Experience of Palestinian Women After Hysterectomy Using a Descriptive Phenomenological Study

Universally, hysterectomy is considered as the second most frequent surgery after cesarean section performed on women in the reproductive age. After a hysterectomy, women no longer have menstrual periods, so they cannot become pregnant. Like most other countries, hysterectomy is the most common major gynecological operation in Palestine. However, the psychological, physical, and sexual consequences of hysterectomy are conflicting, and the findings are mixed. While some studies report that patients experience more significant improvement in their mental health, sexual desire, and overall satisfaction, other studies show that patients report various adverse outcomes, with detrimental effects on sexual functioning being the main concern.


INTRODUCTION
Hysterectomy is the second most common major surgical procedure performed on women worldwide, and by the age of 60, almost one in three women in the USA has undergone this The surgery can take an emotional toll on women as well. All these effects are very personal in that the patient may go through unique feelings. A hysterectomy can trigger feelings of sadness. It can even lead to depression. Besides, losing the ability to become pregnant is hard for many women. Some women feel changed. They may also mourn the loss of their fertility [2]. For fear of looking less womanly, younger women who had a hysterectomy are anxious sometimes about whether the surgery would change their appearance. They worry that it would make them more masculine [2].
Hysterectomy is one of the most common surgical procedures for women over the age of 35, and little has been known so far about their experience or what they go through. Many women feel depressed as a result of this operation because of losing part of their femininity. They might well feel dejected simply because both their body image and self-esteem are disrupted. The deep feelings that they are different from other fertile women render them downhearted. All of these sentiments arise when these women are needed most in the community for their power and productivity. Therefore, this study aims is to describe women's experiences of hysterectomy and to identify their fears, concerns, and what coping mechanisms they use to enhance the quality of their lives.

MATERIAL AND METHODS
A Qualitative Descriptive Phenomenological Design is adopted in this study which focuses on using semi-structured interviews. This is achieved by formulating open-ended questions that allow to capture more data from patients. Descriptive phenomenological research uses a methodological framework that answers the research questions through an accurate description of the experience [3]. Purposive sampling is used so that the best available people to provide rich data on the research questions can be selected. The study was approved by the university's institutional review board and authorities of selected hospitals. Participation in the study was voluntary. The participants were reassured that confidentiality would be strictly maintained, and they were given the right to access the study results. Informed written consent was obtained before the commencement of the study.
The participants were recruited from gynecological wards in governmental and private hospitals. Interviews took place in a private room to protect the privacy and facilitate full disclosure in the interview. Interviews were conducted on a one-on-one basis by a singular interviewer (the researcher). The participant was asked to describe, as deeply and thoroughly as possible, her experience of hysterectomy. It was anticipated that this would include current and past experiences and implications in the lives of the participants. The inclusion criteria were women who were married, have had a hysterectomy, and were willing to participate in the study. However, the exclusion criteria include women, who were unable to communicate, had impaired judgment, delusions, seizures, hypoglycemic reactions, or other conditions known to impair cognition. The information was taken from participants' files and from their families before the interview.
A semi-structured interview guide with open questions and pop questions was used to explore the issue . Also, an interview recorder was used while doing an interview. Then the transcription of the recorded proceedings was prepared for analysis. The interview duration ranged from 20 to 40 minutes. At the beginning of each interview, the researchers introduced themselves, explained the objectives of the study, and obtained informed written consent from participants. Then a brief sociodemographic questionnaire was completed for each interview in order to collect preliminary information. Face-to-face interviews served as the primary method of data collection for this study. This method gave the researcher the opportunity to enter into the informants' world and to have access to their lived experiences [4].
Through intensive dialogue with the participants, the researcher managed to elicit their accounts and helped create their sense of reality. The researchers conducted each interview in a quiet room that was a small distance away from the clinical activity because prior to the planning of the environment, it is an important consideration towards establishing rapport and gaining the respondent's confidence in the first few minutes of an interview.
As interviews progressed, participants were encouraged to elaborate on their experiences and meanings, which were checked regularly with the participants. Reflexivity facilitates the creation of the text by both the researcher and the participants. At the end of each interview, the researchers used debriefing methods by talking to each patient after the interview (Thank you for participating in this research. Thank God for the countless graces that you are healthy and Insha' Allah everything would get better).
Phenomenological psychologists analyzed the data utilizing a systematic and rigorous process. Data analysis consists of four consecutive steps, where each step is a prerequisite for the next [5 -7]. Before the analysis, each interview was transcribed verbatim [8]. All the steps in the analysis must be performed within the phenomenological reduction. The phenomenological reduction used in descriptive phenomenological analysis requires bracketing as a first step [8]. According to Giorgi, bracketing/ epoch implies not taking a stand for or against but allowing the phenomenon to emerge [8]. Phenomenological reductions also require withholding any existential claims and presenting data as it presents itself rather than making ones [8].
The method used to assess findings through evaluation steps of the research determines the quality of research. The rigor of a study is ensured when discussions and debates among members of the research group reach a consensus. Validity in qualitative research may be ensured by keeping personal biases to a minimum, so the data was analyzed by two groups of researchers separately in the same way and period. Then the results were compared until consensus be reached. Discussion on the two analyses for each participant occurred to ensure the reliability and consistency of the results. Credibility is ensured by including the participants' perspective on the study. Conformabilityis the degree to which the results could be confirmed or corroborated by others, which we achieved by recording participants' interviews and documenting the study steps cautiously to prevent researchers from bringing their unique perspectives to the study.

RESULT
The purpose of this study was to investigate the experiences of Palestinian women after hysterectomy and the coping mechanisms they used. The selected sample involved 15 patients (female), with ages, ranged between 18 and 50 years old. Twelve participants were married, two were divorced, and one was widowed. Seven participants used to live in villages; five participants in major cities, while three of the participants were from refugee camps. All of them had a total abdominal hysterectomy; the primary reason was heavy menstrual bleeding due to the uterine fibroid.
There are five themes and eighteen subthemes that emerged from this study. These themes were: firstly, physical that includes pain, insomnia, eating habits, and immobility. Secondly, psychological changes which make many problems that include depression, de socialization, aggression, and anxiety. Thirdly, defense mechanisms that were used by patients: praying, reciting the Holy Quran, listening to music, walking, and sports (yoga), among other things. Fourthly, selfesteem, and body image defects that resulted from the loss of confidence, appearance, and interests. Lastly, sexual satisfaction that already varies among women and includes excitement and sexuality.

Physical Changes
The physical changes theme includes four subthemes, pain, insomnia, eating disorder, and immobility. Patients in the study experienced physical changes that include pain, insomnia, eating disorder and immobility. One of the participants(Participant 6) described pain as saying: "I had never felt like this pain in my life", another one said (Participant (14), "my pain is making me cry" As a consequence of the pain, patients also suffer disturbances at night and changes in the sleep cycle. Participant (2) said: "I cannot sleep from my pain "; participant (12) said "I was trying to sleep, but I failed, my brain is thinking all the time"; participant (8)  Changes in the patients' appetite were reported in the study. However, they differ from one woman to another. Some of the participants expressed that their appetite increased. Participant (5) stated that "My appetite increased, I am eating all the time," and participant (4) said "I gained weight, related to my excessive eating". However, others claimed that their appetite had decreased "I lost my desire to eat anything; I cannot even swallow the food" (P11), while participant (3) said, "I cannot eat anything, I feel nauseated when I smell the food." Another problem that emerged in the patients was the immobility which affected the daily performance and routine activities at home. Participants (2) said: "I cannot take care of my children",p articipant (8) said, "I cannot do anything alone," and participant (7) said, "my daily activity is restricted, I cannot do anything alone."

Psychological Changes
Depression, accompanied by anxiety, de-socialization, and aggression, is the most common complication that our study reported. The current study also noted that depression is the most common psychological complication of hysterectomy. One of the participants (15) said: "I have a bad mood after hysterectomy. I do not know why may be because I'm…am not able to get more kids, sometimes I'm crying, other times I'm shouting and so on. You know…er… our culture, the more male baby you get, the more respect you will gain from your husband's family. This is quite the reality in our culture". Participant (10) described her status as "I lose my smile" while participant (15) said, "I hate myself when I talked with others". One the other hand, participant (13) said "I cannot bear anything, shouting without reason all the time."

Defense Mechanisms
Defense mechanisms include five subthemes, praying, reciting the Holy Quran, listening to music, walking, and sports (yoga). Most of the patients in the study used an adaptation technique, very much like praying, reciting the Holy Quran, listening to music, and other activities such as walking, sports (yoga). One of the participants (1) said: "I feel relaxed when I read the Quran Kareem (Holy Quran), God makes me stronger"; participant (12) said: "I have spent most of the day praying", another claimed (participant 5): "When I pray I feel like God is with me,". Participant (3) said, "walking is changing my mood". While Participant (5) said, "I feel of relaxation and positive thoughts after walking."

Self-esteem & Body Image
This theme has three subthemes, which are confidence, appearance, and interests. Body image and self-esteem of the women who had undergone hysterectomy were significantly lower than that of healthy women. The study findings show that hysterectomy operations have adverse effects on body image, self-esteem, and dyadic adjustment in affected women. One participant (10) complained, "I lost the desire to do anything; I was careless, I don't take care of myself or my kids", Participant (10) said: "I lose my uterus, I am not the same women". In contrast, participant (14) said, "I cannot accept that the part from my body had been removed." Participant (9) described herself as "being so shy," and participant (13) said, "nothing in my life is important, all things that I love, I forget it, like shopping, cooking and parties".

Sexuality Themes
The two subthemes presented under the sexuality theme, are sexual behaviors and excitement. Although sexuality is an essential item after hysterectomy, many participants avoid discussing this topic. Some patients in this study reported sexual effects and others did not. Participant (5) said, "I refuse any sexual relationship; excitement has long gone" ; participant (11) said, "I am lucky there is no change on my sexual life"; participant (9) said, "my sexual life is totally affected", while participant (6) claimed: "there is no effect on my sexual life, still normal without any change".
Hysterectomy surgery has a negative effect on the couples' relationship that might end with divorce as in the story of one of the participants. Participant (15) said, "I was Divorced due to my sexual problem after hysterectomy, he felt that I am not attractive or beautiful as before, he needs more kids, and I cannot do that anymore. By the way, he married after a few weeks by a young lady after our divorce, you know our culture, if a man has any problem, the women should support him, and it is not polite to ask for divorce but for us, they throw us away quickly without thinking when we have a reproductive problem".

DISCUSSION
Removal of the uterus can be a tricky thing that women could face in that it involves emotional, psychological, and cultural factors. The uterus, let alone its biological function, has symbolic values related to femininity [22,23]. This problem among Arabs is noticeable. The womb of a woman is the symbol of femininity and fertility. Its removal makes the woman a "deficient being" in the eyes of herself, her husband, and her mother in law even if they keep silent and never utter a word to this effect. The participants highlighted their concerns after hysterectomy related to physical, psychological, and sexual issues. The influence of this culture on women is a significant factor in how they feel. Culture can be considered as a ''coin that the nurses should use to support women. Nurses should include the whole family into nursing planning and intervention, and they should always keep in mind the impact of culture on women's health.
Patients in the study experienced physical changes that include pain, insomnia, eating disorders, and immobility. These results are consistent with the study of Li Ping et al., who found that women experienced the same physical effects that imposed limitations and created disturbances in their daily life [9].
Depression is the most common complication that our study reported accompanied by anxiety, de-socialization, and aggressiveness. These results are similar to the outcome of the study by Guliz et al.
[10] The current study also noted that depression is the most common psychological complication of hysterectomy. This result is consistent with a study that found that depression negatively affects the patients' social, contacts, and relationships.
Body image and self-esteem of the women who had undergone hysterectomy were significantly lower than in healthy women. The study's findings show that hysterectomies have adverse effects on body image, self-esteem, and dyadic adjustment in affected women. The study performed by Gul Pinar et al., reported the same results that body image and selfesteem decreased and affected the personality of patients [11].
The study focused on planning and implementation of interventions that concentrate on a holistic assessment of the psychosocial needs of women with hysterectomy. Accordingly, this study aims to adequately inform female patients and provide them with appropriate emotional and social support. Besides, nurses can conduct assessments aiming to identify and address the psychosocial problems of the particularly high-risk groups. They also suggest appropriate nursing interventions or making referrals if needed .
The effects of hysterectomy on women's sexuality are debated and controversial [15]. Sexuality is influenced by socio-cultural constructions that involve many factors such as gender, identity, sexual orientation, pleasure, intimacy, and reproduction [28]. Some participants in this study reported no sexual effects post-hysterectomy. This is consistent with a previous study that 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 [12]. Comparing the degree of improvement in sexual satisfaction in different studies is difficult, because various measures are used. In the previous study, it was reported that only 25% of the women reported decreased sexual arousal, while the majority had experienced higher sexual arousal after abdominal and vaginal hysterectomy [13]. The only predictor of negative sexual experience of partners after hysterectomy was a negative sexual experience before hysterectomy [12]. Results of a study carried out by Guliz et al. [10] suggested that, after hysterectomy, sexual functioning is affected by advanced age, women's attitude towards sexuality, and type of hysterectomy. When depression symptoms increase, there is a negative effect on sexual functioning.
The current study shows that some participants reported a negative impact on sexuality after hysterectomy. From the literature, some of the studies are inconsistent with these findings [14, 15, 25 -28]. 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 [25]. The results of a survey conducted in Jordan, where the population had similar characteristics as Palestinians, found that hysterectomy was their most significant concern when it comes to sexual performance, and there was a significant improvement in sexual function and in women's health undergoing this procedure [27].
Literature review reveals that approximately 10 to 20% of the women who underwent a hysterectomy experienced some change in sexual function, such as dyspareunia, and a change in orgasm and/or less sex [19], and sexual dysfunction in the postoperative period [16 -18]. One study found that sexual dysfunction stabilized after two years of operation [20]. The reason for sexual dissatisfaction in the previous study was the lack of or a decrease in vaginal lubrication and the modified self-image perception after surgery [21].
Most of the patients in the study used an adaptation technique, like praying, the Holy Quran, music, and other activities such as walking, sports (yoga). The study of Li Ping et al., found that patients after hysterectomy suffer from psychological effects. The study also found that the operation affects patients' emotional reactions. As a result, they used this technique to cope with their new condition and accept it [9]. 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.

CONCLUSION
The results of the study demonstrate that hysterectomy had significant adverse effects on patients' body image, selfesteem, and identified common meanings and themes associated with hysterectomy stressors, which include difficulties or limitations in physical and psychological aspects perceived by patients after hysterectomy. For effective handling of this problem, medical teams, and particularly nurses, must be aware of these potentially problematic issues and use nursing interventions to combat these complications. Nurses should focus on a holistic assessment of the psychosocial needs of women with a hysterectomy and, accordingly, aim to adequately inform the patients and provide them with appropriate emotional and social support. Also, nurses can conduct assessments aiming at identifying and addressing the psychosocial problems of the particularly highrisk groups accompanied by appropriate nursing interventions or making referrals as needed. In doing so, they will address some of the effects of hysterectomy.

RECOMMENDATIONS
Based on the findings from this research, 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. Nurses could, as well, implement nursing interventions while taking into consideration the cultural issues to enhance the coping mechanisms and collaborate with other professionals and family members. There are also some recommendations for future research based on the results of this study. More research is needed on the experiences of Palestinian patients after hysterectomy, particularly in terms of coping methods and barriers to treatment. Research is also needed to explore what would be helpful to the Palestinian patients with their illness.

LIMITATION OF THE STUDY
The major limitation of the study was the participants' involvement. Taking part in the study was voluntary. As a result, not all of the potential participants agreed to participate in the study.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
This study has been approved by IRB from An Najah National University, Nablus, Palestine under archive number 77/Sept/2015.

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
Informed written consent was obtained from all the participants.

AVAILABILITY OF DATA AND MATERIALS
The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.