TUBAL LIGATION AND GYNECOLOGICAL DISORDERS

Abstract

The present study was undertaken to examine' gynecological consequences of tubal li gation in a cross section of Pakistani women from both urban and rural communities of Islamabad and Rawalpindi. The investigation was divided into three parts: ( I) preligation history of a large sample (2893) of women interviewed face to face at Reproductive Heath Center, (2) postligation incidence of gynecological disorders (GOs) detennined by interviews of women facilitated by Community Health HOllses (CBS-l and CBS-2), and (3) Shldy of post ligation complications through data collected in a hospital setting (1-lBS-l) to assess incidence of GOs and their association with ligation, hysterectomy and any type of abdominal surgery (HBS-2), The sociodemographic profile of women opting for lig'ation showed a generally low socioeconomic status of families. Almost I !3rd of the total sample (2893) was under 30 yrs of age and had no history of abOliions, had a parity of < 6 and very low incidence of disease in both the urban and rural communities, The incidence of GOs was also extremely low, particularly in the urban women, The retrospective COhOli study (CBS- I) of post ligation health and gynecological stahlS of women has revealed a 2-fold greater incidence of GO in ligated COhOli than in the control cohort (nonligated) Both cohorts had very close correspondence in mean age, duration of maniage, abOliion rate, LCB (last child born age) and contraception . The majority of the women in tills study were over 30 yrs of age, were malTied for over 10 years, had no experience of abortion, had LCB of >5 yrs and were non llsers of contraceptives, except a higher percentage' (39 .5 %) in the GO subgroup of control cohort. Also, a greater percentage of women had health problems in the GO subgroups of both the cohorts (ligated and nonligated) suggesting an association with health. The onset of G Os occurred about 2 years after ligation, suggesting possibility of a biological uasis of change, Increased risk of GOs was evident for ligated cohort as compared to control cohort (RR. 2.46, 95 % CI p < 0.00 I) . The follow up study (CBS-2) of 111 women revealed a simil;)r urban/rural ratio, low socioeconomic level , high contraception rate, LeB or >6 yrs (large gap since last child bilih), no experience of abOliions b) majority of the women (80%) . Most of the women were between 30- 35 yrs of age and had laparoscopic surgery. While a high percentage (87.3%) of the COhOli had no preligation health problems, this percentage dropped by --48%, 2.5 yrs after ligation (follow lip 2 yrs postligation) . About l/3n.l of the COhOli suffered from GDs. On paliitioning into GD and No ·GD subgroups: the subgroups did not differ in average age at ligation, number of conceptions and time since ligation . In both subgroups, laparoscopy dominated as method of ligation. Both the CI3S-1 and CBS-2 studies showed that the ligated cohort had increased risk of GDs, especially menstrual disturbance as well as health complaints. Maximum menstrual disturbance was experienced by women of 35 yrs and younger age. This emerged as a consistent picture even after such confounders as age, parity, contraception, educational background and recall bias were accounted for. The hospital-based (I-illS-l) study also suppOlied the above observations, revealing a strong association between ligation, GDs and health . The study also showed that tubal ligation is followed by a sequence of menstrual alterations . In both retrospective-cohOli (CBS-l & 2) and casecontrol analyses (I-illS) in the present investigation, the majority of women underwent laparoscopy and nearly all had interval sterilization. In the HBS-I study, GDs were recorded with considerable postligation delay in both the cases and the control women. This however, also coincided with approaching menopause (>40 yrs age, cases/control). Anemia in the majority of the cases group seemed related to GDs, of which menstrual dysfunction (increased duration and flow rate) was predominant followed by UVP. The majority of women with GDs (~80%) in this part of study were 35 yrs and younger age and ligation had a strong association with GDs (OR=2.29, 95% CI, P<O.OOOl) even after adjustment for such confounders as age, parity, conceptions, abOliion, contraception, and other surgery. Menstrual dysfunction was evident in terms of both duration and flow with a positive association with ligation for women up to 35 yrs of age (OR= 5.25, CI 95%, P<0.005). The association between GDs and ligation appeared to be a consequence of some physiological changes rather than representing an aging phenomenon. The low incidence of PID (pelvic inflam\natory disease) affirms relatively safe surgical procedural handling of the subj ects. This is also evident from the fact that none of the subjects reported postligation surgical complications. The hospital-based study (f-rnS-l) also revealed that leiomyoma was a major uterine pathology followed by adenomyosis and endometrial hyperplasia in both the ligated and nonligated cases. This change tended to increase with age, providing evidence that age also has a role in this pathological state. Whether the observed marginal incidence of hyperplasia has implications of a cancerous state in the long tenn and also whether the overall uterine pathological state is an outcome of sterilization requires further studies. The study showed in addition that age and hysterectomy have a positive association in both the ligated and the nonligated women. The fact that the frequency of hysterectomy was greater in the ligated subjects especially with advancing age implies that there is need of care in advising women to opt for sterilization in view of the impeding risk of subsequent hysterectomy as management for GDs resulting from ligation. Finally, the hospital-based study (HBS-2) that was aimed at analyses of sterilization hazards vis-a-vis any abdominal surgery, indicated that G Os indeed stem from ligation rather than any other type of abdominal surgical procedure. This observation also implies that ligation results in certain honnonal disturbances (ovarian) leading to sequalae that fall within the broad definition of post tubal ligation syndrome_