Sexuality experiences of hysterectomized women

Escola Anna Nery 23(4) 2019

Experiências de mulheres histerectomizadas acerca da sexualidade

Experiencias de mujeres histerectomizadas acerca de la sexualidad

Alessandra Schmidt

Graciela Dutra Sehnem

Lecia Silveira Cardoso

Jacqueline Silveira de Quadros

Aline Cammarano Ribeiro

Eliane Tatsch Neves

1. Universidade Federal do Pampa.

Uruguaiana, RS, Brasil.

2. Universidade Federal de Santa Maria.

Santa Maria, RS, Brasil.

Corresponding author:

Graciela Dutra Sehnem.

E-mail: graci_dutr[email protected].

Submied on 02/27/2019.

Accepted on 05/24/2019.

DOI: 10.1590/2177-9465-EAN-2019-0065

RESEARCH | PESQUISA

Esc Anna Nery 2019;23(4):e20190065

AbstrAct

Objective: To know the sexuality experiences of hysterectomized women. Method: Qualitative study carried out in Family

Health Strategies with 19 hysterectomized women. A semi-structured interview was conducted, combined with the Creativity and

Sensitivity Technique called Speaker Map, after approval by the Ethics Committee from January to February 2018. Data were

analyzed according to analysis of the thematic content. Results: The participants had dierent sexuality experiences after the

hysterectomy. The procedure was associated with restoration of health, resuming sexual activity, and changes in relationships. It

was also related to the onset of dyspareunia and decrease in libido. Conclusion and implications for practice: The changes

experienced after surgery led women to build new meanings for sexuality and their relationships. The surgery shows concrete

results, such as decreased or increased pain in sexual practice, and subjective results, such as the feeling of freedom and the

impact on female identity. These results may contribute to direct educational strategies to approach sexuality with each woman

who undergoes hysterectomy.

Keywords: Sexuality; Hysterectomy; Femininity.

resumo

Objetivo: Conhecer as experiências de mulheres histerectomizadas acerca da sexualidade. Método: Estudo qualitativo realizado

em unidades da Estratégia Saúde da Família com 19 mulheres histerectomizadas. Utilizou-se entrevista semiestruturada,

combinada com a Técnica de Criatividade e Sensibilidade denominada Mapa Falante, após a aprovação do Comitê de Ética,

no período de janeiro e fevereiro de 2018. Os dados foram analisados segundo análise de conteúdo temática. Resultados:

As mulheres sentiram-se diferentes para vivenciar a sexualidade após a histerectomia. Este procedimento foi associado ao

restabelecimento da saúde, à retomada da vida sexual e à mudança nos relacionamentos. Também esteve relacionado ao

surgimento de dispareunia e à diminuição da libido. Conclusão e implicações para a prática: As mudanças vivenciadas a

partir da cirurgia zeram as mulheres construírem novos signicados acerca da sexualidade e dos seus relacionamentos. A

cirurgia desdobrou-se em questões concretas, como a diminuição ou aumento da dor nas relações sexuais, e em questões

subjetivas como a sensação de liberdade e o impacto na identidade feminina. Esses resultados podem contribuir para direcionar

estratégias educativas para abordar a sexualidade com cada mulher que vivencia a histerectomia.

Palavras-chave: Sexualidade; Histerectomia; Feminilidade.

resumen

Objetivo: Conocer las vivencias de mujeres histerectomizadas acerca de la sexualidad. Método: Estudio cualitativo realizado

en Estrategias Salud de la Familia con 19 mujeres histerectomizadas. Se utilizó la entrevista semiestructurada, combinada con la

Técnica de Creatividad y Sensibilidad denominada Mapa Hablante, después de la aprobación del Comité de Ética, en el período

de enero y febrero de 2018. Los datos fueron analizados según el análisis de contenido temático. Resultados: Las mujeres se

sintieron diferentes para vivir la sexualidad después de la histerectomía. Este procedimiento se asoció al restablecimiento de la

salud, la reanudación de la vida sexual y el cambio en las relaciones. También, estuvo relacionado al surgimiento de dispareunía

y a la disminución de la libido. Conclusiones e implicaciones para la práctica: Los cambios vivenciados a partir de la cirugía

hicieron que las mujeres construyeran nuevos signicados acerca de la sexualidad y sus relaciones. La cirugía se desdobló en

cuestiones concretas, como la disminución o aumento del dolor en las relaciones sexuales y, en cuestiones subjetivas como

la sensación de libertad y el impacto en la identidad femenina. Estos resultados pueden contribuir para el direccionamiento de

estrategias educativas para abordar la sexualidad con cada mujer que vivencia la histerectomía.

Palabras clave: Sexualidad; Histerectomía; Feminidad.

EAN

www.scielo.br/

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

INTRODUCTION

Hysterectomy is the total removal of the uterus, when the

uterus and cervix are removed, or partial removal, in which the

cervix is kept, being considered the second most common

gynecological surgery in the world among women in reproductive

age.

1,2

With respect to Brazil, about 83 million hysterectomies

were performed in 2014 and about 34 million of them were

oncological surgeries.

The main indications for this type of surgery include benign

gynecological diseases, such as abnormal uterine bleeding and

symptomatic uterine leiomyoma.

It can be performed vaginally,

through abdominal incision, or by laparoscopic route, the latter

in which the organ is removed through small incisions, which is

a minimally invasive technique.

Removal of the uterus can be a dicult process to be faced

by women, especially as it involves emotional, psychological, and

cultural factors. The uterus, in addition to the biological function,

has symbolic values related to femininity.

2,4

There are sensations

and characteristics related to body perception that are common

to women after surgery, among them, feeling awkward and

change in the body image, the feeling of mutilation of their body,

emptiness, and feeling dierent from other women.

Hysterectomy can have positive or negative implications in

the sexuality experience of these women, which may reect on

their self-image, marital and social relationship, or even revealed

through depressive symptoms.

5,6

Sexuality is inuenced by the

socio-cultural construction, and is interrelated in gestures, words,

behaviors, looks, attitudes, and in the silence of each one as well.

It covers matters such as gender, identity, and sexual orientation,

eroticism, pleasure, intimacy, and reproduction.

Therefore, these women need to receive comprehensive

health care, in which the impacts related to the hysterectomy are

addressed, in order to clarify doubts and expectations regarding

the surgery, as well as their possible interference with the quality

of life. The nurse should welcome these women and establish a

bond using sensitive and qualied listening in order to promote

knowledge about their bodies, to identify the values attributed to

the uterus, and how sexuality is experienced before and after the

gynecological surgery, in order to support them in this process.

6,8

In an attempt to identify the scientic production about the

sexuality of hysterectomized women, there was a search in the

national and international literature. The papers available in

the last ve years have focused on matters such as the eects

of hormone replacement therapy on the sexual function of

women with gynecological surgery; the inuence of dierent

hysterectomy techniques on sexual function; the meaning for

women of removing their uterus; and quality of life after the

procedure. Thus, there is a need for greater investments in

research on the sexuality experiences of women who underwent

hysterectomy in the area of Nursing and health sciences.

The study is based on the following research question:

What are the experiences of hysterectomized women related to

sexuality? In order to answer to this questioning, the objective

was to know the experiences of hysterectomized women related

to sexuality.

METHOD

A descriptive and exploratory qualitative study. The research

scenario was ve Family Health Strategy (ESF - “Estratégia

Saúde da Família”, in Portuguese language) located in the

urban area of a city on the western border of Rio Grande do Sul.

Choosing this scenario is justied by the characterization of the

ESF as the entry point for women in the service network of the

Unied Health System (SUS - “Sistema Único de Saúde”, in

Portuguese language), as well as the importance of these spaces

of care for nursing practices aimed at health education actions

and health promotion of hysterectomized women.

19 women participated in this study, which was based on

data saturation, in which the researcher identied that no new

information was added and was able to understand the internal

logic of the public.

Females older than 18 years of age who

underwent hysterectomy for more than six months were used

as inclusion criteria to participate in the study in order to enable

a longer experience of their sexuality after surgery. Exclusion

criteria were: women undergoing chemotherapy, considering that

this process may change their health status, and consequently,

their perceptions about sexuality.

The selection was intentional, considering that the

participants were indicated by the nurses of the health units.

Those who met the criteria mentioned above received an

invitation at their home through the Community Health Workers

(CHW). After this initial contact, the CHW scheduled the location,

date, and time according to the participants’ availability for the

interview. The interview took place mostly in their households,

except for three conducted at the health service, both individually

to keep the information condential.

For collection of information, the semi-structured interview

was combined with the Creativity and Sensitivity Technique

(TCS - “Técnica de Criatividade e Sensibilidade”, in Portuguese

language)

referred to as Speaker Map (MF - “Mapa Falante”, in

Portuguese language). The TCS is considered an alternative form

of data collection in research in the nursing area and instigates

the participants’ subjectivity.

The collection took place in the rst

half of 2018, the interviews were conducted by the responsible

researcher and lasted about one hour. The interviews were

recorded, with the women’s authorization, in an audio device and

later transcribed in full for analysis and interpretation.

First the objectives of the research were presented, as well

as the ethical principles that would guide the interview. Later

the semi-structured interview was conducted with the following

questions: How do you feel and perceive yourself after surgery?

Do you feel any changes in your self-image after surgery? Which

ones? Can you name some positive eect of hysterectomy on

your aective and sexual life? Can you name some negative

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

eect of hysterectomy on your aective and sexual life? What

do you and your partner talk about this topic? Possible changes

in sexuality were discussed at any time by the nurse? What do

you think the nurse should talk about the sexuality of women

who undergo a hysterectomy? Next the speaker map was

created guided by the following question: How do you perceive

yourself after the hysterectomy? At this moment, the participants

presented the drawing to the researcher and explained their

meaning.

The material was analyzed through Minayo’s thematic

analysis, characterized by three stages.

In the pre-analysis, the

rst exploratory level, the prole was established, comprising

the history and the characterization of the researched group.

In addition, the type of categorization and the coding modality

were outlined. The second stage, exploration of the material,

was characterized by a classicatory operation to understand

the focus of the text. This was the moment when the data

was organized into thematic categories, reducing the text to

meaningful expressions or words. The third stage was the

treatment of the results and their interpretation. In this stage,

inferences and interpretations were made, correlating them with

the initial theoretical framework, but also enabling new theoretical

and interpretative dimensions, suggested from the reading of the

collected material.

The research followed the precepts of Resolution no. 466/12

of the National Health Council of the Ministry of Health, with

approval of the Ethics Committee, under the CAAE protocol No.

80627317.7.0000.5323 and opinion No. 2,437,609. To preserve

the anonymity of the interviewees, the participants were identied

using the alphanumeric system using the codename W, related

to women, followed by an Arabic numeration according to the

order of interviews.

RESULTS

19 women were interviewed in the age group from 33 to 80

years of age. Most of them were aged between 43 and 58 years.

As for marital status, 13 were married and/or had a domestic

partnership, four were widows, and two were single. They stated

they had one to six children, with the average between two and

three children; it is noteworthy that two did not have children.

In terms of education, nine completed high school, nine did

not complete middle school, and one did not complete the higher

education. With respect to the profession, two were retired, two

were housewives, and the others were retail or domestic workers.

The reason for the hysterectomy for 13 of the study participants

was the presence of uterine broids; two were operated due to

ovarian cyst, one due to low-grade neoplasia, one due to spongy

carcinoma, one due to endometriosis, and one due to bladder

prolapse.

The analysis of information provided by the participants

showed three thematic categories, namely: Positive experiences

related to sexuality; Diculties in experiencing sexuality; and

Health care of hysterectomized women.

POSITIVE EXPERIENCES RELATED TO

SEXUALITY

Some participants in this study reported improvement in

sexuality during intercourse after the hysterectomy. For these

women, the surgery freed them from symptoms mostly caused

by uterine broids (benign tumors), which caused bleedings, in

addition to dyspareunia. In this sense, it can be noticed that the

removal of the uterus was intended to restore health, as well as

to resume the sexual life, previously compromised. These issues

are illustrated in the speaking map in gures 1 and 2.

Figure 1. Speaker map produced by parcipant W11.

Source: Invesgaon data.

Figure 2. Speaker map produced by parcipant W18.

Source: Invesgaon data.

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

I couldn't wear white pants, I don't feel any pain today, I

am not angry anymore, I had a chronic anger, all that is

gone. [...] if I want to have sex anytime I do, I don't need

to get desperate or curse because of pain, this is all a

good thing (W10).

Our freedom during sex is very good. To this day we have

used condoms, because we have always used them. [...]

sexual desire has nothing to do with the surgery itself, it

continued the same (W4).

I drawn myself happy, because I don't suer any more

from bleedings, and walking around because it is

something I could not do, I didn't want to leave the house

for being afraid to get my pants dirty (SPEAKER MAP,

W11).

I feel like a rose because the rose is so beautiful and

sturdy. I am a real person with normal problems, but I still

can feel beautiful (SPEAKER MAP, W18).

It is possible to note that the partners supported the women

in this delicate moment, which was important for them to deal

with this situation. These matters are highlighted in the following

reports and on the speaking map (Figure 3):

My husband said that marriage is not just sex, marriage

is a partnership. We have been together for 30 years, it is

not because of sex that we will stop being a family. [...] he

(husband) told me: let's do the surgery, you'll be ne and

we'll solve any problems there might be (W10).

I drew my house happy, together with my son, me, and

my husband, my dog, a tree that I really like, the sky, the

sun, and a few butteries [...] in short, I just got happy

after the surgery (SPEAKER MAP, W3).

Most of the interviewees already had children, hence, for

them, the uterus had already played its role as a reproductive

organ. At this moment, the uterus was perceived as a problem

and the solution was to remove it, which made them feel

somewhat relieved, too, about an unwanted pregnancy, providing

later freedom in the married life.

The relationship with my husband, in my opinion, has

improved, to have sex without getting pregnant, not

having to take contraceptives, it is a type of freedom.

[...] he supported me to do the surgery, he helped me in

everything, he knew about the decision to not have more

children, I had already done the tubal ligation, so for us it

was very good (W11).

The upside is that you no longer have the risk of getting

pregnant and when I have sexual intercourse, for sexual

desire, I have more orgasms than usually. My husband

was very afraid, because of this myth, he thought it

wouldn't be the same, but he said: I will take care of you,

don't worry (W18).

DIFFICULTIES IN EXPERIENCING SEXUALITY

Some participants in the study reported difficulties in

experiencing sexuality after hysterectomy, associated with pain

during sex and decreased sexual desire, as illustrated on the

speaking map (Figure 4). They also reported feeling weird in the

penetration during intercourse, a situation that may be related to

the lack of or decrease in vaginal lubrication and to the modied

self-image perception after surgery.

[...] I usually don't have intercourse. This other partner I

have does not say anything negative or positive in our

sex life. I don't even want to have sex. After a few years

I have a lot of pain, we are not in the same page, I feel

“cold” (W1).

These pains I felt after the surgery to have sex, I do not

know what they may be (SPEAKER MAP, W1).

My body has changed, it is dierent in the penetration

from when you have cervix and uterus. You feel the

dierence and you know it is dierent (W2).

Figure 3. Speaker map produced by parcipant W3.

Source: Invesgaon data.

I feel good [...] today I am a dierent woman, I was born

again. [...]my husband said: if it was better for me, I had

to do the surgery, he even went to the doctor with me to

understand that I would not be “cold”; he understood me

and gave me strength (W19).

My husband was a great partner, I was suering from that

situation and he was too, but he did not abandon me in

any moment (W5).

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

Figure 4. Speaker map produced by parcipant W1.

Source: Invesgaon data.

Now I struggle to have sex, because sex before the

surgery was actually to have a child. Over time, I changed

the way I think, I went to the psychologist, I had treatment

for a year [...] but the downside was the diculty in having

sex, I got very dry, without lubrication, the doctor said that

this is totally normal. Another change is also in sexual

desire, there was a decrease in sexual desire, I don't know

if it is because of surgery or depression (W12).

I thought, I won't be able to get pregnant any more, I had

already lost two children because of the bleeding, I was

sick every month, all year long [...] so I decided to have the

surgery. I feel weird during sexual intercourse for removing

such an important organ of my body (W16).

Women who underwent hysterectomy may suffer uncom-

fortable physical changes that interfere with quality of life. In

this context, some participants brought up issues such as

urinary incontinence and weight change after surgery. This

can be evidenced in the following report and on the speaking

map (Figure 5):

After I had my uterus removed, it looks like I will have to

urinate more, I can't hold the urine when I cough or need

to do a physical eort. To be quite honest, this has cooled

down, the sexual desire has decreased a lot, I don't know

why, but it has (W16).

After the surgery I felt I put on some weight, my body

shape changed, but this was the only change I noticed

(SPEAKER MAP, W15).

Figure 5. Speaker map produced by parcipant W15.

Source: Invesgaon data.

HEALTH CARE OF HYSTERECTOMIZED

WOMEN

The professional nurses, especially those who work in

primary health care, are responsible for providing guidance on this

surgery, explaining the possible changes that may happen in the

woman’s body and that these changes may adversely inuence

her relationships with her partners. However, the reality found from

the reports of the participants shows that this professional does

not carry out this educational process. This matter is sometimes

present in medical practice and associated with merely biological

questions.

I talked to the doctor and he said it was up to me, the head

was important, not the sexual part, because there are

women who are very inuential. He said that this will not

change the sex at all, I will continue the same way, if I didn't

have the desire before, it would continue the same (W5).

The nurse didn't inform me. Only the doctor explained

what he had done in the surgery. (W7).

No one said anything before the surgery, only after. The

doctor asked me if I had a boyfriend, maybe because I

couldn't have sex anymore (W8).

The person who talked to me was the doctor herself, not

the nurse; she did not explain to me about the surgery,

she actually sent me straight to the doctor, and the doctor

was the one who explained to me that it was not a simple

surgery, but everything would be alright because I already

have children, it was not for me to worry (W15).

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

I did not receive any guidance in this regard [...] I would

ask things straight to the doctor, I felt no shame or fear

to ask him: doctor will this happen to me? How will I be?

How will I feel? How will the sexual intercourse be? Then

he informed me about these questions, not the nurses

(W18).

Due to the lack or absence of guidance, by the nurse or the

doctor, women seek information from other sources, such as the

opinion of other women who have already undergone the same

procedure, as well as interviews or watching news on the televi-

sion, and one of the most used media is currently the internet.

At any time this was mentioned, I discovered that it could

aect sexuality, the sexual desire could change, but that

was it, I read about it, no one told me anything (W9).

I remember the doctor only said that it would stop

bleeding, that I wouldn't have my period anymore, but I

mean, only what I studied and browsed, not that anybody

has spoken to me (W11).

I always tried to inform myself and to investigate [...] what

I would feel, I sought testimonies from other women,

the taboo that women were cold and no longer good

for anything, so I studied this deeply and it didn't shake

me (W17).

Given the lack of information and broader guidelines

regarding hysterectomy, the study participants report their

expectations for improved care and assistance for women

undergoing gynecological surgery. For this, they emphasized

the importance of receiving guidelines about the surgery

during the appointment with the primary care nurse. They also

admitted that they needed a hospital-based and comprehensive

follow-up, reinforcing the emotional issue. They recommended

that professionals approach sexual matters and the need for

psychological counseling.

I think that from the moment the woman learns that she

needs surgery, she needs to talk to the nurse or the doctor

about what may or may not happen in the sex life [...] in

some cases, people get depressed and I think people

should see a psychologist during this period(W9).

I think they should try to comfort them, because there are

women who don't seek information, so when someone

says they have to undergo surgery, they already have a

thousand things going through their heads. I think there

should exist a trained person to inform, to follow up,

maybe to talk to our families, a nurse could come along

to inform and clarify the doubts (W17).

I think that before surgery you need a lot of advice from

the nurse, I think sex is a thing that the couple worries

about, so much so that nowadays I tell my friends that

everything is normal [...] after surgery women need the

see a psychologist because they won't get pregnant any

more (W18).

DISCUSSION

Sexuality should be understood as a multifaceted concept,

inter-related in social and cultural aspects experienced by each

individual throughout their trajectory and is revealed through

looks, caresses, expressions, attitudes, posture, and the human

behavior itself. Sex refers to biological characteristics that

distinguish men from women; on the other hand, sexuality goes

beyond the sexual act itself, such as sexual orientation, intimacy,

pleasure, reproduction, and other feelings involved.

The study participants’ understanding of the concept of

sexuality was strongly associated with the sexual act, emerging

from a cultural understanding about the subject and a narrow

view regarding its broad denition.

The eects of hysterectomy

on sexuality are complex and derive from several factors such

as physical, social, psychological, religious, cultural, and

educational factors, changing the woman’s perspective of herself

and her body, in which the uterus has a strong representation

of what is understood as feminine and fertile. The need for

hysterectomy can cause fear and doubt, especially when

sexuality is strongly associated with genitality.

Some of the participants revealed in their reports an

improvement during the sexual act after the hysterectomy.

This fact was also veried in a narrative review, which showed

improvement in most sexual disorders after hysterectomy caused

be benign uterine diseases, as well as in the sexual performance

of women with active sex life before the procedure.

According to a mixed approach study carried out in a

specialized service, female sexual performance and satisfaction

did not change after hysterectomy.

It also emphasizes that the

impact on the quality of sex life depends on several aspects that

surround sexuality as it is a complex and multifactorial area, which

changes over time and with the group women live with, in addition

to internal factors such as aectivity, cognition, and emotion.

The results of a survey conducted in Jordan with a sample

of 124 women who had benign disorders and underwent

hysterectomy indicated that their greatest concern was about

sexual performance.

Therefore, the authors found that there

was a signicant improvement in sexual function and in the health

of women undergoing this procedure. Hysterectomy eliminates

problems of bleeding, pain in sexual intercourse, and issues

related to contraception, which may contribute to a better quality

of life and sexual function.

Regarding the women’ reaction to the loss of the uterus, this

study reveals moments of distress and/or anxiety. They depend

on the intensity of the symptoms, the woman’ emotional state,

and the quality of the relationship with the partner.

Surveys

conducted with women who underwent hysterectomy showed

that the partners showed support during the procedure, which

conveys safety to the partner and proved to be a positive

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

experience that facilitated the experience of gynecological

surgery.

18,19

This opportunity, through gynecological surgery, to re-

evaluate feelings and attitudes within the marital relationship

may be associated with the quality of the couple’s relationship.

In addition, this reiterates that the value that the organ removed

has for women is historically based on social and cultural

constructions, which delimited roles and obligations inherent to

each sex.

Thus, female nature has as its main basis biological

facts that occur in the woman’s body, such as the ability

to generate, give birth, and breastfeed, as well as period.

Accordingly, it is understood that, in order for women to overcome

attributes that associate women’s sexuality only with being a

mother and reproduction, the partners’ support was important

in this study.

Regarding the diculties for experiencing sexuality after the

hysterectomy, some participants associated it with pain during the

sexual act and decreased sexual desire. The study indicates that

there was a decrease in sexual excitement and in the frequency of

sexual intercourses after the hysterectomy, and the symptoms of

depression after this procedure had an adversely eect on sexual

performance. In addition, it revealed the presence of dyspareunia

and decreased vaginal lubrication.

These data were also evidenced in a literature review,

which revealed that approximately 10 to 20% of the women

who underwent a hysterectomy experience some change in

sexual function, such as dyspareunia, change in orgasm and/or

less sex. Those women who undergo surgery for gynecological

malignancy have demonstrated deterioration in sexual function

related to decreased sexual desire and inadequate lubrication.

A research carried out in China with 125 women submitted to

radical hysterectomy showed that after the procedure there was

a high incidence of sexual dysfunction, which was stabilized after

two years.

Pursuant to this data, another study also stated that

there is a comparable improvement in sexual function after a long

period of the procedure.

Hysterectomy can be performed simultaneously with

bilateral oophorectomy.

Removal of the ovaries can cause

long- term adverse eects on sexual function and health, as

they are responsible for the release of hormones, such as

estrogen and androgen, which lead to more severe climacteric

symptoms and sexual changes.

One of the alternatives

would be hormone replacement in order to reduce complaints

of inadequate lubrication and dyspareunia; however, this may

not be a satisfactory choice when there is a concomitant

premenopausal.

As for the understanding of the need to have a uterus

playing its role of generating life, this idea remains and is

clearly imbricated in cultural aspects. Regarding this topic,

a study carried out in Norway corroborates the opinion of

some participants in the current research. Eight women, aged

between 25 and 43, were interviewed, with emphasis on their

experiences related to hysterectomy and the interaction that

this event can evoke. Participants emphasized the importance

of having a biological child, and removal of the uterus aected

this possibility.

Regarding the main morbidities after a radical hysterectomy,

it is highlighted the dysfunctions that aect the bladder, both by

the proximity of the uterus and the urinary tract, and by disturbing

structures such as autonomic innervations and blood supply after

removal of the cervix.

The study showed association between

hysterectomy and changes in the urinary, anorectal, and genital

systems.

The main dysfunctions that emerged as a result of the

surgery were genital prolapse, innervation of the pelvic viscera,

and changes in blood supply, which could lead to stress urinary

incontinence.

These changes in the body happen naturally throughout

life, but when subjected to hysterectomy surgery, it may reect

mainly in negative eects on the physical image, with diculties

in accepting this new body reality,

as experienced by some

participants in this study. It is considered that the understanding

and the experience that the woman has about her sexuality and

femininity before the surgery can somehow reect on the marital

relationship and the quality of life itself.

Regarding the health care of hysterectomized women,

sexuality is a subject that remains unspoken, sometimes ignored

and considered by several professionals as a delicate subject,

belonging to the private sphere, and this situation leads women

to feel uncomfortable talking about it.

Unfortunately, most

professionals do not encourage a discussion about this subject

before the procedure, nor even evaluate the woman’s perception

of her self-image,

that is, sexuality is not even seen or reected

by professionals as a possibility to act or provide care for women.

Moreover, the existence of cultural, personal barriers, low levels

of education, and the very shyness of professionals and women

interfere with the eectiveness of care.

Participants in another survey revealed that the search for

information on the subject occurred through conversations with

other women who had similar conditions.

However, after the

surgery, the same doubts remained and/or new questions were

raised regarding the procedure, and information received during

the preoperative period was unsatisfactory. In this sense, there

are questions regarding the recovery time and return to sexual

life, the care with the wound, and the need for annual cervical

cancer examination.

In this perspective, bonding is an important factor, for ex-

ample, in primary care services, so that the woman feels com-

fortable talking about sexuality with the health care practitioner,

especially when faced with the need for gynecological surgery.

Through the bond, the woman and her partner can clarify doubts

not only about surgery, but also about issues that permeate

motherhood and femininity, demystifying possible myths or beliefs

about sexuality.

For this, the nurse needs to know the individual

and sociocultural factors that surround the life of this woman, so

that the understanding on issues related to surgery and sexuality

can be understood in a singular way.

Escola Anna Nery 23(4) 2019

Sexuality of hysterectomized women

Schmidt A, Sehnem GD, Cardoso LS, Quadros JS, Ribeiro AC, Neves ET

Therefore, it is necessary to include in the educational

process of hysterectomy surgery, not only the woman, but also

her partner, due to the emotional support he provides, their

understanding about the importance of the procedure for the

health of the woman, as well as suppressing existing fears and

ruling out feelings of abandonment. It is essential that the couple

receives psychological support in the pre and postoperative

period so that they can adapt to the new reality and are able

to deal with any sexual complications, in order to improve the

couple’ sexual functioning according to their needs.

Women who undergo hysterectomy have female needs,

which include a support network that integrates the family, the

society, and healthcare practitioners. It is essential that services

on dierent levels with a multidisciplinary approach are prepared

to meet the demands of these women who experience dierent

confrontations, since, in most cases, they have concerns related

to physical and emotional issues.

CONCLUSION

The study showed that after the hysterectomy, women

had reected on the changes inuenced by the surgery in the

experience of sexuality and their relationships. Surgery resulted

on concrete issues, such as decreased or increased pain in

sexual intercourse, and subjective issues, such as the feeling

of freedom and the impact on female identity.

Some participants had an improvement in quality of life

after surgery and denied changes that interfered with sexual

intercourse. One of the reasons that inuenced women to choose

for the hysterectomy was the support they received from their

partner, precisely because of the fear of sexual dysfunctions after

the procedure. On the other hand, some participants associated

the physical loss of the uterus with the construction of the self-

image. They perceived a dierent body, a body marked by loss,

reecting on femininity and reducing sexual desire.

The role of nurses in primary health care, in the care of

women in the pre and post-hysterectomy period, has proved

to be fragile, especially regarding the approach to sexuality

and surgery-specic orientations. With the purpose of avoiding

aggravations and improving women’s quality of life, it is essential

that the nurses follow up these women in the context of health

care and meet their individual needs, especially when the

process involves such individual and important implications. In

addition, some women requested psychological support.

The research limitations are related to the difficulty in

approaching the subject, since, discussing the topic can

generate shyness and insecurity. It is important to reinforce the

need to carry out studies about the multidisciplinary care of

women who undergo gynecological surgery.

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