Perspective of Women about Her Body after Hysterectomy

Hysterectomy is the most common major gynecological operation in worldwide and Arabic countries. However, the psychological, physical and sexual consequences of hysterectomy are conflicting and the findings are mixed. While, some studies report that patients have experience greater improvement in their mental health, sexual desire and overall satisfaction. Others show that patients report various negative outcomes, with detrimental effects on sexual functioning being the main concern. My previous study demonstrated that hysterectomy had significantly negative effects on patients’ body image, self-esteem, and identified common meanings and themes associated with hysterectomy stressors, which includes difficulties or limita-tions in physical and psychological aspects perceived by patients after hysterectomy. In this chapter, author will expand that discuss in details the different factors that influence the perspective of women about body after hysterectomy. Mainly, author will focus on religious, cultural, and psycho-social aspects. All of these factors are interacting with health status of women and effect the situation and productivity of women in her family and culture. Different strategy need to be adopted in order to overcome this problem using evidence and analysis of our Arabic culture and structure. Recommendation of study to health care profession as physician, nurses, midwives and other health care provider to be aware of these potential problematic issues in order to provide a competent health care for women based of her needs.


Introduction and background
One in three women at age of 60 years in the USA have undergone a hysterectomy, it is the second most common major surgical procedure performed in women worldwide [1]. Also, it is the leading reason for non-obstetric surgery among women in many high-income settings [2][3][4]. Fibroids, dysfunctional uterine bleeding, uterine prolapse and chronic pelvic pain are the most indication for this surgery [5]. So, the majority of hysterectomies are performed on benign indications to improve quality of life with few complications post-operative.
In recent years, an increasing number of studies have shown long-term adverse effects of hysterectomy on the pelvic floor and some studies have demonstrated unwanted effects on other health aspects. Long-term effects of hysterectomy on the pelvic floor that should be considered in surgical decision making are: pelvic organ prolapse, urinary incontinence, bowel dysfunction, sexual function and pelvic organ fistula formation. These outcomes are particularly relevant as life expectancy has increased and sequel may occur a long time after the surgical procedure and severely [1]. The surgery can take an emotional toll on woman as well. These effects might be very personal; she may feel differently than others, this leads her to depression. Losing the ability to become pregnant is hard for many women in worldwide and especially in Arabic countries, where the reproductively in considered the main reason for marriage. Some women feel "changed." They may also mourn the loss of their fertility [6]. Fears of looking less "womanly" Younger women who have a hysterectomy sometimes are anxious about whether the surgery will change their appearance. They worry that it will make them more masculine [6]. A lot of Women who are the power of the community depressed, as a result of this operation, because of losing a something that a part of her femininity, make their body image and self-esteem disrupted, feelings that their different from others women who can childbearing, and she is not, all of that make them isolated from the community, when this community need for their power and productivity. In next section authors will highlighted on women perspective on her body, and focus on factors that might directly and indirectly influence these perspectives that includes religious, cultural, economic, political and psycho-social aspects based on review.

Narrative review
In this part, author will offer a narrative review that present a group of studies, to see the experiences and results of previous studies that discuss the experience of women who had done hysterectomy. As well as discuss the role of health care profession and recommended strategies to overcome these problem. This section will include four themes which are quality of life; physical and psychological changes; sexuality; Cultural and religious aspects; finally the review conclusion and recommendations.
Sexuality is written as separate theme not under physical and psychological theme due to its important and effects based on Maslow hierarchy. Another point is the sensitivity of talking in this subject in conservative Arabic culture even from health care profession themselves. If I ask myself if any of health care profession provided women with health education about her sexuality after hysterectomy, the answer is obviously clear. Might be there is no time to provide that after operation but the important point the negligence of this type of education. This indicates that health care professions are playing a big role to solve or complicate this issue. They have to deliver a competent health care for women based of her needs. This is the woman's right not luxury, especially for ethnic minorities group.

Quality of life
Improvements of quality of life and decrease gynecologic symptoms are the main reason of any decision that taken by women for undergoes hysterectomy. In a systematic review study, authors investigated and analyzed six studies which evaluated QOL after hysterectomy. The authors concluded that a significant improvement above baseline in QOL scores [7]. However, many evidence as illustrated in this review showed the suffer of women physically and psychologically post-operative.
Hysterectomy is the one of surgery that needs more physical & psychological support by nurses in hospitals or/and outpatient clinics. Also provide a full background or knowledge for women who will do a hysterectomy that help to avoid the impact of hysterectomy [8]. There are four major subjects relating to the participant's experience were identified by Valerie Fleming [9], doubts and justifications, pain, embodiment Perspective of Women about Her Body after Hysterectomy DOI: http://dx.doi.org /10.5772/intechopen.94260 and sense of bitterness. In addition there are three domains must to integrate biophysical care of women, psychological, sociological, and spiritual domains [10]. Both of these study spotlight on the importance of provider training and education, also efforts must be directed to the community to enlighten men and families about hysterectomy by dispelling myths and providing current health information related to women's gynecological health and alternatives to, indications for, and types of hysterectomy.

Physical and psychological changes
As a result of study that examined by Gul Pinar et al., there is a relationships between hysterectomy and body image, self-esteem, and dyadic adjustment, which appears significantly in the scores, lower than the healthy women [11]. This indicates for the reduction of psychological support from community in general and family in specific. The most impact of hysterectomy as discussed on previous study [12], is the emotional side, seven themes that divided from this side, fear; pain; death and dying; numbness or delay in emotional reaction; bonding with baby; communication; and the need for information. Something that must to focus on managing it by enhances the quality of life or to avoid it before happened by providing correct health information by care providers. Like study which discussed in relation to the importance of information provision by gynecologists and its effects on women's decision-making about hysterectomy [13]. So gynecologists must initiate a comprehensive discussion about other treatments and their advantages and disadvantages. To explain the differences in complications between women after surgery, there are factors can determine this complication, Lifestyle factors (smoking and body mass index) and co-morbidity status, occupation and educational level [14].
The patients need for expressed their emotions and feelings after the major event that had happened in their life, otherwise, physical and psychological changes might be exaggerated. In previous qualitative study on Palestinian women, the most physical changes occur after hysterectomies were including pain, insomnia, eating disorder and immobility. One of the participants described pain as saying: "I had never felt like this pain in my life". As a consequence of the pain, patients also suffer disturbances at night and changes in the sleep cycle. Also, Changes in the patients' appetite were reported in this study and it differs from one woman to another. Some of the participants expressed that their appetite increased and others reported the opposite. Another problem that reported was the immobility which affected the daily performance and routine activities at home [15].
Depression, accompanied by anxiety, de-socialization, and aggression, is the most common complication that reported by women after hysterectomy. The depression was figure as the most common psychological complication of hysterectomy [15,16].
Also psychological and emotional stress was evident in previous study and shown a negative emotional outcome after hysterectomy. It has been suggested that early detection and immediate action by healthcare providers may prevent these negative impacts on the psychological wellbeing of these women. This is especially so in younger women in whom the psychological impacts are the greatest. Furthermore, because the main reason for the psychological impact was related to the immediate postmenopausal status after surgery, younger women appear to be more vulnerable, thus emphasizing the need for proper counseling in younger women undergoing hysterectomy [17].
The most coping mechanism and adaptation technique that used by women after operation from literature were praying, the Holy Quran, music, and other activities such as walking, sports (yoga) [15]. While, other study found that the operation affects patients' emotional reactions. As a result, they used these techniques to cope with their new condition and accept it [17].

Cultural and religious aspects
Another issue that should be highlighted in this review is the role and effect of environment as cultural and religious on the perception of women who undergo hysterectomy. The woman is not presented on isolation; she interacted with surrounding that affect her status and view to her body and problem. It is important to figure that uterus is representing woman's femininity and fertility.
The woman is not totally responsible for her body from legal and cultural aspect, it is partially. In Arabic countries as in Saudi Arabia and Palestine the health care system ask the husband's consent for any medical procedure that affects the reproductive ability of his wife. In recent study that disuses this practice in Saudi Arabia, author recommended that "arguments advocating for discontinuing the requirement are offered along with measures to implement in order to overcome this social artifact" [18].
However, Islamic law closely regulates and governs the life of every Muslim. The basic principle is that it is impermissible for a woman to have her uterus removed because this entails permanent sterilization, and this conflicts with one of the most important higher objectives of the Sharee'ah -fruitfulness in procreation. Anas ibn Maalik narrated that the Prophet, sallallaahu 'alayhi wa sallam, said: "Marry fertile affectionate women, for I will be proud of your numbers in front of the Prophets on the Day of Judgment." [19].
However, if there is concern of real or prevalent harm to the woman's health if the uterus is not removed, or it is feared that it could cause her death or bring about considerable hardship beyond her ability to endure, and it is necessary, according to the advice of reliable and experienced doctors, for the uterus to be removed to ward off such harm, then it is permissible for the woman to have her uterus removed. This is based on the well-established principles that "elimination of harm takes precedence to realization of benefit" and "necessity makes something prohibited permissible". Allaah The Exalted says (what means): {…while He has explained in detail to you what He has forbidden you, excepting that to which you are compelled.} [Quran 6:119].
Moreover, the Prophet, sallallaahu 'alayhi wa sallam, said: "There shall be no harm or reciprocal harm." [Musnad Ahmad and Al-Muwatta'] [19]. According to catholic a hysterectomy by choice over medical necessity would be a sin because it would cause permanent sterilization.
It is obviously clear here the gap between the cultural practice and religions aspect, what presented in religion in not translate totally to reality and practice. The women should have the total freedom to decide what she wants on her body. The powering women and taking her responsibilities will help her to cope well and accept any change to her body and soul.
From literature, other culture as presented in Indian, the author found the term "normalization of hysterectomy" was mentioned in many studies. The women are preferred to do hysterectomy as treatment for any menstrual or uterine problem instead of receiving medical or pharmacological treatment. This term underscores "the complex negotiations between women's agency and medically un indicated procedures, as well as the ethical obligations of providers-both of which require further consideration in the Indian context" [20]. However, this term is not presented in Arabic context; in contrast the family likes to have more children as highlighted above from religious and cultural side. Arabic families like to have more male children because they considered that in Arabic term "Ozwa" as a positive point and they will help them in future when parents become old. The more male children the women have delivered the more respect will receive from their culture, husband family and mother in law. So, we can imagine the scope of problem, how the effect of remove part of her women body "uterus" on her self-image.

Impact on sexual life
It is recognized that effects of hysterectomy on women's sexuality are debated and controversial from literature [17]. A Socio-cultural construction is main factor that influenced the sexuality that involves many factors such as gender, identity, sexual orientation, pleasure, intimacy, and reproduction [22]. Many previous studies reported that the majority of women and their partners reported zero negative impact on sexual satisfaction after abdominal hysterectomy, regardless of the surgery was subtotal or total to [23], for example the majority of Norwegian women and their partners reported no negative impact on sexual satisfaction after abdominal hysterectomy, regardless of whether the hysterectomy was subtotal or total [23]. While From the literature, some of the studies are inconsistent with these findings [15,[21][22][23][24][25][26]35].
Other study reported that only one fourth of the women reported decreased sexual arousal, while the majority had experienced higher sexual arousal after abdominal and vaginal hysterectomy [27]. Various measures are used in these studies so comparing the degree of improvement in sexual is difficult. Guliz et al. mentioned in his study that advanced age, women's attitude towards sexuality, and type of hysterectomy are the main elements that determine sexual functioning after hysterectomy. Depression has a negative effect on sexual functioning [28]. A negative sexual experience before hysterectomy will be a strong predictor of having a negative sexual experience of partners after operation [23]. A survey conducted in Jordan, which is one of Arab countries found that sexual performance after hysterectomy was their most significant concern, and there was a significant improvement in sexual function for women undergoing this procedure [26].
When looking to change in sexual changes, Literature review reveals that dyspareunia, and a change in orgasm and/or less sex are happened to approximately 10 to 20% of the women who underwent a hysterectomy [29], and in post operatively sexual dysfunction [30][31][32][33], then after two years of operation the sexual dysfunction stabilized [24]. The main reason for sexual annoyances were included the modified self-image perception after surgery and decrease in vaginal lubrication a [34].
One of study revealed the negative impact of hysterectomy on the sexual life, which lead to increased depression and anxiety, with sexual dissatisfaction [35]. The counseling and discussion prior hysterectomy for potential sexual changes after surgery is crucial and may enhance the situation [36]. Another problem that might occur is the urinary problems after the operation or hysterectomy for sexually active and healthy women, they resulted in sexual dysfunction and increase in depression. The age, educational status, working condition and family structure is also important in this case [37].
In the other study, that is titled by" Women's attitudes about sexuality". In the third month after hysterectomy 49.5% of the women had begun to have sexual intercourse again, 34.3% of those were determined to have a decrease in sexual functions. It was also found that level of depression was less in the postoperative period compared to the preoperative period. Three months after hysterectomy, sexual functioning had significantly decreased. A clear resolution in symptoms of depression was seen after hysterectomy. It was determined that sexual functioning after hysterectomy was affected by advanced age, a women's attitude about sexuality, and the type of hysterectomy [28].
It is indicated in this review that sexual function is a major cause of women's concern for scheduled hysterectomy; therefore, it is important to spread awareness among women and let them know that most probably they will neither lose their sexual desire after hysterectomy, nor they will lose their feminine shape or style [26]. It is important to figure if ethnicity, socioeconomic status and sexual function are taken into account; it is easily to manage the physical and psychological changes [17].

Conclusion and recommendation
The health care profession should have insight regards the perception of women of her body after hystrectomy. In order to provide a competent health care for women based of her needs. Women's sexuality fractioning is essence and concern of women after hysterectomy, this topic is debated and controversial from literature. It is important here to highlight that uterus has symbolic values related to femininity as mentioned previously and evidence by many studies [38]. This problem among Arabian women is apparent and clear, where the womb of a woman is considered everything for her it represent it femininity and fertility, it means a lot for her. The woman inside herself felt of "deficient being" in the eyes of herself and her extended family, taking into consideration the presented of conservative culture that women's have and early marriage practice that aimed to protect women and produce more children from cultural lenses view. This leads us the significant to power women by increase her awareness pre-operative, follow up post-operative and having a good support system.
Educational programs for women undergoing hysterectomy will promote better self-care behavior, reduce postoperative anxiety and pain, and mitigate some of the negative influences of hysterectomy. So, interventions may not affect the actual incidence of the side-effects; they may help patients cope with adverse outcomes better, thus emphasizing the importance of the adaptation process to accept this condition with a positive thought.
The results of this review reveal that hysterectomy had significant argumentative effects on women's' quality of life, physically, psychological and sexually. For effective handling of this problem, healthcare profession must be aware of these potentially problematic issues and use effective intervention pre-post operation. Multidisciplinary teams have to work together, nurses have to lead the work to ensure of using the holistic approach that cover women's needs that included physical, psychological, spiritually, culturally and be individually. One size not fit all.
The important point here, that we could not change the culture or the mistake in the interpretation of religion. So, the practical solution is to involve the family into the therapeutic plan, identifying and addressing the psychosocial problems of the particularly high-risk groups is another critical point and referred them.
Based on the findings from this review, recommendations can be made to nurses working at gynecological departments. Nurses could also help the patients explore current coping mechanisms and support systems after hysterectomy. Another recommendation is to conduct a future study that examine the current education that provides to women pre-post operatively and it suitability based on her ethnicity and needs where ever the women is presented in her home country or diaspora.

Author details
Eman Alshawish Head of Midwifery and MCH Department, Faculty of Medicine and Health Science, An-Najah National University, Nablus, Palestine *Address all correspondence to: alshawish@najah.edu © 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.