level of education, and type of surgical procedure.
JOGNN, 38, 344-352; 2009. DOI: 10.1111/j.1552-6909.2009.01029.x
Accepted December 2008

Kimberly H. Kim, RN,
PhD, is an associate
professor and assistant
director in the Department
of Nursing and Health
Sciences, California State
University, East Bay,
Hayward, CA. Dr. Kim was
the American Nurses
Foundation Wyeth-Ayerst
Women’s Health Scholar
when this research was
conducted.
Kathryn A. Lee, RN, PhD,
CBSM, FAAN, is a
professor and director of the
Nurse Research Training in
Symptom Management and
the James and Marjorie
Livingston Endowed Chair
in Nursing in the
Department of Family
Health Care Nursing,
School of Nursing,
University of California,
San Francisco, San
Francisco, CA.
he most prevalent non^pregnancy-related sur-
T gical procedure for women in the United States
is a hysterectomy. Approximately 600,000 hysterec-
tomies are performed annually (Edozien, 2005;
Iversen, Hannaford, Elliott, & Lee, 2005). Although
hysterectomy relieves preoperative symptoms in-
cluding heavy bleeding and pain, it also carries a
substantial risk for postoperative symptoms such
as fatigue and sleep disturbance. It is reported that
numbers of women who undergo a hysterectomy
experience complications in the recovery period
(Clarke, Black, Rowe, Mott, & Howe, 1995; Gimbel
et al., 2003; Harris, 1997; Jenkins, 2004; Li et al.,
2007; Rodr|¤ guez et al., 2006; Scho¢eld, Bennett,
Redman, Walters, & Sanson-Fisher,1991; Shen et al.,
2003). Major complaints during posthysterectomy
recovery include fatigue and sleep disturbance.
The likelihood of having a hysterectomy varies with
a woman’s age, diagnosis, and other characteristics
such as ethnicity, education, marital status, having
children, and income. The highest rates for this
procedure occur in women 30 to 54 years of age
(Chandra, 1998; Iversen et al., 2005; Wilcox et al.,
1994) and 49 to 59 years of age (Dia et al., 2003).
The most common diagnosis that indicates the
need for a hysterectomy is uterine leiomyoma (Dia
et al.; Edozien, 2005; Poliquin, Victory, & Vilos,
2008), followed by endometriosis, prolapse of the
uterus, and cancer of the reproductive tract.
There are several surgical options for hysterectomy
(Johnson et al., 2005) including laparotomy ap-
proach to total abdominal hysterectomy (TAH),
laparoscopic approach to TAH, laparoscopic-
assisted vaginal hysterectomy, and vaginal hyster-
ectomy. The option depends on diagnosis and
physician’s preference. Total abdominal hysterec-
tomy is performed more commonly for myomas
and presence of malignancy (Kovac, 2004; Taylor,
Romero, Kammerer, Qualis, & Rogers, 2003; Wilcox
et al.,1994). Li et al. (2007) reported that procedures
had similar e⁄cacy rates and morbidity rates for
cervical cancer. Harris (1997) and Susini et al.
(2005) suggested that although laparoscopic vagi-
nal hysterectomy (LVH) had advantages and

344 & 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org
Kim, K. H. and Lee, K. A.
disadvantages, the complication rate did not ex-
ceed that of TAH when performed by well-trained
physicians. The advantage of LVH is the ability to in-
spect the tissue with laparoscopy once vaginal cu¡
closure is completed.
The speci¢c purposes of this study were to (a)
describe sleep and fatigue experiences before
hysterectomy compared with 3 and 6 weeks after
surgery, (b) compare symptoms by type of surgical
procedure, and (c) examine relationships between
symptoms and biopsychosocial contextual vari-
ables identi¢ed from the theoretical model and
from the review of the literature. Using the Theory of
Symptom Management (Humphreys et al., 2008) as
the conceptual basis for the study, a convenience
sample of ethnically diverse women scheduled for
hysterectomy was recruited to describe the
changes in sleep and fatigue symptoms by type of
surgical procedure; they were selected based on
sociodemographic contextual factors such as age,
ethnicity, income, and education.
Literature Review
Hysterectomy a¡ects many aspects of a woman’s
health, and women considering hysterectomy may
be interested in its e¡ectiveness for relief of symp-
toms, duration of hospitalization and recuperation,
and long-term e¡ects on quality of life. A symptom
experience model (Kim & Lee, 2001) for women af-
ter hysterectomy was used to guide this study. In this
model, a woman’s symptom experience is complex
and should be viewed within the context of biopsy-
chosocial in£uences. Compared with women
undergoing major surgery for other reasons,
women undergoing hysterectomy have additional
physiological, psychological, and social factors to
consider. The physiological factors may di¡er for
women who have had a hysterectomy because of
the removal of the uterus and the hormonal imbal-
ance related to ovarian dysfunction (even when
the ovaries are preserved). Removal of the uterus
results in the loss of reproductive potential and can
symbolize loss of womanhood for some women,
with negative outcomes such as depressed mood.
Social factors vary depending on family relation-
ships, cultural, and societal expectations for
motherhood at any given age, numbers and ages
of children, and support systems that include rela-
tionships with spouse or partner. Although actual
hospitalization time is brief, recuperation from hys-
terectomy entails signi¢cant short-term disability
(Baldaro et al., 2003; Carson, 1997; Jenkins, 2004;
Li et al., 2007) and impact on employment and
JOGNN 2009; Vol. 38, Issue 3
IN FOCUS
Compared with women undergoing major surgery for other
reasons, women undergoing hysterectomy have additional
physiological, psychological, and social factors to
consider.
income. Long-term problems attributed to hysterec-
tomy such as chronic pain, urinary incontinence,
adhesion of the bowel, infection, fatigue, or poor
relationships with spouse or partner and children,
have been reported by about 50% of women
(Gould & Wilson-Barnett, 1985; Rodr|¤ guez et al.,
2006; Scho¢eld et al., 1991; Shen et al., 2003;
Szomstein, Lo Menzo, Simpfendorfer, Zundel, &
Rosenthal, 2006).
Symptom Experience
For the purpose of this study, symptom experience
was conceptualized as a speci¢c cluster of com-
monly experienced symptoms (sleep disturbance
and fatigue) in£uenced by a woman’s biopsycho-
social context as well as the type of surgical
procedure performed (abdominal or laparoscopic
hysterectomy).
Sleep Disturbance
One of the most prevalent postoperative symptoms
following hysterectomy is fragmented sleep. Indica-
tors of disturbed sleep range from self-report
measures of decreased total sleep time to increased
number of awakenings during the night that
contribute to complications and prolonged conva-
lescence (Bisgaard, Kjaersgaard, Bernhard, Kehlet,
& Rosenberg,1999). Previous studies in patients un-
dergoing major abdominal surgery found that total
sleep time decreased by up to 80% during the ¢rst
few postoperative nights (Ellis & Dudley, 1976;
Rosenberg, Wildschiodtz, Pedersen, Von Jessen, &
Kehlet, 1994). In a study of 175 women with abdomi-
nal hysterectomy, Scho¢eld et al. (1991) found that
48% who had preoperative sleep disturbance also
experienced the same or worse sleep disturbance
postoperatively and 9% (n 5 15) reported sleep
disturbance as a new symptom after surgery. Fur-
thermore, postoperative sleep disturbance could
be a contributing factor for fatigue (Christensen &
Kehlet, 1993), although the relationship between
sleep disturbance and postoperative fatigue
remains unknown.
Fatigue
Fatigue is reported as a prominent complaint
after hysterectomy and often interferes with daily
activities. Fatigue may occur as a result of biopsy-
chosocial demands for energy that exceed the
345
IN FOCUS
woman’s resources for coping (Lee, Lentz, Taylor,
Mitchell, & Woods, 1994; Kim & Lee, 2001). Blood
loss, anesthesia side e¡ects, and the surgical pro-
cedure itself may deplete energy reserves. Carlson,
Miller, and Fowler (1994) found that 91% of 271 wo-
men reported postoperative fatigue for 21 days after
abdominal hysterectomy; 35% reported fatigue at 3
months; and 20% reported persistent fatigue at 12
months. Fatigue was the symptom that most inter-
fered with daily activities. De Cherney, Bachmann,
Isaacson, and Gall (2002) reported that 74% of the
300 women experienced moderate to severe fatigue
after surgery, compared with 63% reporting
moderate to severe pain. Fatigue contributed to
di⁄culty concentrating, feeling frustrated, and feel-
ing depressed, and it persisted for twice as long as
the pain (De Cherney et al.). According to the The-
ory of Symptom Management, if symptoms such as
fatigue persist, health outcomes can include
depressed mood, increased health care utilization,
and poor social and family interactions (Humphreys
et al., 2008).
Method
Research Design
A descriptive repeated measures design was used
to prospectively describe changes in sleep and
fatigue experienced before and after hysterectomy,
compare symptoms by type of surgical procedure
(TAH or LVH), and examine relationships between
these two symptoms and biopsychosocial con-
textual factors.
Procedures and Participants
The Committee on Human Research approved the
study. The inclusion criteria included: (a) women
above 35 years of age, (b) no history of pregnancy
or surgery for the past 2 years, (c) no history of psy-
chiatric illnesses, (d) not taking psychotropic drugs,
and (e) living in the San Francisco Bay Area. Poten-
tial participants were accessed through the £yer
provided by investigators in a gynecology clinic
at 1 to 2 weeks before surgery. Once women
expressed an interest in participating, they were
asked to call the investigator who would provide
the details of the study and obtain informed con-
sent, their health history, and baseline data that
included physiological, psychological, and social
variables as well as sleep-wake patterns and symp-
toms. The participants wore a wrist actigraph for 48
hours between 3 days and 2 weeks before their
scheduled surgery. Once discharged from the hos-
pital, women were asked to wear the wrist actigraph
in their home to monitor activity continuously for 48
hours at 3 and 6 weeks after surgery. At each time
346 JOGNN, 38, 344-352; 2009. DOI: 10.1111/j.1552-6909.2009.01029.x
Fatigue in Women With Hysterectomy
point, they were also asked to complete standard-
ized questionnaires and a diary that included
information about their sleep and wake times as
well as fatigue and other symptoms. After each 48
hours session, the investigator collected the wrist
actigraph and diary from the participant’s home.
Participants were paid $20.00 for each of the three
time points after retrieval of the wrist actigraph and
diary data.
Variables and Instruments
The biopsychosocial contextual factors associated
with a woman’s symptom experience were evalu-
ated using questionnaires for self-report and
objective data for sleep-wake patterns. Physiologi-
cal factors included the surgical procedure:
laparotomy approach to TAH or LVH. Social factors
included age, ethnicity (Asian American, Black,
Hispanic American, or White), marital status (single,
married, divorced, or widowed), education (gradu-
ated from high school, college, or postgraduate
work), employment (full-time, part-time, home-
maker, or retired), and children living in the home
(categorized as either none, 1 to 2, 3 to 4, or greater
than or equal to 5 children). These data were
collected at baseline.
Symptom Experience
Symptom measures included sleep disturbance and
fatigue. Sleep disturbance was measured using the
Pittsburgh Sleep Quality Index (PSQI), General Sleep
Disturbance Scale (GSDS), and wrist actigraphy.
Perception of sleep quality was assessed with the
19-item PSQI that asks about sleep quality in the past
month. A global sleep quality score can range from
0 to 21 and a score above 5 indicates severe sleep
disturbance (Buysse, Reynolds III, Monk, Berman, &
Kupfer, 1989). Internal consistency reliability (Cron-
bach a coe⁄cient) was .73 in this sample. Current
perception of sleep disturbance was assessed using
the 21-item GSDS that asks about sleep during the
past week on a scale of 0 5 not at all to 7 5 every
day. Scores can range from 0 to 147 and a score
greater than 60 indicates severe sleep disturbance
while scores between 40 and 60 indicate moderate
sleep disturbance (Lee,1992; Lee & Taylor,1996). In-
ternal consistency reliability (Cronbach a coe⁄cient)
for this sample was .87.
Wrist actigraphy was used to objectively assess
sleep-wake patterns over 48 hours at baseline and
at 3 and 6 weeks after surgery. The same 2 days of
the week were used for each subject at all three time
points. The actigraph detects motion from the
nondominant wrist and quanti¢es the number of
http://jognn.awhonn.org
Kim, K. H. and Lee, K. A.
movements over a preprogrammed interval, and
was set at 30 seconds epochs for this study. It has
been demonstrated to be reliable and valid against
the gold-standard measure of sleep time using
polysomnography in clinical settings (Mason &
Redeker,1993).
Actigraphy is also useful in assessing improved
sleep as an outcome measure for patients with
insomnia before and after therapy (Morgenthaler
et al., 2007). Wrist actigraphy has accompanying
software for an automatic sleep-scoring algorithm
to allow for quantifying activity and sleep time with-
out researcher bias, and objectively estimates time
spent asleep and awake during the night. Sleep pa-
rameters of interest included (a) total sleep time in
minutes, from the time of ‘‘lights out’’ to ¢nal awak-
ening, (b) time to fall asleep in minutes, from the
time at which the event marker is pressed to ¢rst
minute of sleep, (c) wake after sleep onset (WASO),
as a percentage of time awake during the night after
falling asleep, and (d) number of awakenings last-
ing at least 3 minutes. A sleep diary was also used
for self-monitoring of participant’s sleep and day-
time activities. A sleep diary is often used in
conjunction with actigraphy to provide an indica-
tion of daily activity, including bedtimes, trips to the
bathroom, and exercise.
The Lee Fatigue Scale was used to measure fatigue
at baseline as well as 3 and 6 weeks after surgery.
This 18-item instrument asks the participant to rate
various components of fatigue, sleepiness, and en-
ergy on an 11-point rating scale from 0 5 low to
10 5 high in the morning and evening as part of the
daily sleep diary. Scores for both evenings were av-
eraged for this analysis. A score of greater than 6.6
indicates severe fatigue, scores between 3.3 and 6.5
indicate moderate fatigue, and scores from 0 to 3.2
indicate mild or no fatigue (Lee & Taylor, 1996).
Validity and reliability were established in healthy
persons and sleep disorder patients (Lee, Hicks, &
Nino-Murcia,1991). For this sample, the Cronbach a
coe⁄cient was .95 for the 13-item fatigue subscale.
Data Analyses
Data were analyzed using descriptive and inferen-
tial statistics. Objective sleep data were ¢rst
downloaded from the actigraph into a personal
computer using an interface unit, and then ana-
lyzed using Action 4 automatic sleep analysis
software. Because of a potential ¢rst-night adapta-
tion e¡ect, only the second night was used for
analyses at each time. Pearson’s product-moment
correlation coe⁄cients were used to test relation-
ships among the two symptoms (sleep disturbance
JOGNN 2009; Vol. 38, Issue 3
IN FOCUS
Higher educational attainment was associated with
more severe preoperative fatigue, and higher fatigue was
associated with self-reported sleep disturbance but not
objective sleep disturbance.
and fatigue) and biopsychosocial contextual
factors (sociodemographic variables). Repeated
measures analysis of variance was used to test for
within-subject changes in sleep disturbance and
fatigue scores from baseline to 3 and 6 weeks after
surgery and to test between-subjects di¡erences by
type of surgical procedure.
Results
Sample Characteristics
A sample of 25 ethnically diverse women partici-
pated in the study. They ranged in age from 39 to
80 years, with a mean of 49  10 years (median 48
years). There were 12 White, 5 Black, 4 Asian Ameri-
can, and 4 Hispanic participants. Most (72%,
n 5 18) were employed full-time outside the home
and 7 (28%) were homemakers. Most (72%) had
more than a high-school education. Fifteen women
(60%) were married, 5 (20%) were single, 4 (16%)
were separated or divorced, and 1 (4%) was wid-
owed. The majority (84%) had children, and 72%
reported a net family annual income of over
$60,000. The most common diagnostic indication
for hysterectomy was uterine leiomyoma (n 5 16),
followed by heavy bleeding (n 5 8) due to endome-
triosis and uterine cancer (n 5 1). Time since
diagnosis ranged from 2 months to 15 years. Eigh-
teen (72%) reported preoperative pain, with 15 of
the 18 having the most pain in their pelvic and
abdominal areas, and the other 3 having pain
primarily in joints or back and shoulders. Ten wo-
men had LVH and 15 women had TAH. Three
women experienced complications after TAH that
included infection, severe leg pain due to thrombo-
sis, or chronic diarrhea.
Symptom Experience
Subjective sleep disturbance was evident in this
sample, with PSQI global scores greater than 5 at
all three time points (Table 1). The 5 Black partici-
pants perceived signi¢cantly higher scores for
sleep disturbance on the GSDS than the 12 White
participants at baseline and 3 weeks after surgery
(F 5 8.1, p 5 .015). Similarly, Hispanic and Black
participants had signi¢cantly higher PSQI scores
than White and Asian American participants at
baseline and at 3 weeks after surgery. Compared
with baseline, self-reported sleep was perceived as
347
IN FOCUS Fatigue in Women With Hysterectomy

Table 1: Objective (Actigraphy) and Subjective Sleep Data at Baseline, 3, and 6 Weeks
after Hysterectomy (n 5 25)
Sleep
Total Sleep Efficiency Wake After Sleep Number Sleep Onset Day Sleep PSQI GSDS
Time Time (min) (%) Onset (% of TST) Awakenings Latency (min) (min) (Mean) (Mean)
Baseline

Mean 401.9 88.69 8.48 9.9 11.1 3.72 7.6 42.3

Median 404 90.6 6.45 8 8 3.05 6.5 41.5

SD 125.68 8.42 7.36 6.04 9.5 2.93 4.6 21.6

3 weeks post

Mean 441.67 86.47 9.38 18.5 16.33 2.62 9.5 45.7

Median 423 89.75 5.15 15 9.5 2 11 50.0

SD 76.18 9.79 10.58 14.52 15.88 1.52 5 23.8

6 weeks post

Mean 411.1 81.8 14.69 19.6 13.7 3.97 7.6 39.1

Median 436.5 86.75 11.65 18 6.5 2.65 6 31.0

SD 102.29 15.63 12.5 8.18 2.61 4.05 4.8 24.3

Signi¢cance

F (p) (ns) (ns) (ns) 2.0 (.02)

Note. GSDS 5 General Sleep Disturbance Scale (range 0-147); PSQI 5 Pittsburgh Sleep Quality Index (range 0-21); TST 5 total sleep time.

worse 3 weeks after surgery and improved beyond
baseline values by 6 weeks after surgery.
There was no signi¢cant di¡erence in self-reported
sleep quality or fatigue severity between TAH and
LVH groups at baseline or at 3 weeks after surgery
(Table 2). However, there was a signi¢cant time-by-
group interaction, with improved self-reported sleep
and fatigue for the TAH group at 6 weeks compared
with their own baseline (post hoc paired t test,
po.05) and compared with the LVH group at 6
weeks (post hoc unpaired t test, po.05).
The objective sleep actigraphy data are also
presented in Table 1 with means, medians, and
standard deviations at all three time points. At base-
line, total sleep time ranged from 5.0 to 11.7 hours
(6.7  2.1 hours), and increased at 3 weeks after
surgery by almost 45 minutes and ranged from 6.0
to 9.8 hours (7.4  1.3 hours). Compared with base-
line, number of awakenings and time spent awake
during the night WASO were signi¢cantly (p 5 .02)
increased at 3 weeks after surgery. Although there
was less daytime sleep at 3 weeks compared with
baseline, this di¡erence was not statistically signi¢-
cant (Table 1).
At 6 weeks after surgery, total sleep time ranged
from 3.0 to 8.5 hours (6.7  1.7 hours). Sleep e⁄-
ciency improved for women with LVH and was
worse for women with TAH, primarily due to more
wake time during the night (WASO) than due to time
spent initially trying to fall asleep. Number of awak-
enings at 6 weeks did not di¡er signi¢cantly from
the third postoperative week. At 6 weeks, the aver-
age amount of daytime sleep was similar to baseline
levels but more variability in nap time was noted
in the sample (Table 1). When sleep was compared
by type of surgical procedure, there were no statisti-
cally signi¢cant di¡erences between TAH and LVH
groups by objective actigraphy measures, in con-
trast with self-report measures. There was a trend
for number of more awakenings and poorer sleep
e⁄ciency in the LVH group compared with the TAH
group at each time point, but these di¡erences were
not statistically signi¢cant in these small group
comparisons.
For the entire sample of 25 women, sleep problems
by self-report and by objective measures were more
in the clinically severe range of scores than their le-
vel of evening fatigue. Fatigue averaged 3.7  2.32
(median 5 4.5) at baseline and decreased to

348 JOGNN, 38, 344-352; 2009. DOI: 10.1111/j.1552-6909.2009.01029.x http://jognn.awhonn.org

Kim, K. H. and Lee, K. A. IN FOCUS

Table 2: Symptom Experience of Sleep Table 3: Pearson’s Correlation Coefficients

Disturbance and Fatigue Before and After for Sleep (PSQI and GSDS) and Fatigue
TAH and LVH (LFS) Perceived Symptoms With
Biopsychosocial Contextual Factors and
TAH (n 5 15) LVH (n 5 10)
Actigraphy-Recorded Sleep Efficiency at
Mean (SD) Mean (SD) Baseline and at 6 Weeks After Surgery
Sleep disturbance (0-147) a (n 5 25)
Baseline 42.1 (22.3) 35.0 (21.2) PSQI GSDS LFS
Time 1: Baseline pre-operatively
3 weeks after surgery 45.7 (23.6) 44.5 (36.1)
Age .67  .63  .38
6 weeks after surgery 38.7 (23.5) 42.8 (29.2)
Education levels .04 .22 .50 
Fatigue (0-10)b
Having children .31 .32 .14
Baseline 3.5 (2.3) 3.2 (3.9)
Sleep e⁄ciency by .64  .51  .45 
3 weeks after surgery 3.3 (2.4) 3.3 (4.2)
actigraphy
6 weeks after surgery 2.7 (2.4) 3.5 (4.2)
Time 3: 6 weeks post-operatively
Note.
.47 
a
GSDS 5 General Sleep Disturbance Scale: Scores greater Age .45 .3
than 60 indicate severe sleep disturbance, scores from 30 to 60
indicate moderate sleep disturbance, and scores from 0 to 29 Education levels .25 .18 .16
indicates mild or no sleep disturbance.
b
Fatigue (Lee Fatigue Scale): Scores more than 6.6 indicate Having children .37 .25 .47
severe fatigue, scores from 3.3 to 6.5 indicate moderate fatigue,
and scores from 0 to 3.2 indicate mild fatigue. Sleep e⁄ciency by .065  .39 .19
actigraphy
3.4  2.51 (median 5 3.1) at 3 weeks after surgery
Note. GSDS 5 General Sleep Disturbance Scale (past week);
and to 2.8  2.47 (median 5 1.9) at 6 weeks after LFS 5 Lee Fatigue Scale (current evening); PSQI 5 Pittsburgh
surgery. Hispanic and Black women perceived Sleep Quality Index (past month).
po.05 level (two-tailed).
higher fatigue than White women at all time points. po.01 level (two-tailed).

Correlates of Symptom Experience

As seen inTable 3, age was negatively related to sleep
quality, indicating that younger women had more
self-reported sleep disturbance. Age was also nega-
tively associated with fatigue but the relationship was
not statistically signi¢cant in this small sample. Level
of education was positively related to preoperative
fatigue, indicating that women with higher education
experience higher fatigue severity before surgery.
There was no association between education and
fatigue at either postoperative time point. Table 3
displays Pearson’ product-moment correlation co-
e⁄cients for the signi¢cant biopsychosocial
contextual factors associated with sleep and fatigue
before hysterectomy and 6 weeks after surgery.
Preoperative perception of sleep disturbance (PSQI
and GSDS) was positively related to evening ratings
of fatigue severity and negatively related to sleep
e⁄ciency by actigraphy. Postoperative perception
of sleep disturbance was also positively related to
evening ratings of fatigue severity and negatively
related to sleep e⁄ciency by actigraphy (Table 3).
In other words, regardless of whether it is before or
after surgery, women who perceive more severe
fatigue also report more disturbed sleep, and their
self-report of sleep disturbance was highly related
to objective measures of disrupted sleep.
Discussion
This study describes changes in sleep and fatigue
experienced by women who have undergone either
a vaginal or abdominal surgical procedure for hys-
terectomy, and documents relationships between
these two symptoms and signi¢cant biopsycho-
social contextual factors that include ethnicity, age,
and education. Results indicate that women per-
ceive high levels of sleep disturbance before and
after surgery compared with levels of fatigue. This
may have been related to opportunities for napping
during the day to relieve fatigue but further re-
search is needed to study this particular
relationship. Black and Hispanic women perceived
higher levels of fatigue and sleep disturbance at
baseline and 3 weeks after surgery. This ¢nding
supports Brooks et al. (2002) who reported a higher
prevalence of comorbidity after hysterectomy
among Black compared with White patients.
Sleep disturbance was related to fatigue severity,
indicating that these two symptoms cluster together

JOGNN 2009; Vol. 38, Issue 3 349

IN FOCUS
Nurses should provide anticipatory guidance about how
sleep and fatigue may be experienced in relation to
different surgical procedures.
regardless of time point or opportunities for nap-
ping during the day. Interestingly, De Cherney et al.
(2002) reported that postoperative fatigue was the
most frequent symptom that interfered with daily
activities in women recovering from hysterectomy.
Objective sleep measures using actigraphy moni-
toring also provided data about the changing
pattern of sleep over time. Women experienced low-
er sleep e⁄ciency, with a progressive increase in
the number of awakenings and time spent awake
from baseline to 3 and 6 weeks after surgery. Be-
cause time to initially fall asleep was not di¡erent at
the three time points, lower sleep e⁄ciency was pri-
marily a result of awakenings during the night rather
than di⁄culty falling asleep. At 6 weeks after sur-
gery, sleep e⁄ciency improved for women who
had vaginal hysterectomy and had not yet improved
for women who had abdominal surgery.
Women with more education experienced higher
preoperative baseline fatigue in our sample, but
there was no di¡erence in fatigue during their post-
operative recovery and no di¡erence in either their
self-report or objective sleep measures. It is interest-
ing to note that Byles, Mishra, and Scho¢eld (2000)
found lower education level to be a major risk factor
for having a hysterectomy, and reported signi¢-
cantly poorer mental and physical health in those
women after surgery compared with women who
did not have a hysterectomy.
There were signi¢cant di¡erences in sleep and fa-
tigue symptom experiences by both age and ethnic-
ity. Black women in this sample were about 5 years
younger than White women, and younger women ex-
perienced more disturbed sleep and fatigue than
older women. Our ¢ndings are in contrast with Geisler
and Geisler (2001) who found no di¡erence in symp-
toms between younger (less than 50 years) and older
(greater than 65 years) women before and after hys-
terectomy. Their arbitrary age dichotomy may ac-
count for these di¡erent ¢ndings.While these ¢ndings
are limited by the small sample size, results suggest
that complaints about sleep or fatigue should be
evaluated, particularly in younger, more educated
women and in minority populations of women.
Clinical Implications
Biopsychosocial factors that in£uence a woman’s
symptom experience before and after hysterectomy
350 JOGNN, 38, 344-352; 2009. DOI: 10.1111/j.1552-6909.2009.01029.x
Fatigue in Women With Hysterectomy
appear to be related more to age, education, and
ethnicity rather than income level, employment sta-
tus, marital status, or having children in the home.
Health care providers should consider these factors
when preoperative teaching is done with this popu-
lation. If ¢ndings from this study are replicated in
other samples, preoperative teaching materials
should then be developed to include information
about changes in sleep and fatigue during postop-
erative recovery and patient expectations should be
discussed and tailored to the individual woman
during her preoperative evaluation.
A major limitation of this study was its small sample
size, particularly with respect to ethnic diversity and
the numbers who had either aTAH or an LVH type of
surgery located at one university hospital setting.
Hence, caution should be used in interpreting ¢nd-
ings from this study or in generalizing to all women
who experience a hysterectomy. More research is
needed to better understand why certain groups of
women may be at greater risk of sleep disturbance
and fatigue symptoms after a hysterectomy. Al-
though hysterectomy may relieve some unpleasant
preoperative symptoms, particularly bleeding and
pain, women still experience various intensities of
sleep disturbance and fatigue depending on age,
type of surgery, and other biopsychosocial factors.
This study is also limited by its brief time frame and
assessing only symptoms of sleep and fatigue dur-
ing the postoperative recovery period. The long-
term consequences of hysterectomy on sleep and
fatigue, and other symptoms such as depression
and anxiety, are not well known. Therefore, more re-
search is needed to examine these symptoms and
other symptoms for longer time frames after hyster-
ectomy.
Based on results of this small descriptive repeated
measures study, health care providers caring for
women after hysterectomy should not attribute their
sleep or fatigue symptoms entirely to physiological
factors resulting from a surgical procedure. There
are psychological and social factors in women’s
lives that also should be considered, particularly
when planning interventions to minimize their post-
operative symptom experience. These interventions
need to be tested and then integrated into educa-
tional programs for health care providers as well
as patients. These programs can provide current
information about gynecologic health, potential
alternatives to hysterectomy, and anticipatory guid-
ance about the course of sleep and fatigue, and the
pros and cons of napping to relieve fatigue and
sleep disturbance during postoperative recovery.
http://jognn.awhonn.org
Kim, K. H. and Lee, K. A.
Conclusion
There were many factors in the lives of women who
participated in this study that support the impor-
tance of a careful clinical assessment and
understanding of their symptom experience before
and after hysterectomy. Information learned from
this study can be integrated into developing a com-
prehensive and tailored nursing intervention plan
for women undergoing hysterectomy. Understand-
ing the social and demographic factors for women
of di¡erent ethnicities is as important as under-
standing the physiological process and treatment
model when it comes to their experience of postop-
erative symptoms. With the small sample, results are
di⁄cult to generalize to the large population of all
women after hysterectomy. However, signi¢cant
correlates of sleep and fatigue were identi¢ed to
begin to allow for formulating potential interven-
tions that could be tested and o¡ered as strategies
for health care providers as well as for patients to
participate in improving their symptom experience
and quality of life after hysterectomy.
Acknowledgments
Funded by American Nurses’ Foundation and Na-
tional Institutes of Health, National Institute of
Nursing Research, Grant T32 NR07088.
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