Evaluation of relationships, self-evaluation and self-esteem of women’s with histerectomy

Ilknur A.A.1 A-F *, Birsen A. 1 A,D,E,F , Busra A. 2 A,B,D-F

 

  1. Ondokuz Mayis University, Faculty of Health Sciences, Turkey

  2. Selcuk University, Faculty of Health Sciences, Turkey

 

___________________________________________________________________________

 

A- Conception and study design ; B - Collection of data; C - Data analysis; D - Writing the paper;

E- Review article; F - Approval of the final version of the article; G - Other

 ___________________________________________________________________________

 

 

ABSTRACT

__________________________________________________________________________________________

 

Purpose: To evaluate the marital relationships, the thoughts about femininity and sexual identity, and the self-evaluation and changes in the self-esteem of women having a hysterectomy operation, during the period of both before and after surgery.

Material and methods: This study was designed according to the principles of the comparative descriptive research carried out between 15 January 2013 – 15 June 2014 at Ondokuz Mayis University, Faculty of Medicine Clinic of Obstetrics and Gynaecology. The power sample size was determined to be 72. The research included 88 contactable women who were admitted to the clinic at the time of the research, who had agreed to participate in the study, and who lived in the province where the research was conducted (as the final tests were done via home visits). A questionnaire form, the Coopersmith Self Esteem Scale, and the Social Comparison Scale were used in the collection of the data. Descriptive statistics and x2 and Paired t tests were used in the data analysis.

Results: Changes in the self-esteem of women having a hysterectomy were examined before surgery, one week after surgery, and three months after surgery; while there weren’t any changes in self-esteem one week after surgery, a significant decrease in the women’s self-esteem was discovered three months after surgery (p<0.01).

Conclusion: It was discovered that a change in self-evaluation and self-esteem occurs after hysterectomy surgery in women.

Key words; hysterectomy, self-evaluation, self-esteem

__________________________________________________________________________________________

 

 

 

 

*Corresponding author:

Ilknur Aydin Avci

Ondokuz Mayis University, Faculty of Health Sciences

Samsun, Turkey

Tel.: +905052031286, e-mail: ilknura@omu.edu.tr

 

Received: 11.04.2016

Accepted: 14.07.2016

Progress in Health Sciences

Vol. 6(1) 2016 pp 7-13

© Medical University of Białystok, Poland

INTRODUCTION

 

The biggest negative impact of the medical and surgical treatment administered after diagnosing gynaecological cancer is on woman’s sexual health [1,2]. According to the World Health Organization, sexual health makes up the whole of an individual’s somatic, intellectual, mental, emotional and social aspects. Therefore, sexuality is a concept that goes far beyond having a sexual relationship, and it explains a lot more than just this. For most women, sexuality means complicated emotions, including their external appearance, their sense of femininity, and their ability to bear a child and to continue sexual functions. The diagnosis and treatment of gynaecological cancer adversely affect women’s sexual functions and sexual health [3,4].

A hysterectomy is one of the most significant surgeries performed on various genital system diseases with regard to the uterus, cervix, and ovaries; it involves simply removing the uterus. Since structural changes occur in the genital organs of patients who have undergone a surgical intervention, their reproductive and sexual functions are generally affected. Studies carried out on this subject show that sexual dysfunctions may vary between 20% and 100% [1,5]. Corney, Crowther and Everett (1993) indicated that sexual dysfunctions are common among women who have had a radical hysterectomy and vulvectomy operation, and this situation continues to be a chronic problem. A radical hysterectomy is a surgical operation which is generally performed in stages IB and IIA of cervical cancer, and results in the dysfunction of the uterus, ovaries, 1/3 upper part of the vagina, the parametrium, and the lymph node. Shortening of the vagina, dyspareunia, and postmenopausal problems such as a decrease in vaginal lubrication, sexual desire, and orgasmic ability are often encountered. A total abdominal hysterectomy with a bilateral salpingo-oophorectomy is a surgical operation which is frequently performed in endometrial carcinoma and other nonmalignant gynaecological cases. After this kind of operation, women have significant problems caused by surgical menopause, such as a decrease in vaginal elasticity and vaginal lubrication [4,6].

One study indicated that women’s sexual health is affected at a rate of 80% in gynaecological cancers2. The reason patients with a diagnosis of gynaecological cancer are much more affected sexually is that four substantial factors (body image, gender role (female/feminine identity), sexual functions, and reproductive ability) are affected by the disease. A problem in one of these areas affects the others [2,4].

Gynaecological cancers cause changes to an individual’s body depending on the disease and treatments, and the responses to these changes by the individual herself or her partner greatly affect the body image of the woman. Body image is a concept regarding how a person feels about himself/herself and his/her body.

Satir states that there is a strong link between body image and the self-esteem and gender identity of an individual. Every individual needs to feel himself/herself as being attractive as a sexual partner. The sexual self-image of a man or woman comprises factors such as feeling physically attractive, and meeting the sensual needs of his/her partner such as tenderness, kindness, and attentiveness. The experience of cancer, though, demolishes this self-confidence [7]. One of the main reasons that destroys a women’s body image in gynaecological cancers or other problems is surgery. Since the reproductive organs are one of the determinants of ‘being a woman,’ they play an important role in shaping the body image and self-esteem of a woman. Diseases in these organs, or their absence, can be interpreted as a loss of femininity, and a feeling of being imperfect or incomplete. After major operations such as a radical hysterectomy, most women experience different emotions such as the fear they will not appeal to their partners, their attractiveness will decrease as a sexual partner, or that their sex life will be ruined [4,7].

Another element of sexual health which is harmed is the role of gender (female/feminine identity). Fertility, motherhood, and the role of a wife are an important part of “feminine identity” as seen by society. Most women still define “being a woman” as being equivalent to “having a uterus” and “giving birth to a child.” Therefore, the loss of the uterus means the loss of femininity [8]. One of the negative effects of treatments such as a hysterectomy is on the roles of wife/partner and motherhood, which are the main elements making up the feminine identity.

A woman being treated for gynaecological cancer generally makes an effort to regain her feminine identity, values, priorities and her responsibility as a sexual partner. Furthermore, she struggles with what cancer treatments mean to a woman. During this period, cancer support organizations and counselling by experts play an important role in eliminating worries and anxiety [9].

The high levels of critical self-evaluation and body perception in women increases the rates of negative perceptions as a severe result of a hysterectomy, which in turn has a direct impact on their femininity and sexual identity. This subject has been discussed only in a limited way in the literature, and the effects of long-term changes have not yet been studied sufficiently. However, changes during the period of adaptation to the problem take place as a longer process. Therefore, the self-esteem and self-evaluation of women after a hysterectomy, as well as the changes in their relationships with their husbands will emerge at a later time. Thus, an evaluation of these changes will form an important data source for studies carried out in this area.

For this reason, this research has been carried out in order to evaluate the marital relationships, thoughts about femininity and sexual identity, self-evaluation, and changes in the self-esteem of women having a hysterectomy operation, during the period both before and after surgery.

 

MATERIALS AND METHODS

 

This study was designed according to the principles of comparative descriptive research and was carried out between 15 January 2013 – 15 June 2014 at Ondokuz Mayis University, Faculty of Medicine Clinic of Obstetrics and Gynaecology. The power sample size was determined to be 72. The research included 88 contactable women who were admitted to the clinic at the time of the research, who had agreed to participate in the study, and who lived in the province where the research was conducted (as the final tests were done via home visits).

 

Data Collecting Tools:

A questionnaire form, the Coopersmith Self Esteem Scale, and the Social Comparison Scale were used in the collection of the data.

 

Coopersmith Self-Esteem Scale

In this study, in order to determine the levels of self-esteem in adolescents, the “Coopersmith Self-EsteemScale (CSES),” developed by Coopersmith (1967) and translated into Turkish by Turan and Tufan (1987), is used. CSES consists of 25 “yes”or “no” statements. The statements included in the scale consist of phrases relevant to the person’s family relations, their outlook on life, an assesment of the person in question by his/her family members, and his/her perception of the environment. The scale items are rated either as 0 or 1, and the total score is multiplied by 4, making a total score which ranges from 0 to 100. High scores indicate a high level of self-esteem [10].

 

Social Comparison Scale

The Social Comparison Scale was developed by Gilbert, Allan and Trent (1992), and was adapted to the Turkish culture by Sahin, Durak Sahin and Sahin (1993). The scale assess an individual’s comparison of him/herself to others with respect to “rank and achievement” (inferior or competent), “social attractiveness” (likeable, reserved or left out) and perceived group

 

membership (different). The wording of the scale was simplified while retaining the original meaning of each item. The adapted versions of the constructs are: Worse than other people/better than other people, not as good at things/better at things, less friendly/more friendly, less shy/more shy, on your own/with other people, and different/the same. The meanings of the items were retained sufficiently to retain the intended achievement, social attractiveness and group-belonging dimensions.  The original scale form consists of 5 items. The adapted scale form consists of 18 items. Each item has both positive and negative sides, and is also rated on a six-point Likert scale. Higher scores were related to higher levels of positive self-evaluation [11].

 

Data Collecting

The data were collected before the patients had surgery, when the patients were discharged from hospital after surgery, as well as through visits to the patients’ houses 2 months after surgery. The data were collected via face-to-face interviews conducted by the researchers themselves.

 

Ethics

The women were informed about the study before the interviews, and the volunteers were included. Furthermore, written permission was taken from the institution where the research was conducted, and approval was received from Ondokuz Mayis University, the Clinical Research Ethics Committee (Decision Number; B.30.2.ODM.0.20.08/869).

 

Data Analysis:

Descriptive statistics, and x2 and Paired t tests were used in the data analysis.

 

RESULTS

 

Table 1 illustrates the distribution of women’s descriptive characteristics. It was discovered that 54.5% of women finished primary school, 94.3% of them do not work, 50% of them have expenses equal to their income, 85.2% of them are married, and 53.4% of them have three or more children. Furthermore, 39.8% of the women have a systemic disease, the most common being hypertension in the first rank (27.2%) and diabetes in the second rank (11.4%), and 35.2% of the women were diagnosed with myoma.

When it was analyzed how the women’s experiences of undergoing a hysterectomy affected their relationships with their husbands, the number of women during the preoperative period who though that the surgery would affect their marital relations, increased during the postoperative period (p<0.05).

 

Table 1. Descriptive features

 





Features

 

Sayı

%

Age

Mean ±SD=49.8 ±9.6 (Min=28, Max=80)

 

Educational status

Literate

31

35.2

Primary school

48

54.5

High School

9

10.2

Working status

Work

5

5.7

Not work

83

94.3

Income status

Expenses low from their income

37

42.0

Expenses equal to their income

44

50.0

Expenses high from their income

7

8.0

Marital status

Married

75

85.2

Widowed or separated

13

14.8

 

NumBer of child

Don’t have a child

8

9.1

1 child

10

11.4

2 children

23

26.1

Three and more children

24

53.4

Have a systemic disease status

Yes

35

39.8

No

53

60.2

Disease status

Diabetes mellitus

10

11.4

Hypertention

23

27.2

Goiter

1

1.1

Diagnose for operation

Cancer

20

22.7

Myoma

31

35.2

Cyst

23

26.2

Pelvic mass

14

15.9

Total

 

88

100.0

 

 

When it was analyzed how the women’s experiences of undergoing a hysterectomy affected their thoughts about themselves as women, the number of women during the preoperative period who thought that the surgery would affect some of the aspects of being a woman, increased during the postoperative period (p<0. 001). (Table 2).

When the women’s thoughts about the feeling of not menstruating were analyzed, it was discovered that more changes in the way they thought occurred after the surgery in comparison to the preoperative period (p<0.001).

When the women’s thoughts about the feeling of not being pregnant were analyzed, it was discovered that more changes in the way they thought occurred after the surgery in comparison to the preoperative period (p<0.001).

Changes in the self-evaluation of the women who had a hysterectomy were examined before surgery, one week after surgery, and three months after surgery, and it was confirmed that a significant decrease occurred in the women’s self-perceptions one week after surgery and three months after surgery.

Changes in the self-esteem of the women who had a hysterectomy were examined before surgery, one week after surgery, and three months after surgery; and while there were no changes in self-esteem one week after surgery, a significant decrease in the women’s self-esteem was discovered three months after surgery (p<0.01). Details are sown in table 3.

 

DISCUSSION

 

A hysterectomy is an operation which can considerably affect the lives of women and their perceptions about their sexual identity. This study was carried out in order to evaluate the changes in women’s thoughts about their marital relations, their femininity and sexual identity, their self-perceptions, and their self-esteem before and after the surgery.

At the end of the research, it was discovered that the number of the women who thought the surgery would affect their marital relations before surgery increased after surgery (p<0.05) (Table 2).

This is a significant result. While the women thought there wouldn’t be any changes in their lives with their husbands before surgery, this changed after surgery. This may result from their “I am like a man” evaluation when they expressed their opinions about themselves and their self-perceptions after surgery.

It was discovered that some of the women’s thoughts about “being a woman” were more intense after surgery (p<0.001). In particular, the thought “I am like a man” may be considered as significant damage caused by the surgery to the body image in terms of sexual identity. As a consequence, a change in body image and self-esteem will be an expected result. Wu et al. [12] stated that women preserve their femininity even if they do not have a uterus. In this research, similar to the study of Wu et al, 60.2% of women said that nothing would change after the operation [12].

 

Table 2. Ideas of participants deal with pre or post hysterectomy conflicts and sexuel life

 








 

Pre-operative

Post-operative

x2

p

N

%

N

%

Women’s experiences of undergoing a hysterectomy affect the relationship with their family

Affected

10

11.4

3

3.4

1.488

>0.05

Non-affected

78

88.6

85

96.6

Women’s experiences of undergoing a hysterectomy affect the relationship with their husbands

Affected

8

9.1

13

14.8

6.669

0.027

Non-affected

67

76.1

62

70.5

Women’s experiences of undergoing a hysterectomy affect their thoughts about themselves as a woman

I was a half-human

13

14.8

12

13.6

 

43.944

 

.000

I am like a man

12

13.6

19

21.6

Anxiety about not being pregnant

2

2.3

4

4.5

Nothing

61

69.3

53

60.2

Sexuel life

Affected

12

13.6

35

39.8

2.296

>0.05

Non- affected

63

71.6

40

45.5

Thoughts about the feeling of not menstruating

Unknown

17

19.3

3

3.4

 

 

69.657

 

 

.000

Happiness

10

11.4

9

10.2

Anxiety

17

19.3

25

28.4

Not change

40

45.5

49

55.7

Worried

4

4.5

2

2.3

Thoughts about the feeling of not being pregnant

Unknown

10

11.4

4

4.5

 

66.424

 

.000

Do not want a child

31

35.2

31

35.2

Not change

32

36.4

30

34.1

Worried

2

2.3

10

11.4

 

Changes in the self-evaluations of women who had a hysterectomy were examined before surgery, one week after surgery, and three months after surgery, and it was confirmed that a significant decrease occurred in the women’s self-perceptions one week after surgery and three months after surgery. This is an important result. The decrease in women’s self-evaluation is indicative of a negative attitude that individuals begin to have when evaluating themselves.

Indeed, it was suggested during the studies that psychosocial changes occurred in women, especially depression and anxiety disorders after the hysterectomy surgery [13-16]. Significant problems arise in self-evaluation in psychological disorders such as depression. Therefore, this result is quite significant. Cohen et al. examined psychosocial adaptation during the recovery period in their studies (2011) and it was ascertained that while there may be anxiety and depression in the earlier periods, a decrease in depression and anxiety was seen eight weeks after the surgery [17]. Unlike this study, a decrease in self-evaluation was identified in this research. Although the parameters measured were not the same, it can be said this result is different based on the fact that a decrease in self-evaluation occurs in depression. This may result from the fact that the studies were carried out in two different cultures, and thus some cultural factors may have an effect on psychosocial adaptation.

Changes in the self-esteem of women who had a hysterectomy were examined before surgery, one week after surgery, and three months after surgery; while there were no changes in self-esteem one week after surgery, a significant decrease in the women’s self-esteem was discovered three months after surgery (p<0.01). This is a significant result. This change in self-esteem can cause women to feel worthless, which is an aspect that must be considered carefully because it may result in a decrease in self-esteem and other psychological problems. In the study by Pınar et al. [18], it was ascertained that there was a decrease in women’s self-esteem after a hysterectomy. The study’s results are similar to the literature.

Table 3. Changes at self-evaluation and self- esteem of women at pre-operative, a week post-operative and third month post-operative (n=88)








Duration

self-evaluation

self- esteem

x

sd

p

x

sd

p

Pre-operative

58.8

9.4

.003*

.000**

 

65.2

13.7

.779*

.003**

At a week postoperative

56.5

10.3

65.5

14.4

At third month postoperative

49.8

10.6

60.7

16.5

*Comparison of status at a week post-operative with pre-operative status

** Comparison of status at third month post-operative with pre-operative status

 

 

CONCLUSION

 

As a result of this study, it was found out that a change in self-evaluation and self-esteem occurs after hysterectomy surgery in women. Concepts such as self-evaluation and self-esteem can yield results that may cause psychological problems such as anxiety and depression. Therefore, it can be suggested based on the results of this study that women who are having a hysterectomy should be given counselling in self-esteem, coping with stress, and adaptation to social life before their surgery. the disease, self-esteem, self-evaluation, and the social lives of those patients.

 

Study limitations

In this study the findings should be interpreted when considering the limitations of the study:

  • There are traditional, social, cultural, and economic differences between different communities.

  • The number of the patients within the scope of this study is low.

  • This limitation needs to be considered when interpreting the results of this study.

 

Relevance to clinical practice

As a result of this study, it is suggested that nurses and midwifery working in the field of gynecology, oncology, home care, and womens health consider self-esteem and self-evaluation levels in their treatment of women who are undrgoing a hysterectomy during both the pre- and postoperative period. Thus, counseling offered by health professionals may have a positive effect on

 

Conflicts of interest

None declared.

 

 

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