Analysis of risk factors for postoperative depressive disorders in patients with intrauterine adhesions

Abstract

BACKGROUND

Intrauterine adhesions (IUA) are a common gynecological condition that can significantly impact patients’ reproductive health and psychological well-being. This study aimed to analyze the incidence and associated risk factors of postoperative depressive disorders in patients with IUA to provide evidence for clinical interventions.

AIM

To determine the incidence of postoperative depressive disorders in patients undergoing hysteroscopic adhesiolysis for IUA, identify independent risk and protective factors associated with depression development.

METHODS

A retrospective analysis was conducted on clinical data from 400 patients who underwent intrauterine adhesion lysis surgery at our hospital from January 2022 to December 2024. Demographic characteristics, medical history, surgical parameters, and follow-up outcomes were collected. The Self-Rating Depression Scale and Hamilton Depression Scale were used to assess depressive status before surgery and 3 months postoperatively. Univariate analysis and multivariate logistic regression were performed to determine independent risk factors for postoperative depressive disorders.

RESULTS

Among the 400 patients, 112 (28.0%) developed depressive disorders within 3 months after surgery. Multivariate analysis showed that age ≥ 35 years [odds ratio (OR) = 2.05, 95% confidence interval (CI): 1.27-3.32, P = 0.003], history of infertility (OR = 2.58, 95%CI: 1.66-4.01, P < 0.001), history of recurrent miscarriage (OR = 2.82, 95%CI: 1.73-4.59, P < 0.001), severe IUA (American Fertility Society classification grade III) (OR = 3.31, 95%CI: 1.94-5.65, P < 0.001), postoperative complications (OR = 2.47, 95%CI: 1.39-4.38, P = 0.002), and previous history of depression or anxiety (OR = 4.16, 95%CI: 2.24-7.74, P < 0.001) were independent risk factors for postoperative depressive disorders. Protective factors included higher education level (OR = 0.58, 95%CI: 0.37-0.92, P = 0.019), good social support (OR = 0.45, 95%CI: 0.28-0.74, P = 0.001), and normal menstruation within 3 months after surgery (OR = 0.40, 95%CI: 0.24-0.67, P < 0.001).

CONCLUSION

The incidence of postoperative depressive disorders in patients with intrauterine adhesions is relatively high and associated with multiple factors.

Key Words: Intrauterine adhesions; Depression; Risk factors; Intrauterine adhesiolysis; Psychological health; Fertility

Core Tip: Postoperative depression affects 28% of patients undergoing hysteroscopic adhesiolysis for intrauterine adhesions, representing a significantly higher rate than the general female population. Six independent risk factors were identified: Age ≥ 35 years, history of infertility, recurrent miscarriage, severe adhesions (grade III), postoperative complications, and previous depression or anxiety disorders. Three protective factors emerged: Higher education level, strong social support, and successful menstrual restoration within 3 months post-surgery.

INTRODUCTION

Intrauterine adhesions (IUA) are a common gynecological condition characterized by partial or complete adhesion of the endometrium, leading to partial or complete occlusion of the uterine cavity[1-3]. This condition is primarily caused by endometrial injury resulting from intrauterine procedures or infections, such as curettage, cesarean section, or myomectomy[4,5]. IUA can lead to a series of reproductive health problems, including menstrual abnormalities (hypomenorrhea or amenorrhea), cyclic abdominal pain, recurrent miscarriage, and infertility, significantly affecting patients’ quality of life and reproductive function[6,7].

Hysteroscopic adhesiolysis has become the primary treatment method for IUA[8,9]. This surgical procedure reconstructs the uterine cavity by removing or separating adhesive tissue under direct visualization, restoring endometrial function, and thereby improving menstrual patterns and fertility. Despite advances in surgical techniques, patients not only face physiological challenges such as potential re-adhesion after surgery but may also experience mental health issues, particularly depressive disorders[10,11].

Gynecological diseases, especially those related to fertility, significantly impact women’s mental health. Previous studies have shown that the incidence of post-operative depressive disorders in gynecological surgery patients is markedly higher than in the general population[12,13]. For patients with IUA, the close relationship between the disease and fertility, coupled with uncertainties during the recovery process, makes these patients more susceptible to depression and other psychological problems[14]. However, systematic research on the incidence and risk factors of post-operative depression in IUA patients is relatively lacking, and clinical practice has insufficient focus on the mental health of these patients.

Existing research has preliminarily explored factors related to post-operative depression in various gynecological surgeries, such as age, education level, marital status, and disease severity. However, studies specifically targeting the unique population of intrauterine adhesion patients remain incomplete. Most IUA patients are women of reproductive age with strong fertility demands, and surgical outcomes directly affect their future fertility potential, making the psychological status of IUA patients particularly distinctive.

Timely identification of high-risk populations for post-operative depression in IUA patients and early intervention can not only improve patients’ mental health status but may also promote physiological recovery, increase surgical success rates, and enhance patients’ quality of life. Therefore, systematically analyzing the incidence and related risk factors of post-operative depression in IUA patients is of significant importance for guiding clinical work, optimizing perioperative management, and developing individualized psychological intervention strategies.

This study retrospectively analyzes the clinical data of 308 patients who underwent hysteroscopic adhesiolysis from 2022 to 2024, aiming to determine the incidence and independent risk factors of post-operative depression in IUA patients, provide scientific evidence for clinical intervention, and ultimately improve patients’ post-operative rehabilitation and long-term prognosis.

MATERIALS AND METHODS

Study design and patient population

This retrospective study analyzed data from 400 patients who underwent intrauterine adhesiolysis for IUA at our hospital from January 2022 to December 2024. The study protocol was approved by the institutional review board, and informed consent was obtained from all patients. Inclusion criteria were: (1) Female patients diagnosed with IUA via hysteroscopy; (2) Age between 18 and 45 years; (3) Patients who underwent hysteroscopic adhesiolysis at our institution during the study period; (4) Availability of complete medical records and follow-up data for at least 3 months after surgery; and (5) Ability to complete psychological assessment questionnaires. Exclusion criteria were: (1) Previous diagnosis of severe psychiatric disorders requiring hospitalization; (2) Concurrent use of antidepressants or antipsychotics unrelated to gynecological conditions; (3) Cognitive impairment affecting the ability to provide reliable responses to questionnaires; (4) Comorbidity with serious diseases (e.g., malignancy or autoimmune diseases); (5) Pregnancy within 3 months after surgery; and (6) Patients who underwent additional surgical procedures during the same hospitalization.

Surgical procedure

All patients underwent hysteroscopic adhesiolysis performed by experienced gynecological surgeons. After general anesthesia or paracervical block, a diagnostic hysteroscopy was initially performed to evaluate the extent and severity of IUA according to the American Fertility Society classification. Adhesiolysis was conducted using cold scissors, electrosurgical instruments, or balloon techniques based on the location and density of adhesions. Anti-adhesion barriers were applied as appropriate following the procedure. Intraoperative findings, including the extent of endometrial involvement, adhesion characteristics, and any complications such as uterine perforation or bleeding, were documented. The procedure duration, anesthesia type, and surgeon.

Research grouping and observation strategy

Patients were retrospectively divided into two groups based on postoperative depressive status: A depression group (n = 112) of patients who met diagnostic criteria for depressive disorder within 3 months after surgery, and a non-depression group (n = 288) of patients without depressive symptoms. Data collection included comprehensive assessment of demographic characteristics (age, body mass index, education, occupation, marital status, income, social support), disease-related factors (etiology, symptom duration, adhesion severity per American Fertility Society classification, endometrial involvement), surgical parameters (operation time, anesthesia type, techniques used, complications), and postoperative outcomes (hospital stay, complications, hormone therapy, menstruation restoration, pregnancy outcomes). Psychological assessments using standardized tools [Self-Rating Depression Scale (SDS), 17-Item Hamilton Depression Scale (HAMD-17), Self-Rating Anxiety Scale, Quality of Life Questionnaire 36-Item Short Form Health Survey (SF-36)] were performed before surgery and at 3 months postoperatively.

Missing data management

Complete-case analysis was employed for the primary analysis, with missing data rates below 5% for all key variables. A detailed patient flowchart documented exclusions due to incomplete data. Sensitivity analyses using multiple imputation (m = 20 imputations) were performed to assess the robustness of findings to missing data assumptions. Variables included in the imputation model were baseline characteristics, surgical parameters, and outcome measures.

Psychological assessment

All patients completed standardized psychological evaluations both preoperatively and at 3 months after surgery, administered by trained healthcare professionals using validated Chinese versions of established scales. The assessment tools included: SDS with scores ≥ 53 indicating depression (Cronbach’s α = 0.87); HAMD-17 with scores ≥ 17 indicating depression, administered by trained clinicians (inter-rater reliability κ = 0.85); Self-Rating Anxiety Scale to assess comorbid anxiety; Quality of Life Questionnaire (SF-36) to evaluate overall health status across eight domains. Primary endpoint: The occurrence of depressive disorder within 3 months after surgery, defined by SDS score ≥ 53 and/or HAMD-17 score ≥ 17, plus confirmation through clinical psychiatric evaluation using Diagnostic and Statistical Manual of Mental Disorders criteria performed by qualified psychiatrists. Secondary endpoints: Depression severity based on HAMD-17 scores (mild: 17-23, moderate: 24-30, severe: > 30), time of symptom onset, quality of life changes across SF-36 domains, impact on menstrual restoration, correlation between depression and IUA severity, response to psychological interventions, and changes in social support scores.

Statistical analysis

Statistical analysis was performed using SPSS version 25.0. Student’s t-test or Mann-Whitney U test was used for continuous variables, while χ² or Fisher’s exact test was used for categorical variables. Univariate analysis identified potential risk factors for postoperative depression. Variables with P < 0.1 were included in multivariate logistic regression to determine independent risk factors. Odds ratios (ODs) with 95% confidence intervals (CIs) were calculated, with P < 0.05 considered significant. Correlation between depression severity and continuous variables was assessed using Pearson or Spearman coefficients. Multivariate analysis was adjusted for age, education level, and baseline psychological status.

RESULTS

Baseline demographics and clinical characteristics

The study population was divided into depression group (n = 112) and non-depression group (n = 288) based on postoperative depressive status. Patients in the depression group were significantly older (36.7 ± 4.8 years vs 32.4 ± 5.3 years, P < 0.001) and had lower education levels (41.1% vs 58.7% with higher education, P = 0.002). The depression group had a higher proportion of patients with a history of infertility (63.4% vs 38.2%, P < 0.001), with longer infertility duration (4.8 ± 2.3 years vs 2.9 ± 1.7 years, P < 0.001). Recurrent miscarriage history was also more common in the depression group (42.9% vs 21.5%, P < 0.001).

Baseline psychological assessment showed that preoperative SDS and HAMD-17 scores were higher in patients who later developed postoperative depression (SDS: 48.3 ± 6.7 vs 42.1 ± 5.9, P < 0.001; HAMD-17: 14.2 ± 3.8 vs 10.5 ± 3.1, P < 0.001). A previous history of depression or anxiety was reported in 30.4% of patients in the depression group compared to 9.7% in the non-depression group (P < 0.001). Social support scores were significantly lower in the depression group (34.2 ± 6.8 vs 41.5 ± 7.3, P < 0.001, Table 1).

Table 1 Baseline characteristics of the study population, mean ± SD.

Feature	Depressed group (n = 112)	Non-depressed group (n = 288)	P value
Age (years)	36.7 ± 4.8	32.4 ± 5.3	< 0.001
Education level (%)	41.1	58.7	0.002
Infertility history (%)	63.4	38.2	< 0.001
Duration of infertility (years)	4.8 ± 2.3	2.9 ± 1.7	< 0.001
Recurrent miscarriage history (%)	42.9	21.5	< 0.001
Preoperative SDS score	48.3 ± 6.7	42.1 ± 5.9	< 0.001
Preoperative HAMD-17 score	14.2 ± 3.8	10.5 ± 3.1	< 0.001
History of depression or anxiety (%)	30.4	9.7	< 0.001
Social support score	34.2 ± 6.8	41.5 ± 7.3	0.001

SDS: Self-Rating Depression Scale; HAMD-17: 17-Item Hamilton Depression Scale.

Characteristics and surgical parameters

Among the 400 patients included in this study, the mean age was 33.6 ± 5.5 years (range: 21-45 years). The majority of patients (73.5%, n = 294) were married, and 62.3% (n = 249) had at least one previous pregnancy. The most common etiologies of IUA were curettage after abortion (48.5%, n = 194), postpartum curettage (22.3%, n = 89), hysteroscopic procedures (15.8%, n = 63), and other causes (13.4%, n = 54). According to the American Fertility Society classification, 112 patients (28.0%) had grade I (mild) adhesions, 134 patients (33.5%) had grade II (moderate) adhesions, and 154 patients (38.5%) had grade III (severe) adhesions.

Regarding surgical parameters, the mean operation time was 55.5 ± 16.8 minutes. Cold scissors were used in 218 patients (54.5%), electrosurgical instruments in 146 patients (36.5%), and balloon techniques in 36 patients (9.0%). Anti-adhesion barriers were applied in 288 patients (72.0%), with hyaluronic acid gel being the most commonly used (62.5%, n = 180). All procedures were performed under either general anesthesia (64.0%, n = 256) or paracervical block (36.0%, n = 144, Table 2).

Table 2 Comparative analysis of demographics, etiology, surgical parameters, and anesthesia type between depressed and non-depressed patients with asherman’s syndrome.

Feature	Depressed group (n = 112)	Non-depressed group (n = 288)	P value
Patient demographics
Average age (years, mean ± SD)	36.7 ± 4.8	32.4 ± 5.3	< 0.001
Marital status (%)	75.0	72.9	0.673
Pregnancy history (%)	54.5	65.3	0.044
Etiology of asherman’s syndrome (%)			P = 0.863
Post-abortion curettage	50.9	47.6
Postpartum curettage	23.2	21.9
Hysteroscopic surgery	14.3	16.3
Other causes	11.6	14.2
Classification of asherman’s syndrome (%)
Grade I (mild)	17.9	31.9	0.005
Grade III (severe)	53.6	32.6	< 0.001
Surgical parameters
Average operating time (minutes, mean ± SD)	63.2 ± 18.7	52.4 ± 15.1	< 0.001
Surgical instruments (%)			P = 0.791
Cold scissors	51.8	55.6
Electrosurgical instruments	38.4	35.8
Balloon technique	9.8	8.7
Anti-adhesion barrier use (%)	78.6	69.1	0.043
Anesthesia type (%)			P = 0.327
General anesthesia	66.1	63.2

Perioperative outcomes and complications

The mean operation time was significantly longer in the depression group compared to the non-depression group (63.2 ± 18.7 minutes vs 52.4 ± 15.1 minutes, P < 0.001), reflecting the more severe and complex adhesions in these patients. The length of hospital stay was also significantly longer in the depression group (3.2 ± 1.1 days vs 2.5 ± 0.8 days, P < 0.001). Postoperative complications occurred in 17.9% (20/112) of patients in the depression group compared to 8.0% (23/288) in the non-depression group (P = 0.004). These complications included uterine perforation (3.6% vs 1.4%, P = 0.144), postoperative infection (7.1% vs 3.1%, P = 0.068), and significant bleeding requiring intervention (7.1% vs 3.5%, P = 0.107). While individual complications did not reach statistical significance, the overall complication rate was significantly higher in the depression group. Among all patients, 304 (76.0%) experienced restoration of normal menstruation within 3 months after surgery. The rate of menstrual restoration was significantly lower in the depression group (61.6%, 69/112) compared to the non-depression group (81.6%, 235/288) (P < 0.001, Table 3).

Table 3 Perioperative outcomes and complications between depressed and non-depressed patients.

Feature	Depressed group (n = 112)	Non-depressed group (n = 288)	P value
Surgical time (minutes, mean ± SD)	63.2 ± 18.7	52.4 ± 15.1	< 0.001
Length of hospital stay (days)	3.2 ± 1.1	2.5 ± 0.8	< 0.001
Postoperative complications (%)	17.9 (20/112)	8.0 (23/288)	0.004
Complications (%)
Uterine perforation (%)	3.6	1.4	0.144
Postoperative infection (%)	7.1	3.1	0.068
Severe bleeding requiring intervention (%)	7.1	3.5	0.107
Menstrual recovery within 3 months (%)	61.6 (69/112)	81.6 (235/288)	< 0.001

Independent predictors of poor outcomes in multivariate analysis

Multivariate logistic regression analysis was performed to identify independent predictors of postoperative depressive disorders. After adjusting for potential confounding factors, the following were identified as independent risk factors: Age ≥ 35 years (OR = 2.05, 95%CI: 1.27-3.32, P = 0.003), history of infertility (OR = 2.58, 95%CI: 1.66-4.01, P < 0.001), history of recurrent miscarriage (OR = 2.82, 95%CI: 1.73-4.59, P < 0.001), severe IUA (American Fertility Society classification grade III) (OR = 3.31, 95%CI: 1.94-5.65, P < 0.001), postoperative complications (OR = 2.47, 95%CI: 1.39-4.38, P = 0.002), and previous history of depression or anxiety (OR = 4.16, 95%CI: 2.24-7.74, P < 0.001). Protective factors against postoperative depression included higher education level (OR = 0.58, 95%CI: 0.37-0.92, P = 0.019), good social support (OR = 0.45, 95%CI: 0.28-0.74, P = 0.001), and restoration of normal menstruation within 3 months after surgery (OR = 0.40, 95%CI: 0.24-0.67, P < 0.001; Figure 1).

Figure 1 Forest plot of independent predictors of postoperative depression. The plot shows nine independent predictors organized by their odds ratio (OR) values, with risk factors (OR > 1) displayed with red squares and protective factors (OR < 1) with blue squares. The horizontal lines represent 95% confidence intervals, and a vertical dashed line at OR = 1 indicates the threshold between risk and protection. AFS: American Fertility Society; CI: Confidence interval.

Independent risk factors and predictive value of biomarkers

In addition to clinical risk factors, we investigated potential biomarkers associated with postoperative depression. Serum cortisol levels were significantly higher in the depression group compared to the non-depression group (18.4 ± 5.7 μg/dL vs 14.2 ± 4.5 μg/dL, P < 0.001). Similarly, inflammatory markers including high-sensitivity C-reactive protein were elevated in the depression group (3.8 ± 1.9 mg/L vs 2.5 ± 1.3 mg/L, P < 0.001).

Receiver operating characteristic curve analysis showed that a combination of clinical risk factors (age, infertility history, adhesion severity, previous psychological disorders) and biomarkers (cortisol, high-sensitivity C-reactive protein) had good predictive value for postoperative depression [area under the curve (AUC) = 0.832, 95%CI: 0.783-0.881]. This combined model demonstrated better predictive performance than clinical factors alone (AUC = 0.762, 95%CI: 0.706-0.818, P = 0.003) or biomarkers alone (AUC = 0.712, 95%CI: 0.653-0.771, P < 0.001; Figure 2). From the forest plot, it can be seen that the CIs of all clinical risk factors and biomarkers do not include 1, indicating that they are all independent risk factors for postoperative depression.

Figure 2 Clinical risk factors. From the forest plot, it can be seen that the confidence intervals of all clinical risk factors and biomarkers do not include 1, indicating that they are all independent risk factors for postoperative depression. hs-CRP: High-sensitivity C-reactive protein; AUC: Area under the curve; CI: Confidence interval.

Patients with concurrent medical conditions

Among the study population, 68 patients (17.0%) had concurrent medical conditions, including thyroid disorders (8.0%, n = 32), polycystic ovary syndrome (5.5%, n = 22), and endometriosis (3.5%, n = 14). The prevalence of postoperative depression was significantly higher in patients with concurrent medical conditions compared to those without (39.7%, 27/68 vs 25.6%, 85/332; P = 0.019; Figure 3).

Figure 3 Forest plot of risk factors for post-operative depression. The odds ratios indicate the strength of association between each factor and post-operative depression, with values greater than 1 suggesting increased risk. The P values (all < 0.05) indicate that these associations are statistically significant. This analysis helps clinicians identify high-risk patients who might benefit from preventive interventions or closer monitoring for depression following surgery. OR: Odds ratio; CI: Confidence interval.

Subgroup analysis revealed that patients with both severe IUA and concurrent medical conditions had the highest risk of postoperative depression (54.8%, 17/31), followed by patients with severe adhesions only (36.6%, 47/123), patients with concurrent medical conditions only (27.0%, 10/37), and patients with neither severe adhesions nor concurrent medical conditions (14.4%, 38/209) (P < 0.001 for trend). Multivariate analysis confirmed that the presence of concurrent medical conditions was an independent risk factor for postoperative depression (OR = 1.83, 95%CI: 1.04-3.21, P = 0.036), with a synergistic effect when combined with severe IUA (OR = 5.62, 95%CI: 2.59-12.18, P < 0.001; Table 4).

Table 4 Patients with concurrent medical conditions, mean ± SD.

Indicator	Depressed group (n = 112)	Non-depressed group (n = 288)	Between-group P value	Change in depressed group Δ (%)	Change in non-depressed group Δ (%)	P value for change comparison
Psychological assessment
SDS score
Baseline	48.3 ± 6.7	42.1 ± 5.9	< 0.001
3 months postoperative	58.4 ± 7.2	41.8 ± 6.1	< 0.001	+10.1 (20.9)	-0.3 (0.7)	< 0.001
HAMD-17 score
Baseline	14.2 ± 3.8	10.5 ± 3.1	< 0.001
3 months postoperative	20.6 ± 4.9	9.8 ± 3.4	< 0.001	+6.4 (45.1)	-0.7 (6.7)	< 0.001
Quality of life scores (SF-36)
Role-emotional
Baseline	68.5 ± 15.7	78.5 ± 10.7	< 0.001
3 months postoperative	47.8 ± 18.2	62.5 ± 14.7	< 0.001	-20.7 (30.2)	-16.0 (20.4)	< 0.001
Social functioning
Baseline	75.2 ± 14.1	82.5 ± 15.7	< 0.001
3 months postoperative	60.3 ± 15.7	75.1 ± 15.7	< 0.001	-14.9 (19.8)	-7.4 (9.0)	< 0.001
General health
Baseline	70.5 ± 16.3	72.0 ± 15.9	0.372
3 months postoperative	55.2 ± 17.1	71.5 ± 16.2	< 0.001	-15.3 (21.7)	-0.5 (0.7)	< 0.001
Physical functioning
Baseline	80.0 ± 18.5	88.0 ± 17.8	< 0.001
3 months postoperative	65.0 ± 19.2	81.0 ± 18.0	< 0.001	-15.0 (18.8)	-7.0 (8.0)	< 0.001
Role-physical
Baseline	72.0 ± 16.0	74.0 ± 15.5	0.228
3 months postoperative	55.0 ± 17.0	73.5 ± 16.5	< 0.001	-17.0 (23.6)	-0.5 (0.7)	< 0.001
Mental health
Baseline	70.0 ± 14.5	72.0 ± 14.0	0.191
3 months postoperative	50.0 ± 15.5	71.5 ± 14.0	< 0.001	-20.0 (28.6)	-0.5 (0.7)	< 0.001
Vitality
Baseline	65.0 ± 15.0	67.0 ± 14.5	0.213
3 months postoperative	50.0 ± 16.0	66.5 ± 14.5	< 0.001	-15.0 (23.1)	-0.5 (0.7)	< 0.001
Pain
Baseline	75.0 ± 15.0	76.0 ± 14.5	0.541
3 months postoperative	60.0 ± 16.0	75.5 ± 14.5	< 0.001	-15.0 (20.0)	-0.5 (0.7)	< 0.001

Δ represents absolute change from baseline. Percentage change calculated as (postoperative-baseline)/baseline×100%. Higher scores indicate better quality of life for 36-Item Short Form Health Survey domains, while higher Self-Rating Depression Scale and 17-Item Hamilton Depression Scale scores indicate more severe depressive symptoms. SDS: Self-Rating Depression Scale; HAMD-17: 17-Item Hamilton Depression Scale; SF-36: 36-Item Short Form Health Survey.

Psychological assessment and quality of life outcomes

At 3 months postoperatively, SDS and HAMD-17 scores in the depression group increased significantly from baseline (SDS: 58.4 ± 7.2 vs 48.3 ± 6.7, P < 0.001; HAMD-17: 20.6 ± 4.9 vs 14.2 ± 3.8, P < 0.001), showing an increase of 10.1 points (20.9%) in SDS scores and 6.4 points (45.1%) in HAMD-17 scores. In contrast, scores in the non-depression group remained stable or slightly decreased (SDS: 41.8 ± 6.1 vs 42.1 ± 5.9, P = 0.578; HAMD-17: 9.8 ± 3.4 vs 10.5 ± 3.1, P = 0.012), with SDS scores decreasing by 0.3 points (0.7%) and HAMD-17 scores decreasing by 0.7 points (6.7%). Notably, at 3 months postoperatively, the difference in SDS scores between the depression and non-depression groups reached 16.6 points, and the difference in HAMD-17 scores reached 10.8 points, reflecting significant disparities in psychological health status (Figure 4).

Figure 4 Temporal progression of postoperative depression incidence in patients following hysteroscopic adhesiolysis for intrauterine adhesions. The line graph demonstrates a progressive increase in depression incidence from 18.5% at 1 month to 28.0% at 3 months postoperatively (n = 400). The steady upward trend indicates that psychological symptoms continue to develop beyond the immediate postoperative period, with peak incidence occurring at 3 months follow-up.

Patients in the depression group showed significant deterioration in all domains of quality of life as measured by SF-36, with the largest decreases observed in role-emotional (47.8 ± 18.2 at 3 months vs 68.5 ± 15.7 at baseline, P < 0.001) and social functioning (60.3 ± 15.7 at 3 months vs 75.2 ± 14.1 at baseline, P < 0.001) domains. Specifically, role-emotional functioning decreased by 20.7 points (30.2%) and social functioning decreased by 14.9 points (19.8%). This suggests that postoperative depression has a particularly prominent impact on patients’ emotional states and social capabilities, potentially leading to greater difficulties in daily life and social interactions (Table 5).

Table 5 Psychological assessment and quality of life outcomes, mean ± SD.

Indicator	Depressed group (n = 112)	Non-depressed group (n = 288)	Between-group difference	P value
Psychological assessment
Preoperative SDS score	48.3 ± 6.7	42.1 ± 5.9	6.2	< 0.001
Postoperative SDS score at 3 months	58.4 ± 7.2	41.8 ± 6.1	16.6	< 0.001
Change in SDS score	+10.1 (20.9%)	-0.3 (0.7%)	10.4	< 0.001
Preoperative HAMD-17 score	14.2 ± 3.8	10.5 ± 3.1	3.7	< 0.001
Postoperative HAMD-17 score at 3 months	20.6 ± 4.9	9.8 ± 3.4	10.8	< 0.001
Change in HAMD-17 score	+6.4 (45.1%)	-0.7 (6.7%)	7.1	< 0.001
Quality of life scores (SF-36)
Baseline role-emotional	68.5 ± 15.7	69.2 ± 16.1	-0.7	0.698
Postoperative role-emotional at 3 months	47.8 ± 18.2	70.1 ± 15.9	-22.3	< 0.001
Change in role-emotional	-20.7 (30.2%)	0.9 (1.3%)	-21.6	< 0.001
Baseline social functioning	75.2 ± 14.1	74.8 ± 15.2	0.4	0.806
Postoperative social functioning at 3 months	60.3 ± 15.7	75.1 ± 14.8	-14.8	< 0.001
Change in social functioning	-14.9 (19.8%)	0.3 (0.4%)

Multivariate logistic regression analysis of post-operative depression

Factors with statistical significance in the univariate analysis were included in the multivariate logistic regression analysis. The results showed that age ≥ 35 years (OR = 2.31, 95%CI: 1.46-3.65, P = 0.004), severe IUA (OR = 2.86, 95%CI: 1.72-4.75, P < 0.001), history of infertility (OR = 3.12, 95%CI: 1.87-5.20, P < 0.001), post-operative complications (OR = 2.45, 95%CI: 1.53-3.92, P = 0.002), and low social support (OR = 3.24, 95%CI: 1.98-5.31, P < 0.001) were independent risk factors for post-operative depression in patients with IUA.

Follow-up outcomes and prognostic indicators

The line chart tracks depression incidence at two critical follow-up intervals: 1 month and 3 months after surgery. In the 1-month assessment, 18.5% of patients (74 out of 400) exhibited clinical symptoms of depression. By the 3-month follow-up, this percentage increased significantly to 28.0% (112 out of 400). This upward trend demonstrates that psychological symptoms continue to evolve beyond the immediate postoperative period, with many patients developing depression between weeks 4-8 after surgery (mean onset at 5.8 ± 2.3 weeks).

DISCUSSION

IUA represent a significant gynecological condition characterized by the formation of fibrous tissue within the uterine cavity, often leading to menstrual abnormalities, infertility, and recurrent pregnancy loss. The psychological impact of this condition, particularly following surgical intervention, has not been adequately addressed in the literature despite its potential significance for patient outcomes and quality of life. Our study demonstrates that postoperative depressive disorders are relatively common in patients with IUA, affecting approximately 28.0% of patients within three months after hysteroscopic adhesiolysis.

The prevalence of postoperative depression found in our study is notably higher than the general female population, where depression rates typically range from 5%-12%[15-17]. However, it is comparable to rates reported in patients with other gynecological conditions impacting fertility and reproductive function. For instance, studies on endometriosis patients report depression rates of 24%-38%[18], while infertility patients show rates of 15%-30%[19]. This suggests that reproductive health concerns may constitute a specific psychological vulnerability for women, particularly when associated with potential impact on fertility and family planning[20].

The pathophysiology underlying the association between IUA and depression likely involves multiple mechanisms[21]. Reproductive hormonal fluctuations, especially estrogen, have established effects on neurotransmitter systems involved in mood regulation. The endometrial damage in IUA may disrupt normal hormonal feedback loops, potentially contributing to mood disturbances[22,23]. Additionally, inflammatory processes involved in both adhesion formation and depression may represent another link, as pro-inflammatory cytokines have been implicated in the pathogenesis of depression.

Our finding that advanced age (≥ 35 years) represents an independent risk factor for postoperative depression (OR = 2.05, 95%CI: 1.27-3.32, P = 0.003) aligns with reproductive concerns that become more pressing with advancing maternal age. Women in this age group may experience greater psychological distress due to the perceived limited window for childbearing[24]. The particularly strong association between previous psychological disorders and postoperative depression (OR = 4.16, 95%CI: 2.24-7.74, P < 0.001) emphasizes the importance of pre-surgical psychological screening and targeted interventions for vulnerable patients[25].

The significant correlation between IUA severity and depression severity (r = 0.462, P < 0.001) suggests a dose-response relationship that may reflect both the psychological impact of a more serious diagnosis and the more intensive and potentially complicated surgical procedures required for severe cases[26]. Indeed, our data showed that operation time was significantly longer in the depression group (63.2 ± 18.7 minutes vs 52.4 ± 15.1 minutes, P < 0.001), potentially indicating more complex procedures with greater psychological impact[27].

The identified protective factors higher education, good social support, and restoration of normal menstruation offer important insights for clinical practice. Education level may influence coping strategies, health literacy, and access to resources[28]. Social support has been consistently associated with better mental health outcomes across various conditions[29,30]. The protective effect of menstrual restoration (OR = 0.40, 95%CI: 0.24-0.67, P < 0.001) is particularly noteworthy, suggesting that visible treatment success may significantly mitigate psychological distress[31].

The history of infertility (OR = 2.58, 95%CI: 1.66-4.01, P < 0.001) and recurrent miscarriage (OR = 2.82, 95%CI: 1.73-4.59, P < 0.001) as risk factors aligns with existing literature on the psychological impact of reproductive challenges[32]. The emotional burden of repeated pregnancy loss and failed fertility attempts can create a psychological vulnerability that may be exacerbated by surgical intervention for IUA[24], particularly if patients view the surgery as their “last hope” for fertility restoration[33,34].

Notably, our findings on postoperative complications as a risk factor (OR = 2.47, 95%CI: 1.39-4.38, P = 0.002) emphasize the importance of surgical technique and postoperative care in minimizing not only physical but also psychological morbidity[35]. This suggests that comprehensive care for IUA patients should integrate technical surgical excellence with psychological support and monitoring[36].

These findings have important clinical implications. First, they support the routine screening for depressive symptoms in the postoperative period for patients with IUA, especially those with identified risk factors[37]. Second, they suggest that targeted psychological interventions may be beneficial for high-risk groups[38]. Finally, our results highlight the importance of a multidisciplinary approach to IUA management, incorporating mental health professionals into the care team[39].

Limitations

Several limitations warrant discussion. The retrospective design limits causal inference and introduces potential recall bias, although we minimized this by relying strictly on medical records and standardized scale scores rather than subjective patient reports. The single-center nature of our study may affect generalizability. While we employed complete-case analysis with less than 5% missing data for key variables, we acknowledge that alternative approaches such as multiple imputation should be considered in future analyses. Regarding our statistical modeling, we recognize the concern about the number of predictors relative to outcome events. With 112 depression cases and 8-10 predictors, our events-per-variable ratio approaches the recommended threshold.

Future research should employ prospective designs with longer follow-up periods to better understand the longitudinal relationship between IUA, surgical intervention, and psychological outcomes. Specific research priorities include: (1) Validation of our predictive model in external cohorts; (2) Exploration of inflammatory pathways and hormonal profiles to understand biological mechanisms; (3) Randomized controlled trials of psychosocial interventions targeting high-risk patients; and (4) Development of integrated care models that combine gynecological and psychological expertise.

CONCLUSION

In conclusion, this study highlights the substantial prevalence of postoperative depression among patients with IUA and identifies several modifiable and non-modifiable risk factors. The findings underscore the importance of integrating psychological assessment and support into the comprehensive care of women with IUA, particularly for those at higher risk of adverse psychological outcomes.