Tubal Reversal Blog ‘sterilization regret’

The ligation reversal specialists at Chapel Hill Tubal Reversal Center are experts in tubal ligation reversal. We evaluate and treat a large number of women who request sterilization reversal. While most women seek ligation reversal to have more children,  some seek relief from worsening physical and psychological symptoms experienced after they had their sterilization procedures. Many of these women report symptoms of Post Tubal Ligation Syndrome (PTLS). Previously, we described medical conditions that can mimic PTLS. This article describes common psychological conditions that can have symptoms similar to PTLS. These conditions can exist independently of a sterilization procedure or could be associated with the profound guilt and regret some women experience after sterilization.

Depression

Depression is a common condition affecting many people. Depression can be categorized into several types; however, for simplicity we will focus on major depression.

Major Depression

Symptoms of major depression last for a minimum of six months and may include:

• Loss of interest in normal daily activities
• Feeling sad or down
• Feeling hopeless
• Crying spells for no apparent reason
• Problems sleeping
• Trouble focusing or concentrating
• Difficulty making decisions
• Unintentional weight gain or loss
• Irritability
• Restlessness
• Being easily annoyed
• Feeling fatigued or weak
• Feeling worthless
• Loss of interest in sex
• Thoughts of suicide or suicidal behavior
• Unexplained physical problems, such as headaches

There are many overlapping symptoms between major depression and Post Tubal Ligation Syndrome. Identifying the symptoms of depression can be easy, but identifying the cause of depression can be difficult.

Anxiety

Generalized anxiety disorder can be a common condition. Anxiety is characterized by excessive or exaggerated worry about life events. People with symptoms of generalized anxiety disorder tend to expect disaster and can’t stop worrying about health, money, family, work or school. The degree of worry is often unrealistic or out of proportion for the situation. Daily life becomes a constant state of worry, fear and dread. Eventually, the anxiety so dominates thinking that it begins to interfere with daily functioning, including work, school, social activities and relationships.

Generalized Anxiety Disorder

The symptoms of generalized anxiety disorder may include:

• Excessive, constant worry and tension
• An unrealistic view of problems
• Restlessness or a feeling of being “edgy”
• Irritability
• Muscle tension
• Headaches
• Sweating
• Difficulty concentrating
• Nausea
• The need to go to the bathroom frequently
• Tiredness
• Trouble falling or staying asleep
• Trembling
• Being easily startled

People with anxiety disorders have an extreme sense of nervousness, panic, and inability to concentrate or focus. They may have depression as well. Anxiety can be generalized (happens during most of the day without any apparent cause) or can be situational (triggered by a specific event).

Post Traumatic Stress Disorder

Post traumatic stress disorder (PTSD) can develop after a person has experienced a traumatic or terrifying event in which serious physical harm occurred or was threatened. PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, or a natural disaster. Most people who experience a traumatic event will have reactions that may include shock, anger, nervousness, fear or guilt. For a person with PTSD, however, these feelings continue and even increase, becoming so strong that they prevent the person from living a normal life. Symptoms of PTSD often are grouped into three main categories:

• Reliving – This involves reliving the event through thoughts, memories, and dreams of the trauma. These may include flash backs, hallucinations, and nightmares. People with this form of PTSD may also feel great distress when events occur that remind them of the trauma they suffered.
• Avoiding – This involves avoiding people, places, thoughts or situations that are reminders of the trauma. This may lead to detachment from family, friends, and loss in interest in things that were once enjoyed.
• Increased arousal – This includes excessive emotions and problems relating to others, including difficulty feeling or showing emotion, difficulty sleeping, irritability, outbursts of anger, and difficulty concentrating. Physical symptoms may also occur.

Self Evaluation

Women seeking tubal ligation reversal may be at higher risk for the above conditions for various reasons, such as sterilization performed while in an abusive relationship, sterilizations done under pressure, or death of a child or spouse after a tubal ligation. It is helpful to discuss with yourself and your partner whether you may be experiencing symptoms of depression, anxiety, or Post Traumatic Stress Syndrome. The insights of a trusted friend or loved one help in this self evaluation. In some cases the advice and intervention of an experienced mental health provider may be helpful.

If you have had a tubal ligation and are experiencing any of the problems associated with Post Tubal Ligation Syndrome (PTLS), consider having an evaluation by your doctor for undiagnosed medical conditions. If  depression, anxiety or other symptoms interfere with your daily life, work, or relationships, then you may benefit by consultation with an experienced mental health provider.

PTLS Article Series

This is the fifth article in our fourteen part series on PTLS and associated medical conditions. Our next article, Post Tubal Ligation Syndrome|A Long Journey, will address our experience with Post Tubal Ligation Syndrome.

Readers can also view patient submitted stories about their menstrual symptoms, reasons for reversing tubal ligation, and outcomes after reversal reversal surgery. Each patient’s story is listed below:

Meet Momzilla
Meet Andrea
Meet Rebecca
Meet Praybelieving
Meet Katherine

We invite readers to join the Tubal Reversal Message Board and participate in the PTLS Forum to share personal experiences with physical or psychological symptoms following a tubal ligation.

Has your body gone ‘haywire’ after having your ‘tubes tied’? Many women report a variety of changes occurring after a tubal ligation. There are various gynecologic conditions that may be the cause and deserve proper evaluation by your doctor.

Problems that can occur after a tubal ligation

Previously, we introduced the topic of Post Tubal Ligation Syndrome (PTLS) as a suspected cause of problems that can occur after a tubal ligation. Women who experience problems after a tubal ligation may not have PTLS. If women have problems after a tubal ligation they commonly have two complaints: changes in their periods (menstrual pattern) and/or more painful periods. If you have had a tubal ligation and are experiencing these complaints, you could be suffering from an undiagnosed medical condition.

To determine if you have an underlying medical condition causing the above symptoms, it is helpful to be aware of the medical terminology for menstrual disorders.

Medical terminology

The medical terminology for changes in the frequency or amount of bleeding with your periods are:

• Oligomenorrhea
• Hypomenorrhea
• Hypermenorrhea (menorraghia)

Menstrual periods that are infrequent or irregular is termed oligmenorrhea. Periods that are scanty in amount of bleeding is called hypmenorrhea. Periods that are heavier in the amount of bleeding is termed hypermenorrhea or menorraghia (both terms refer to heavier periods).

The medical terminology for painful periods is dysmenorrhea.

Dysmenorrhea is divided into two categories:

• Primary (since puberty)
• Secondary (developed as you became older)

More painful periods developing after a tubal ligation would be categorized as secondary dysmenorrhea.

Medical causes of menstrual disorders

There can be many medical causes for oligomenorrhea, hypomenorrhea, or hypermenorrhea:

Uterine fibroids
Endometrial polyps
Adenomyosis
Uterine infections
Thyroid abnormalities
Endometrial hyperplasia
Endometrial cancer
Blood abnormalities (platelet disorders)
Ovulation disorders?
Polycystic Ovarian Syndrome?
Pregnancy*
Anorexia nervosa*
Congenital adrenal hyperplasia*
Perimenopause?
Pituitary abnormalities?

* Marked items are mostly associated with oligomenorrhea
? Marked items can be associated with both oligo and hypermenorrhea

Most women who develop abnormalities in their menstrual cycle after a tubal ligation will not have a serious medical condition. Most will have hormonal abnormalities, uterine fibroids, or anovualtion as the cause for changes in their menstrual cycle. These are common conditions that occur as a person either ages or experiences significant changes in weight.

Dysmenorrhea

There can be many medical causes for dysmenorrhea. These are the major causes of secondary dysmenorrhea:

Gynecologic disorders
Endometriosis
Adenomyosis
Ovarian cysts
Pelvic adhesions
Pelvic inflammatory disease
Uterine polyps
Congenital obstructive Müllerian malformations
Cervical stenosis
Nongynecologic disorders
Inflammatory bowel disease
Irritable bowel syndrome
Uteropelvic junction obstruction
Psychogenic disorders

Secondary dysmenorrhea can be experienced by many women. The most common causes are endometriosis, adenomyosis, and ovarian cysts. Causes of secondary dysmenorrhea can sometimes be difficult to identify. Sometimes, women may need to be referred to other medical specialists to diagnose the cause of secondary dysmenorrhea.

Changes in one’s menstrual cycle are common and can also occur after a tubal ligation procedure. When a woman has a tubal ligation and then develops any of the symptoms discussed above, it is tempting to attribute them to Post Tubal ligation Syndrome; however, there may be other underlying medical or gynecological conditions responsible for these changes.

The tubal ligation reversal experts at Chapel Hill Tubal Reversal Center recommend you see your medical provider if you develop any of the above symptoms after a tubal ligation. The purpose of your visit will be to diagnose any medical conditions which could the cause of your symptoms. If your doctor is unable to determine any medical explanation or if your symptoms are more extensive than those listed above, the doctor might attribute your symptoms to depression, anxiety, post traumatic stress disorder, or regret over your prior decision to have a surgical sterilization.

PTLS Articles on the Tubal Reversal Blog

This is the third article of a fourteen part series about Post Tubal Ligation Syndrome. Our next article is Guilt or Regret About Tubes Tied.

Readers can also view patient submitted stories about their menstrual symptoms, reasons for reversing tubal ligation, and outcomes after reversal reversal surgery. Each patient’s story is listed below:

Meet Momzilla
Meet Andrea
Meet Rebecca
Meet Praybelieving
Meet Katherine

We invite readers to join the Tubal Reversal Message Board and discuss and share personal experiences with tubal ligation. We also would like patients to join our PTLS Forum and share their personal experiences with worsening physical or mental symptoms noticed after tubal ligation.

Comment by Dr. Berger

The terms introduced in this article – such as oligomenorrhea, hypomenorrhea, hypermenorrhea, and dysmenorrhea – are descriptive medical terms for common menstrual disorders. When they occur, they deserve a thorough medical evaluation. As Dr. Monteith has described, there are many underlying causes or diagnoses for these conditions.

The question that seems to be at issue regarding Post Tubal Ligation Syndrome is this: when symptoms develop after a tubal ligation, are they attributable to the tubal ligation itself or to some other underlying condition? If no other underlying causes are found, then is PTLS the diagnosis remaining by exclusion? If a doctor does not believe in the existence of PTLS and no underlying medical or gynecologic diagnosis is evident, is attributing the symptoms to depression, anxiety, post traumatic stress disorder, or sterilization regret reasonable, accurate, or sufficient?

Articles About Post Tubal Ligation Syndrome

It is difficult to identify the first reported instance of a patient with Post Tubal Ligation syndrome (PTLS). The early literature from the 1950 – 1970’s has sporadic reports of patients who underwent tubal ligation and, subsequently, developed menstrual irregularities. In the mid – twentieth century, PTLS seems to have been discussed more that it was studied by the medical community.

Several medical studies from the 1980’s and 1990’s suggested there was no association with tubal ligation and menstral irregularities. These studies have been criticized because they involved a small number of patients, had methodological problems, and were not designed to critically evaluate for the existence of PTLS.

U.S. Collaborative Review of Sterilization Study

The most conclusive medical study to evaluate female sterilization and the effects upon American women was the U.S. Collaborative Review of Sterilization study. This study is commonly referred to as the CREST study. A synopsis of this study can be found on-line at the medical research organization Contraception Online.

The CREST study conducted by the Center for Disease Control and Preventions (CDC) and was published in the New England Journal of Medicine in 1996. To date, the CREST study has been the largest and most comprehensive evaluation of women who have undergone surgical sterilization in the United States. The study was primarily designed to evaluate the types of sterilization methods that were commonly being performed by U.S. doctors and the failure rates associated with each of the different methods of sterilization.

The study examined over 14,000 women who had tubal sterilizations (tubal ligation) from 1978 to 1986. Women were examined for up to 14 years after their sterilization procedures. The investigators specifically looked at the method of tubal ligation and failure rates (pregnancies) based on each method. They also examined the number of women who regretted their decision to undergo sterilization.

CREST  Findings

The main findings of the CREST study were that pregnancies after tubal ligation and sterilization regret were both more frequent than had been previously thought.

Women were also asked questions about changes in their menstral patterns after tubal ligation. The study compared 9514 women who underwent tubal ligation to 573 women whose partners underwent vasectomy. The women were asked about changes in their menstral patterns for up to five years after sterilization. The women who underwent sterilization were found to have fewer irregularities with their menstral patterns. The authors’ conclusion was there were no significant differences in menstral patterns in women who had tubal sterilization. A commentary by the study investigators regarding these findings can be found at the National Institute of Health.

The existence of Post Tubal Ligation syndrome has been widely speculated by many but never substantiated in a rigorous fashion by medical investigators. Many poorly done small studies have suggested PTLS does exist; however, the largest study to date, the CREST study seems to suggest otherwise.

Limitations of the CREST Study

Although the CREST study has been the largest study with the longest follow-up of women who have undergone sterilization, some investigators have criticized the study.

The CREST study has limitations evaluating PTLS because of three reasons:

1. The study population is mostly from academic centers and is made up of a large number of African American women. This has led some cautious medical investigators to suggest the study has population bias and the findings of the study may not be applicable to the general population of United States women who undergo sterilization.

2. The study did not address the question whether women may develop menstral irregularities beyond five years after their tubal ligaiton. Most of the questions regarding menstrual irregularities were not asked after five years of follow-up.

3. The study was not designed to investigate the diverse symptoms of PTLS. The primary goal was to identify what the most popular methods of tubal ligation were and what the failure rates of each method were.

If PTLS does not exist then what is going on?

Many patients come to Chapel Hill Tubal Reversal Center requesting sterilization reversal for the sole purpose of treating symptoms they identify as PTLS. Many of these patients report substantial improvement in their symptoms after tubal ligation reversal. We are not certain why patients report improvement, but it is hard to ignore their reports of improvement in symptoms after ligation reversal surgery.

Most women who have tubal ligations will not have any problems. Some women will have difficulty after a tubal ligation. Many, or perhaps the majority of them will not have PTLS. Instead, they may have an underlying medical or gynecologic illness. To aid our patients in the evaluation of difficulties they may be having after a tubal ligation, our next article will have information for patients about abnormal bleeding, painful menstruation, and possible underlying causes.

This is the second article in a fourteen part series. Our third article in this series is Diagnosing Menstrual Problems After Tubal Ligation.

Readers can also view patient submitted stories about their menstrual symptoms, reasons for reversing tubal ligation, and outcomes after reversal reversal surgery. Each patient’s story is listed below:

Meet Momzilla
Meet Andrea
Meet Rebecca
Meet Praybelieving
Meet Katherine

We invite readers to join the  Tubal Reversal Message Board where they can discuss and share personal experiences with tubal ligation. We also would like patients to join our PTLS Forum and share personal experiences regarding physical or mental symptoms noticed after tubal ligation.

Past topics in the Tubal Reversal Blog include posts and comments about patient care at Chapel Hill Tubal Reversal Center. This topic summarizes important articles about tubal ligation and tubal reversal reported in the news during 2007.

Sterilization is Most Popular Family Planning Method
Approximately 10 million American women use the pill for contraception, while sterilization has been chosen by 15 million men and women.

One In Five Women Regret Decision For Tubal Ligation
One in five women under age 30 who undergo tubal sterilization later regret the procedure, despite the number of children they have.

Is Sterilization the Best Contraception Choice?
Women requesting a tubal ligation should be counseled regarding other long-term, reversible methods of contraception and informed that vasectomy is safer and more effective than tubal ligation.

Relationship Conflict Before Sterilization
Women whose relationship was marked by substantial conflict before they underwent tubal ligation were most likely to regret the decision.

Young Age, Prodding Partner and Sterilization Regret
Young age and a prodding partner are risk factors indicating that a woman undergoing sterilization may later regret her decision.

Tubal Reversal Among Overweight Women
Overweight women’s chances of becoming pregnant after tubal reversal improve when they lose weight.

Dr. Berger’s Comment

These news reports touch on some of the issues patients talk about when they come to Chapel Hill Tubal Reversal Center for tubal sterilization reversal. The popularity of tubal ligation, and the fact that many women regret their decision to have a tubal ligation, are well documented. Young age and marital conflict are risk indicators for subsequent regret. Before performing a tubal ligation, doctors should ensure that the implications of ending childbearing potential are clearly understood and discuss vasectomy as an alternative permanent method of birth control. Women undergoing tubal reversal who are overweight should be aware that losing weight will improve their chances of becoming pregnant again.

At Chapel Hill Tubal Reversal Center, we receive requests 7 days a week, 365 days a year, for information about tubal ligation reversal. These requests come from women who regret having a tubal ligation. A staff member recently asked me how big a problem this is throughout the country. The following is in response to this question.

How Many Women Have Had A Tubal Ligation?

There is no single data source reporting the number of surgical sterilizations performed in the United States. Based on multiple sources of information, it is likely that 650,000 to 700,000 tubal sterilizations are performed each year, and more than 11 million American women have had a sterilization operation. The latest study, conducted in 2002 by the US Department of Health and Human Services, indicates that between one in four to one in five of adult, sexually active women have had a tubal ligation.⁽¹⁾

How Common Is Tubal Ligation Regret?

Many factors can affect a woman’s likelihood to regret sterilization. Among women who had a tubal ligation, risk factors for regret include young age, less education, and a husband or partner who wanted the woman to have a tubal ligation.

In 1999, a study called the Collaborative Review of Sterilization (CREST) found that 20% of women who were sterilized before the age of 30 regretted their decision. Women who were sterilized at a young age had a higher chance of requesting information about reversal, regardless of their number of living children. Also, women who reported conflict with their husbands or partners before tubal sterilization were more than three times as likely to regret their decision and more than five times as likely to request a reversal than women who did not report such conflict. ⁽²⁾

Dr. Berger’s Comment

This statistical information helps give a broader picture to the significance of the issues and comments raised in the previous blog topic – Ethics of Tubal Ligation. Additional comments on this issue are welcome from all readers.

References

1. MMWR Surveillance Summary, “Contraceptive Use — United States and Territories, Behavioral Risk Factor Surveillance System, 2002.
2. Mosher WD, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982–2002. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics, 2004. Advance Data from Vital and Health: no. 350.