The study focuses on women who have undergone a hysterectomy in Mississippi without comprehensive informed consent law. While hysterectomy is one of the most complicated procedures that may result in serious damages to the reproductive systems as well as fatalities, most states, including Mississippi, have not instituted a comprehensive informed consent law. The comprehensive informed consent law is aimed at providing women with an opportunity to understand the available surgical procedures apart from hysterectomy. The study is critical in understanding the feelings and experiences of women who have undergone the surgical procedure without the comprehensive informed consent law, not only in Mississippi but also across various states in the United States.
Besides providing a brief summary of the research literature and describing the gap in knowledge on the concerned topic on the background, this chapter will state the research problem and provide a clear statement that connects the problem being addressed and the focus of the study. In addition, the chapter will state the research questions and discuss the theoretical or the conceptual framework on which the study is based.
Background of the Study
Hysterectomy is one of the major health problems facing women in the United States (Wu, Wechter, Geller, Nguyen & Visco, 2007). Studies indicate that about 40% of women globally would undergo hysterectomy at an average age of 64 years (Qamar-Ur-Nisa, Memon & Shaikh, 2011). In the United States, the average age of women who have undergone hysterectomy is 60 years (Wu et al., 2007). Further, studies indicate that about 25% of women in the United States have undergone the surgery due to reproductive complications such as severe vaginal bleeding, uterine fibroids and cervical cancer. In most cases, the main objective of hysterectomy is to relieve pain and enhance the quality of life (Marks & Shinberg, 2007).
While hysterectomy is not new, it is widely applied without a legal framework controlling the consent of women who undergo the procedure (McPherson, Herbert & Judgeetal, 2005). In particular, most states have not established comprehensive consent statutes that act as a cover against potential dangers of hysterectomy. Additionally, most states lack a policy framework aimed at offering women and physicians an increased opportunity to provide information and enhance the understanding of the dangers associated with the procedure (McPherson et al., 2005).
Recent studies that have been conducted focus on the dangers and consequences of the surgical procedure. However, few studies have been conducted on hysterectomy in relation to the legal framework controlling the consent of women who undergo the surgical procedure. Therefore, this study will fill the missing data on the study of hysterectomy as it relates to the lack of policy and comprehensive consent statutes that offer protection against potential dangers of the surgical procedure.
High mortality rates are normally associated with hysterectomy. In fact, studies indicate that about 120 in 1000 women who undergo the procedure die due to related complications (Butt, Jeffery & Van DerSpuy, 2012). As a result, hysterectomy should only be conducted in extreme cases such as uncontrollable vaginal bleeding, complications arising from childbirth, and severe uterine complications (Marks & Shinberg, 2007). Further, localized illnesses are the main cause of hysterectomy in the United States (Magon & Chauhan, 2012).
Despite incessant cases of hysterectomy, most states have not enacted consent laws aimed at providing protection against potential dangers of the surgical procedure. To that end, legal frameworks aimed at educating women concerning the potential risk of undergoing hysterectomy are lacking (Jianjun, Yan, Xiujing & Biru, 2013). Regardless of the increased number of women undergoing the surgery in Mississippi, the state is deficient of comprehensive informed consent law aimed at providing women with the opportunity to understand the alternatives that are available for hysterectomy.
Previous studies have focused on issues concerning the consequences of the surgical procedure. Also, the most recent studies indicated that the decisions of women undergoing the surgical procedure differ greatly between the states that have enacted the comprehensive informed consent statute and those that lack the law. Even though the study focuses on the case of Mississippi, the research will provide data that will be applied generally in all states that have not enacted the comprehensive informed consent law.
The Purpose of the Study
The study tends to explore the decision-making processes of women in Mississippi who have undergone hysterectomy in the absence of a comprehensive informed consent. In particular, the study aims to examine the attitudes and beliefs of women in Hinds County, Mississippi, who have undergone hysterectomy without any comprehensive law concerning their informed consent. Additionally, the study will identify the perceptions and new ideas emerging from the lived experiences of women who have undergone hysterectomy in the absence of comprehensive informed consent law.
The study will utilize the Health Belief Model (HBM) to explain the behavioral aspects of patients based on the principles of individual perceptions (Bellamy, 2004). In addition, the study will primarily apply the phenomenological approach, which is utilized extensively to gather more information concerning individual perceptions through qualitative research methods (Creswell, 2013). Since the main purpose of the study is to examine the beliefs and attitudes of women in Hinds County, the study will fully utilize interviews to gather the information. The interviews will focus on the participants’ personal experiences and detailed accounts of the occurrences of women who have undergone hysterectomy in the absence of comprehensive informed consent.
Upon completion of the study, the following questions will be answered
- What are the perceptions of women who have undergone hysterectomy without prior awareness of comprehensive informed consent law?
- What are the new themes that emerge from the lived experiences of women who have undergone hysterectomy in the absence of comprehensive informed consent law?
The Health Belief Model (HBM) guides this study. The theory is often applied to explain the behavioral aspects of patients based on the principles of individual perceptions (Bellamy, 2004). Initially, HBM was developed to provide explanations on the reasons for the failure of patients to participate in preventive care and treatments. Besides, HBM is one of the behavioral theories that have been widely applied in explaining the behaviors of an individual in relation to perceptions concerning personal vulnerability to infections. In addition, the theory is based on the principle of individual perception of personal health-related issues. The theory asserts that individuals make decisions based on the perceived medical care (Fredericks, 2013).
HBM is critical in explaining the experiences of women who have undergone hysterectomy in Mississippi by exploring how the absence of the comprehensive informed consent law affected the participants’ decisions to undergo the surgery. The HBM is useful in answering the research questions and uncovering new areas that relate to the common incidents the participants experienced.
Nature of the Study
This paper is a social health project that strives to understand the experiences of women who have undergone hysterectomy. Data will be collected using interviews as the main data collection technique. Information will come from members of different focus groups around Mississippi. Using a qualitative research approach, their responses this dissertation will sample their responses using a phenomenological research approach.
- Hysterectomy – A surgical procedure to remove the uterus
- Mortality – The state of being susceptible to death
- Cyst – a pocket of human tissue
- Antisepsis – A medical practice of using antiseptics to eliminate disease-causing mechanisms
- General Anesthesia – A medical treatment that puts patients into a deep sleep to help them avoid pain
This paper proposes to use interviews as the main data collection technique. Based on this research instrument, we assume that the respondents would answer the questions truthfully. Similarly, since this paper chooses a specific research sample, we assume that the sample would be representative of the views of women who have undergone hysterectomy in Mississippi. However, to overcome this assumption, the methodology of this paper chooses a random sampling technique to make sure that the sample chosen represents the desired demographic.
Scope and Delimitations
Delimitations of a study refer to issues that are within the researcher’s control. The geographical region covered by the study is a delimitation of this study. This study chooses to cover the experience of Mississippi women who have undergone hysterectomy. Another delimitation of the study is the selection of focus groups as the main reference point for gathering the experiences of women who have undergone hysterectomy. This strategy is attractive because women in focus groups tend to “open up” more about their experiences, as opposed to those that are not in such groups.
Study limitations refer to issues that are out of the researcher’s control. In this study, time is a significant limitation of this paper. Another limitation of the paper is the demographic of analysis. The study will mainly focus on sampling the views of Mississippi residents. Therefore, its findings may be limited in the same regard.
The findings of this study will contribute to existing academic knowledge regarding hysterectomy and the absence of informed consent when undergoing such procedures. Policymakers and health practitioners would also find this information useful in developing policies and procedures that guide this health process. This way, they will have a proper guiding framework for the development of informed consent law in Mississippi and around the country.
This chapter highlights the nature of the study and sets the tone for the rest of the dissertation. It shows that the study will explore the lived experiences of women who have undergone hysterectomy without informed consent. Its findings will be important in adding to existing literature about the research topic. Similarly, it will inform policymakers about the importance of informed consent law when undertaking the medical procedure.
This chapter evaluates previous research studies that have explored the intrigues surrounding women who have undergone hysterectomy without informed consent. It highlights key variables and concepts surrounding the medical procedure and the different ways that researchers have approached the issue. This way, it is easy to understand the major theoretical composition of the research issue and any major hypothesis that arise from the same.
Literature Search Strategy
Information included in this study has come from credible sources of secondary research. There has been a keen focus on sourcing information from books, journals, and credible websites. Some key data bases consulted include emerald insight and sage journals. Key search terms included “hysterectomy” and “informed consent.”
As highlighted in the first chapter of this paper, the HBM model outlines the main theoretical foundation of this paper. This framework guides the research process outlined in this paper by narrowing down our focus to behavioral responses and perceptual influences about hysterectomy. Researchers have used this theory (before) to investigate the behavioral patterns of patients, based on perceptual responses to policy and environmental issues.
Literature Review Related to Key Variables and Concepts
Hysterectomy has its origin in pre-historic times, with the first operation performed as early as 120 AD by Soranus in Greece (Sutton, 1997). One historian claimed that Themison of Athens performed a hysterectomy 50 years before Christ (Lameras, 1975 as cited in Sutton, 1997). Alsaharavius, a physician in the 11th century, made a commentary about a surgical excision of the uterus. Vaginal hysterectomies had been performed in the middle ages, as revealed by some medical writings (Sutton, 1997).
In 1809, Ephraim McDowell performed the first abdominal hysterectomy on Jane Todd Crawford, who had a massive ovarian cyst weighing 10.2 kilograms. It took McDowell 25 minutes to remove the left tube and the ovary, while outside his house townsfolk were building a gallows for him in case the patient would die. Five days later, Jane Todd was well and up in McDowell’s house and after 20 days, she went home to Greensburgh, Kentucky. At that time, surgeons operated without anesthesia, antisepsis or antibiotics, and the patient was allowed to recite the psalms to slightly ease the pain. McDowell performed 13 hysterectomies in the course of his practice, with only one death. It was an extraordinary feat considering that sepsis and peritonitis were complications after laparotomy (Sutton, 1997).
Charles Clay (as cited in Sutton, 1997) coined the word “ovariotomy.” On September 13, 1842, he removed a 17-pound, 5-ounce ovarian tumor, with the patient having a brandy and milk for analgesia. When anesthesia was discovered, Clay did not want to apply it for his patients as he considered it a distraction. He reasoned out that patients who had the courage to undergo surgery without anesthesia were imbued with a strong will to live. On January 3, 1863, Clay (1863) performed the first successful hysterectomy with oophorectomy and salpingo-oophorectomy (Sutton, 1997).
In 1853, Ellis Burnham successfully performed a subtotal hysterectomy and the patient survived. Another surgeon named Kimball (1855 as cited in Sutton, 1997) performed a deliberate but successful hysterectomy due to fibroid tumor. Chloroform as a form of anesthesia was used during the operation. Before this time, surgeons used opiates, which contained hyoscyamus and mandragora, mixed with alcohol to desensitize patients undergoing surgery. The nitrous oxide gas was introduced which could induce amusement and euphoria and reduce sensitivity to pain. In 1831, a combination of ether, nitrous oxide and chloroform was later used as anesthesia. Dentists used ether as dental anesthesia and it was Oliver Wendell Holmes who first coined the word anesthesia (Sutton, 1997).
Many women undergo hysterectomy for noncancerous illnesses and as a preemptive measure for ovarian cancer. Gynecological problems and cancer are the primary causes of hysterectomy (Sparić, Hudelist, Berisava, Gudović & Buzadzić, 2011). Many hysterectomy cases in the United States are result of localized sickness, which means the sickness does not spread to the uterus, and removal of the uterus is not necessary (Sparić et al., 2011).
About a quarter of women in the United States may have undergone hysterectomy when they have reached 60 years old, whereas in the United Kingdom, the ratio is one to five women (Marks & Shinberg, 2007). More than 90 percent of those surgeries were performed for benign tumors and symptoms for uterine fibroids, vaginal bleeding, and others which are non-life threatening (Wilcox et al., 2005). Gupta and Manyonda (2014) indicated that 40 percent of all women worldwide will have a hysterectomy when they reach 64 years old, with the primary objective of relieving pain and enhancing quality of life. With the introduction of alternative treatment, hysterectomy has become less prevalent in most countries (Forsgren & Altman, 2013).
There are still doubts surrounding hysterectomy and why women should undergo hysterectomy. Forsgren & Altman (2013) have asked these questions: Can hysterectomy provide the essential treatment for diseases in women’s reproductive organs? Should other less invasive treatment be considered first before a woman should undergo hysterectomy? How informed are women of the legal aspects of hysterectomy, particularly the subject of informed consent?
Women have to be informed on treatment options other than hysterectomy which has complications. A comprehensive informed consent law requires doctors who plan to perform hysterectomy on their patients to provide the necessary information and other treatment options. The benefits of informed consent law will allow women to decide before any treatment is performed. This information and knowledge of the law should be properly understood by women.
Hysterectomy is one of the most frequently used operative techniques among many gynecological procedures, but is significantly decreasing because there are alternative options and patients have reported some complications after hysterectomy (Darwish, Atlantis, & Mohamed-Taysir, 2014). Hysterectomy is more prevalent in the United States than in other Western countries, and studies have shown that people of color are more susceptible than Whites (Farquhar & Steiner, 2002). A longitudinal study found that more women who belonged to lower socio-economic class had undergone hysterectomy than those of the higher socio-economic status (Materia et al., 2005).
Knowledge about, and access to, other treatment may not be available in specific areas, which is one of the reasons why those who are of the lower socioeconomic status mostly undergo hysterectomy (Bower, Schreiner, Sternfeld, & Lewis, 2009). An example is what has occurred in the Mississippi Delta Region where women had to face poverty and unemployment. As a result of the prevailing situation, women also lacked education and experienced poor nutrition and not enough health care (Hall, Jamison, Coughlin, & Uhler, 2004). These factors could have resulted in lack of valuable information for women who might have undergone hysterectomies, and there was also dearth of knowledge on cancer screening and other health-care expenses (Hall et al., 2004).
Every year, approximately 600,000 American women undergo hysterectomy for non-cancerous causes (Harvard Women’s Health Watch, 2009; Perera et al., 2013). Hysterectomy cases in the United States are believed the highest on record among developed countries (Brett & Higgins, 2007). The Centers for Disease Control and Prevention (2014), reported that there were 5.4 hysterectomies for every 1,000 women annually during the period 2000 to 2004. However, hysterectomy rate is decreasing in the Scandinavian countries and in the United Kingdom (Schollmeyer et al., 2014).
Ovarian and uterine cancers are primary causes for hysterectomy (Singh, Ryerson, Wu, &Kaur, 2014). In a study on cervical cancer, researchers found that hysterectomy did not reduce the survival rate but provided comfort in the pelvic region (Keys et al., 1999). Moreover, some doctors performed hysterectomy on complaints of endometriosis, which can be treated with analgesic therapies and other non-invasive methods (Graaff et al., 2013).
A study on endometriosis and its effects on the quality of life revealed that this sickness impacted on impacted on women’s quality of life, particularly on their work, education and home and family life (Graaff et al., 2013). The effect of endometriosis on work was more pronounced with 51 percent of the participants saying that endometriosis significantly affected their work life. Endometriosis also affected the women’s relationships with their husbands, with some participants saying that their sickness caused divorce. The data collected in the study confirmed the negative effects of endometriosis on women’s quality of life (Graaff et al., 2013, p. 2682).
Fibroids and uterine myomas or leiomyomas are some of the common causes of menstrual bleeding. Approximately 30 percent of hysterectomies are caused by fibroids. Myomectomy is an alternative to hysterectomy in removing fibroids, but it requires a longer recovery period (Harvard Women’s Health Watch, 1998).
Meaning and Causes
Hysterectomy is a surgical method to treat gynecological problems with the aim of removing a part or the uterus. After hysterectomy, a woman experiences a menopausal period and will be unable to become pregnant (Parkinson-Hardman, 2007). Uterus removal eliminates uterine cancer and oophorectomy (removal of the ovary) eradicates the risk of ovarian cancer (Wong et al., 2011). Yeh et al. (2013) indicated that bilateral salpingo-oophorectomy (BSO) can reduce the risk of ovarian cancer − the reason why it is performed bilaterally with hysterectomies. While ovarian cancer can be avoided, oophorectomy increases risks of heart disease and lung cancer (Harvard Women’s Health Watch, 2009).
Cardiovascular risks may be higher due to reduced production of endogenous sex hormone (Yeh et al., 2013). A previous cohort study conducted by Ingelsson, Lundholm, Johansson, and Altman (2011 as cited in Yeh et al., 2013) supported evidence on the relation of hysterectomy and cardiovascular disease in women who were less than 45 years of age during operation.
Relation of HRT and CHD
There have been studies saying that hormone replacement therapy (HRT), which is prescribed for women who have undergone hysterectomy, causes coronary heart disease (CHD). However, there were studies reporting that HRT users did not have cardiovascular risks, while some studies showed that the effects of HRT were not clear and “over-estimated” (Matthews, Kuller, & Wing, 1996; Posthuma, Westendorp, & Vandenbrouche, 1994; Vandenbroucke, 1995 as cited in Lambert, Straton, Knuiman, & Bartholomew, 2003, p. 294).
Women with the uterus intact take prescribed estrogen and progestin as protection from cancer occurrence. HRT, which has a dose of progestin, can ease estrogen in controlling CHD, although there has been a reported little increase in CHD in women who take the combined dosage. The study of Lambert et al. (2003) provided inconclusive evidence that HRT caused CHD but the findings also stated that HRT was associated with hysterectomy. Women who use HRT have lower levels of systolic blood pressure and low cholesterol (Prior, Stanley, Smith, & Read, 1992).
Techniques and Types of Hysterectomies
Techniques in hysterectomy include open surgery performed through the vagina or a method using laparoscopy, and the most modern, which is robot-assisted operation (Tapper et al., 2014). Laparoscopic hysterectomy (LH) is usually applied in benign and malignant tumors. Vaginal hysterectomy is used in many cases while LH is usually performed in cancer cases (Tapper et al., 2014). LH can be performed vaginally accompanied by laparoscopic procedures or where there is no vaginal component. The American Gynecologic Laparoscopists issued a statement in 2010 that hysterectomies for benign cases should use vaginal or laparoscopic procedures because of the benefits on women (Gupta &Manyonda, 2014).
These benefits include lower costs effective, shorter hospital stay and quick recovery (Padial et al., 1992 and Liu, 1992 as cited in Weber & Lee, 1996). However, in a later study in Ohio by the same authors, they found that this method was associated with higher charges than the other two techniques of hysterectomy. In this same study, Weber and Lee (1996) found that the rate of hysterectomy in the state decreased between 1988 and 1994 due to the introduction and constant use of laparoscopically-assisted vaginal hysterectomy.
Complete hysterectomy aims for the uterus along with the cervix while partial hysterectomy does not aim for uterus removal. Supracervical hysterectomy is the removal of the body of the uterus and a portion of the cervix is sewn up to close. Supracervical is performed when complications during operation necessitates completing the required surgery as early as possible. However, supracervical hysterectomy should be planned for patients who are perceived to have higher perioperative complications (Jones, Shackelford, & Brame, 1999, p. 514).
Vaginal hysterectomy is surgery performed through the vagina wherein the surgeon conducts operation on the vaginal wall to be able to see the ligaments and tissues of the uterus, ovaries, and fallopian tubes (Sheth, 2013). These organs can be removed through the vagina (Thakar, Ayers, Clarkson, Stanton, &Manyonda, 2002). Findings in randomized trials have shown that “vaginal hysterectomy is the most beneficial hysterectomy procedure for women, as well as being the most cost-effective” (Benassi et al., 2003; Ayoubi et al., 2003; Ribeiro et al., 2003 as cited in Boosz et al., 2011, p. 269).
In total hysterectomy, the portion called the “top” of the vagina is closed, creating a “blind” pouch. In this case, intestines are placed (instead of the uterus) in the blind pouch created due to hysterectomy (Harvard Women’s Health Watch, 2009). Abdominal hysterectomy is performed when the woman has acquired an enlarged uterus and cancer has been diagnosed or suspected. This procedure takes a vertical incision, about 4” to 6”, along the pubic section and the navel (Harvard Women’s Health Watch, 2009).
With respect to morbidity and mortality, research found complications in 44 percent for abdominal and 27.3 percent for vaginal hysterectomies. A Cochrane study found fewer infections and rapid recovery attributed to vaginal and laparoscopic hysterectomies than abdominal hysterectomy (Gupta & Manyonda, 2014).
Hysterectomy is most necessary when pain cannot be controlled due primarily to fibroids, or pressure and severe bleeding. It can be applied to postmenopausal women who might have malignant tumors and for symptoms of endometriosis which cause pelvic pain, pain during intercourse, and when there is extreme bleeding (Harvard Women’s Health Watch, 2006). Hysterectomy is effective treatment for menometrorrhagia, leiomyoma, and symptoms associated with postmenopause (Altman, Granath, Cnattingius, & Falconer, 2007, p. 1494).
Women with no history of ovarian disease still have their ovaries and fallopian tubes left in place and even if they experience lapses of menstrual periods the ovaries will continue to produce hormones. However, when they undergo hysterectomies, they will occasionally cease from producing estrogen and experience the menopausal stage (Harvard Women’s Health Watch, 2009).
Complications in Hysterectomy
Hysterectomy can lead to psychological or mental problems but some studies have found that hysterectomy provided comfort to women and improved their quality of life. However, women should seek other options before undergoing hysterectomy (Harvard Women’s Health Watch, 2006). The doctor and the patient should have substantial discussion before proceeding and the doctor must observe the highest ethical standards of medical practice.
There are valid medical reasons for hysterectomy but there are as many valid reasons for not performing it, which means there are other options rather than immediately subjecting under the knife the woman’s reproductive region (Gimbel et al., 2003). Epidemiological studies showed that approximately 90 percent of hysterectomies were done for only benign surgical reasons (Darwish et al., 2014). Women who undergo this surgical procedure must be informed of the reasons why it has to be done, how it should be done, including other medical options and complications in later life. Patients have to think of it and give their consent only on life-threatening conditions (Harvard Women’s Health Watch, 2001).
Due to the results of the various studies, the medical profession has raised concerns over the long-term effects of hysterectomy. For example, there have been reported six complications for every 10,000 surgeries performed in the United States (Ruuskanen, Hippelainen, Sipola, & Manninen, 2010). Additionally, studies have found that women who had bilateral oophorectomy had a 17 percent risk of having heart disease and a 28 percent risk of succumbing to death due to complications. Lung cancer was also one of the complications (Harvard Women’s Health Watch, 2009).
Moreover, “hysterectomy with oophorectomy has been shown to accelerate menopause by 3-4 years,” which is caused by the disturbance of blood supply in the ovaries and “can have a deleterious effect on cognitive functions” (Phung et al., 2010, p. 44). Some studies also found that women who had undergone premenopausal bilateral oophorectomy showed signs of reduced cognitive functions, but those taking HRT reported improved cognitive functions. The reported dementia because of hysterectomy is still unexplored, but a longitudinal study of homozygous twins who had undergone hysterectomies showed symptoms of Alzheimer disease (Phung et al., 2010). Brown, Sawaya, Thom and Grady (2009) reported six deaths in 10,000 hysterectomies.
Some studies reported major complication in urinary incontinence (loss of control in urination) and bowel dysfunction, which occur in old age and affect women’s quality of life. However, the study of Forsgreen and Altman (2013) on a few randomized clinical trials focusing on the relation of hysterectomy and urinary incontinence provided inconclusive evidence. This is shown in Table 1.
|Study, country Participants Duration of Urinary incontinence |
Year follow-up symptoms
|Thakar, UK 279 1 Fewer symptoms in both groups |
|Gimbel, Denmark 319 1 Fewer symptoms after total abdominal |
|Learman, USA 135 2 Fewer symptoms in both groups |
Table 1. Randomized clinical trials on relation of hysterectomy and urinary incontinence.
Randomized clinical trials, shown in table 1, indicated that the studies had little evidence to offer because of the few cohort studies conducted. Despite this few evidence of cohort studies, Forsgreen and Altman (2013) still concluded that urinary incontinence and bowel dysfunction were complications for hysterectomies when women reached old age. Brown et al. (2009) supported this finding when they researched on urinary incontinence through Medline articles, using search words, and found that women who had hysterectomy were 40 percent higher in acquiring urinary incontinence at later life than women who had not undergone hysterectomy (Brown et al., 2009). Other complications included occasional fever, hemorrhage, and other life-threatening events (Brown et al., 2009).
Pelvic floor dysfunction is a common problem of women who are of the menopausal stage. Uterine problems can greatly affect women’s social lives, especially in this age of globalization where women have vast roles in society. Hysterectomy can relieve symptoms that have interfered in their daily activities. In the study by Kinnick and Leners (2005) wherein 40 percent of the participants had both ovaries removed, the hysterectomy experience of participants actually decreased their degree of depression.
Moreover, all the participants had “a very positive perception of their social support network both pre and post operatively” and the “quality of life experienced by the sample studied increased significantly post-hysterectomy” (Kinnick & Lenners, 2005, p. 141). Physical complications in hysterectomy include edema and swelling in both legs. Long-term physical effects include numbness, tingling, and limited movement of the legs (Hawighorst-Knapstein et al., 2004).
Another factor that affects women undergoing hysterectomies is inequities. Studies have found evidence of inequities for women which need to be addressed by healthcare professionals for a corresponding intervention. The team should determine the psychosocial drawbacks of hysterectomies and meet the psychological needs of women (Guler & Taskin, 2001).
There are cases that hysterectomy is necessary, such as the occurrence of postpartum hemorrhage (PPH), which is related to birth events threatening a mother’s life that affects her adjustment to motherhood (Beck 2004 as cited in Elmir, Schmied, Wilkes, & Jackson, 2012). Severe PPH is described as blood loss equivalent to about 1,000 milliliter right after giving birth until weeks postpartum (Department of Health New South Wales [NSW], 2005 as cited in Elmir et al., 2012, p. 1120). There are cases that PPH needs emergency hysterectomy to control the bleeding (Haynes et al., 2004 as cited in Elmir et al., 2012). PPH and subsequent hysterectomy are two difficult situations that a mother should be able to adjust to after giving birth (Haynes, Hodgson, Anderson, & Turnbull, 1977).
Elmir et al. (2012) conducted a study on perspectives of early mothering by describing their adjustment and recovery from an emergency hysterectomy after a severe PPH. During the recovery period, the mother may be separated from her baby, as she has to be admitted to the Intensive Care Unit (ICU) for observation and careful recovery (Fenwick et al., 2009 as cited in Elmir et al., 2012). During this time, the mother may experience guilt feelings, shame and failure. In Australia, the incidence of women admitted to ICU after birth is 1.84 to 2.6 percent of all pregnant women (Pollock, 2006 as cited in Elmir et al., p. 1120). UK has 0.9 percent of pregnant or postnatal women admitted to ICU (Elmir et al., p. 1120).
On the relation of hysterectomy and breast cancer rate, the study by Woolcott et al. (2009) found no relation between breast cancer rate and simple hysterectomy. However, the researchers found that risk factors for hysterectomy were also common risk factors for breast cancer. This meant the conditions were similar for both illnesses but there was no relation between hysterectomy and breast cancer (Brett & Madans, 2005).
An analysis of hysterectomy performed for benign disease was conducted at the Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Campus Kiel, Germany, in which the data were taken from hospital records. The causes for surgery included fibroids and precancerous abrasions of the uterus (Schollmeyer, et al., 2014, p. 45). The techniques used in the various operations included vaginal hysterectomy, abdominal hysterectomy, TLH, LSH, and laparoscopically assisted vaginal hysterectomy (LAVH). Only 766 patients qualified for the criteria of the study. The common cause for hysterectomy was uterine myoma, which accounted for 58.6 percent of the study. Vaginal hysterectomy was the common technique used for uterine prolapsed. In the study period, the researchers found no mortalities for hysterectomy for benign reasons but there were 52 (5.5 percent) cases, which had complications out of the total 953 operations. For the period 2007 to 2010, the numbers of abdominal hysterectomy and vaginal hysterectomy decreased due to the increase of laparoscopic hysterectomy (LH) and total laparoscopic hysterectomy (TLH).
Some studies found symptoms of psychological co-morbidity due to hysterectomy which can result into negative feelings about body image, sexual orientation, youth, energy and physical activities, and “loss of child-bearing capacity” (Darwish et al., 2014, p. 6). However, in conducting a meta-analysis of the different studies and articles on hysterectomy, Darwish et al. (2014, p. 14) found that hysterectomy performed for benign gynecological conditions was “not adversely associated with depression or anxiety outcomes.” Moreover, long-term studies suggested that women returned to their physical and psychological functioning after hysterectomy.
Darwish et al.’s (2014) study further found that hysterectomy, no matter what type and technique used, had improved the quality of life and psychological outcome of women. There was a reduction in the symptoms of depression and depression scores compared to the preoperative indications. This suggests that women usually felt comfort after the non-malignant indications were removed due to hysterectomy. Sexual pleasure, arousal and desire improved after hysterectomy, regardless of the surgical technique used (Darwish et al., 2014).
Impact of Hysterectomy on Women’s Lives
In other cases, hysterectomy creates psychological problems such as depression and low self-esteem, and negative outcome on patients’ social lives (Cohen, Hollingsworth, & Rubin, 1989; Bachman, 1990; Griffith-Kenny; Hugnagel, 1989 as cited in Kinnick&Leners, 2005).
Fleming (2003 as cited in Elmir et al., 2011) indicated that women feel intense pain right after hysterectomy. In a similar case, Linenberger and Cohen (2004 as cited in Elmir et al., 2011) studied 65 women, who had a mean age of 42 years, experiencing abdominal or vaginal hysterectomies. The researchers found that hysterectomies limited their physical activities while others felt the experience was worse than a caesarian operation. A caesarean operation accompanied with hysterectomy requires time to recover, as this may result into emotional, physical and psychological stresses (Kinnick&Leners, 1995; Fleming, 2003; Flory et al., 2005 as cited in Elmir et al., 2011).
Hysterectomy without ovary removal is a different case. Bachman (1990 as cited in Kinnick & Leners, 2005) argued that hysterectomy should not greatly affect women if the ovaries are not removed. However, quality of life should be considered when determining the effects of illness (Goodinson & Singleton, 1989 as cited in Kinnick & Leners, 2005).
Quality of life is linked with the individual’s sense of comfort and happiness in life. Studies in Taiwan and Turkey have found that women regard “the uterus as the symbol of femininity, sexuality, fertility, and maternity, and the loss of this organ is identified as the loss of womanhood because giving birth to a child is an important function for many women” (Pinar, Okdem, Dogan, Buyukgonenc, &Ayhan, 2012, p. E99). In the study on hysterectomized women, Pinar et al. (2012, p. E103) found that “hysterectomy had significant negative effects on patients’ body images, self-esteem, and marital adjustments.”
Some other studies showed that hysterectomies improved women’s quality of life. To answer the various concerns about the overuse of hysterectomy, scholars from the University of California at San Francisco conducted a study on hysterectomy and other treatment options and their impact on women’s quality of life. The study employed 63 participants, aged 30 to 50, who were suffering from excessive bleeding for four years. The women took synthetic progesterone treatment but this was unsuccessful. The researchers recommended hysterectomy to a group of participants and some to hormonal medication or birth control pills.
The researchers asked the participants of their opinion about quality of life, their physical and mental conditions, and their feeling after hysterectomy. After a period of six months, the participants who underwent hysterectomies reported reduced abnormal bleeding, and had improved sleep and quality of life, including overall health and wellbeing. Seventeen of the 32 members of the medication group opted to have hysterectomy and also reported improved well-being. But the participants who did not undergo hysterectomy also reported improvement in their quality of life (Harvard Women’s Health Watch, 2004).
Additionally, in a 2000 survey of hysterectomized women, the researchers found that respondent women reported improved sexual functioning (Obstetrics and Gynecology, 2000 as cited in Harvard Women’s Health Watch, 2007). A randomized survey in 2007 by “BJOG: An International Journal of Obstetrics and Gynecology” supported this finding, wherein respondents who had hysterectomy reported enhanced sexual functioning than they had before they underwent hysterectomy (Harvard Women’s Health Watch, 2007). In a report by the Maine Women’s Health Study, many women indicated that they were satisfied with the result of hysterectomy.
In a study on women aged 25 to 50 who had either hysterectomy or noninvasive treatments for benign tumors, fibroids, abnormal bleeding, and pain in the pelvic region, Dr. Karen Carlson of the Women’s Health Unit at Massachusetts General Hospital in Boston found positive perceptions of hysterectomy. The respondents reported that hysterectomy relieved their gynecologic problems and that their physical and mental health improved. A small percentage of the population indicated that they lost libido and had little sex enjoyment (Harvard Women’s Health Watch, 1994).
Women and Informed Consent Law
It is noteworthy to provide some actual cases of hysterectomy in this section to define the impact of this medical practice on women’s lives. Nora Coffey (2013) underwent surgery to get rid of a benign cyst but later found out that the doctor who operated her also removed the uterus and ovaries. It was a traumatic experience for this woman that led her to some unexplored activities as a woman and as a health activist later on. Coffey then founded a not-for-profit foundation known as the “Hysterectomy Educational Resources and Services Foundation” (HERS) to provide valuable information for women who might experience non-life threatening medical situations and the benefits of an informed consent law before they undergo hysterectomy (Coffey, 2013).
Another case involved a happily married woman who was rushed to a hospital for emergency appendectomy. During the operation, the surgeon found severe endometriosis. A gynecologist was asked to give an opinion and she concluded that the best option was to remove the fallopian tubes and the ovaries. It was found that the patient had a bilateral ovarian cystectomy for endometriosis in 1979 but was not informed that it would create a serious problem in the future. The patient was completely depressed to learn that she had lost her reproductive organs. She went into a depression and her marriage crumbled.
In 1992, her case was reopened upon the woman’s request, and the review stated that the gynecologist did not have a chance to talk to the patient. The endometriosis was so severe that the patient would not have a chance of natural conception and the cysts should be removed. The review also concluded that new consent forms should have a space in which patients can designate procedures which they do not wish to be done. According to Brahams (2009), women who awoke finding that they had lost their womb and reproductive organs considered their situation as if they were raped or went under “castration”. Brahams (2009, p. 361) recommended that there should be “a delayed procedure with renewed consent, albeit with the risks and inconveniences attached to a second operation.” In other words, the patient should have time to consult and think about her situation and all information should be provided.
The Sarah Lee Brown case
In 1981, a case involving Sarah Lee Brown and Dr. John Mladineo became the subject of a legal battle over medical malpractice. Instead of only the tumor to be removed, Dr. Mladineo made a complete hysterectomy on Ms. Brown. After a week of discharge from the hospital, Brown complained of excreting bodily waste by way of her vagina. When the doctor was informed of Brown’s complaint, he advised the patient to take a peculiar treatment – drink some vinegar.
Brown was admitted to the same hospital where Dr. Helen Barnes treated her for rectovaginal fistula, which was caused when Dr. Mladineo performed the surgery and accidentally created a canal in the rectum to the vagina (Justia US Law, 1987). This case should not have happened if there was an adequate informed consent law regulating surgeons before performing hysterectomy.
Comprehensive Informed Consent Law
During the days of slavery in America, black women were subjected to sterilization because they were deemed unworthy to provide offspring. This was known as the “Mississippi Appendectomy”. In the 1950s, black women were provided with contraceptives so that the black population would not grow (University of Maryland, n.d.).
It is a different environment today. A woman’s reproductive decisions are protected under the Fourteenth Amendment of the U.S. Constitution. Court decisions support the principle that reproduction is part of the “very core of human identity” and “reproductive choices are deemed protected rights belonging to the realms of individuality, privacy, and autonomy,” which should not be bypassed by any government agency or regulation (Laufer-Ukeles, 2011, p. 569).
Although Supreme Court jurisprudence states that the right to reproduce includes “the context of contraception, abortion, and the right not to undergo sterilization” (Skinner v. Oklahoma, 316 U.S. 535, 541, 1942 as cited in Laufer-Ukeles, 2011, p. 569), law scholars and practitioners contend that these rights should extend to the areas of “procreation and birth decision making as well” (Amy Cohen, 1992 as cited in Laufer-Ukeles, 2011, p. 569). Birth decision making and procreation are personal choices that are supported by public policy, husbands and wives’ testimonies on the meaning of such choices and the social consequences of those choices (May, 2004).
However, Laufer-Ukeles (2011) argued that reproductive choices are usually made with the influence of a doctor in the hospital, supported by government funding and legislative mistake. The state regulates and controls reproductive choice based on its policy of promoting “citizen health and societal values,” despite the constitutional provision that protects such choices (Laufer-Ukeles, 2011, p. 569). In a country which has a comprehensive informed consent law, a woman with problems in the reproductive organs is given options to choose. The doctor must explain the various reasons, but the woman must have the final choice.
Other states have passed their version of the law. North Carolina enacted the “Woman’s Right to Know Act” which provides that women should be provided necessary information before they decide to have an abortion (Stam, 2012, p. 4).
The traditional practice of hospitals is that when a patient is scheduled for surgery, she is made to sign a consent form. The form contains provisions where the surgeon is authorized to perform further surgery where the surgeon thinks necessary. In this case, there should be an open discussion with patient regarding those options that will come out during the surgery. The form should not be over-all consent. The patient can seek redress by asking police assistance or directly go to court (Brahams, 2009).
Alternatives to Hysterectomy
Complications in hysterectomy force some in the medical profession to perform alternative treatment and one of these is uterine artery embolization (UAE). According to a study, UAE provides symptomatic relief compared to hysterectomy (Ruuskanen, 2010). There have been positive findings of patient satisfaction for UAE, like shorter time of hospitalization, but the patient has to go through surgical intervention after a few years (Scutiero et al., 2013). UAE is also effective treatment for myoma (Dueholm, Langfeldt, Mafi, Eriksen, &Marinovskij, 2014).
There are other alternatives to hysterectomy provided by the medical profession. For menorrhagia, women are now aware of the other treatment options. Endometrial ablation, which targets the lining of the uterus, is simpler to perform with lesser complications than hysterectomy (Greenberg, 1983). The National Heavy Menstrual Bleeding Audit of the Royal College of Obstetricians and Gynecologists and the National Institute for Health and Clinical Excellence (NICE) have advised that women experiencing extreme menstrual bleeding should undergo “second generation ablative procedures” (Higham& Shaw, 1990, p. 211). NICE reported that ablation as alternative to hysterectomy can improve women’s quality of life. If it still failed, then the patient should be advised to undergo hysterectomy (Gupta &Manyonda, 2014).
A technical innovation that is gaining popularity is the use of uterine manipulator (UM) which is under the classification of minimally invasive hysterectomy (MIH). The doctor moves the uterus by way of the vagina, improving exposure in the pelvis and increasing “the distance between the ureter and the operative field” (Zhang et al., 2014, p. 212). One problem with MIH is when the UM disseminates cancer cells, although this is still a debatable one because of the lack of empirical studies regarding this issue.
The surgeon inserts the manipulator which increases intrauterine pressure when the balloon is inflated. This can enhance lymph vascular space invasion (LVSI) or enhance the passage of malignant cells through the fallopian tubes into the peritoneal cavity. Another problem with the UM is that it can disaggregate tumor cells (Zhang et al., 2014).
An alternative to hysterectomy for women with excessive menstrual bleeding (that is not due to cancer, fibroids, or endometriosis) is “the procedure called balloon ablation” which destroys the endometrium, or uterine lining, but does not involve uterus removal. The principle reflects that of the balloon angioplasty procedure, which also uses a “balloon” to open blocked coronary arteries. In balloon ablation, a balloon-tipped catheter is inserted into the vagina, passing through the cervix, and finally into the uterus.
A sterile solution is attached to the balloon so that it coincides with the shape of the uterus. Something is placed in the balloon to heat the fluid to 190 degrees Fahrenheit temperature. The heating process lasts for 8 minutes. The purpose of the heating process is to destroy the endometrial tissue that touches the balloon. The final stage consists of deflating the balloon, draining the fluid through the catheter, and removal of the catheter (Harvard Women’s Health Watch, 1996).
Reducing Variations in Surgery
Doctors can reduce variations in surgeries for ethical and economic reasons. Reducing variation can help a lot of patients and reduce mortality and unwarranted use of resources. Patients can have other choices if the surgery can offer no benefits. McCulloch and colleagues (2013) suggest that patient autonomy can reduce variation. However, reducing variations should be assessed by experts in the health profession who must have a broad and clear interpretation of the facts in a particular case. The doctors involved should conduct further investigation if a proposed hysterectomy case is clear with the patient or not. There should be good evidence to provide a surgical intervention that is effective for such a disease (McCulloch et al., 2013).
Causes of variation include “the need or value, the delivery system factors, local cultural beliefs (both public and professional), and the availability of robust, relevant, and casemix-adjusted data. The decision pathway to surgery can be modified in numerous and complex ways” (McCulloch et al., 2013, p. 1131). Medical reports have noted lower deaths and complications than few decades ago as a result of surgery (Polk, 2006).
Polk (2006) suggests that signs for operation are difficult to discern in surgical guidelines and many published material only point to patient care after the decision for operation has been made. Indications for hysterectomy have been much abused because these were not clear, which means hysterectomies were conducted without substantial reasons or causes why they should be performed (Carlson, Nichols, & Schiff, 1993).
Evidence about the benefits and risks of surgery is significant in the decision to reduce variations but it is not a decisive one. Variation for surgery can be provided if there is no treatment benefit or if there is no identification of best treatment. Some new techniques of surgical practice have been introduced but these are incomplete and slowly implemented, which means there is still lack of evidence for its success (McCulloch et al., 2013).
A Cochrane study on the effects of clinical decision making of passive distribution of review evidence showed that appropriate reduction in surgery rates can be accomplished with the distribution of a bulletin. Educational measures distributed to surgeons doing operations resulted in 9 percent fall in the operation rate. Additionally, shared decision making, which aims to give patients balanced information and a friendly atmosphere to give them the chance to choose the right treatment that fits their values and beliefs, is an ethical priority for the doctor and can reduce unwanted variation in surgery rates (McCulloch et al., 2013).
The Principle of Informed Consent
The principle of informed consent states that doctors and other health professionals should provide information on health risks and treatment options and get their consent to proposed medical procedures from their patients (Manian, 2009 as cited in Laufer-Ukeles, 2011). Women should be legally and humanely advised before undergoing hysterectomy. Without a consent law, it is possible that some physicians will not brief their patients about the complications.
Passage of a law means reducing threats or health risks and patients are protected from medical malpractice. A comprehensive informed consent law provides that doctors inform women of the parameters and consequences before they give their consent to undergo hysterectomy. Informed consent is provided to enhance “patient autonomy” (Laufer-Ukeles, 2011).
Mississippi women give their consent for surgical procedure without an informed consent law, which challenges their health and rights as women. With informed consent law, the doctor is mandated to provide information about all treatment options and effects of hysterectomy to a woman who is about to undergo hysterectomy. The doctor should provide all the information and the patient should be the last to decide with the assistance of the doctor. Laufer-Ukeles (2011) suggests that there should be a consensus between the doctor and the patient undergoing hysterectomy. With an informed consent law, the doctor is obliged to discuss with the patient on whether hysterectomy should be performed (Broder, Kanouse, Mittman, & Berstein, 2000).
Informed consent is a legal term that lays down the manner in which physicians or surgeons conduct treatment or surgeries on their patients. In the medical profession, physicians are obliged “to explain the nature of proposed medical treatment, its prognosis for treating the medical problem, its dangers, and alternatives to the proposed treatment” (Owens, 2009, p. 34). The law provides for fines and other punishments if physicians diverge from what they are supposed to observe under the law and ethical principles, based on people’s treasured worth of “autonomy” (Berg, Appelbaum, Lidz, & Parker, 2009). When a patient and surgeon enter into an agreement, they are governed with certain rules and ethical practice (Maclean, 2009). This is one ground why such a law should be passed in Mississippi.
The principles of medical law provide that autonomy and consent are related. The focus of informed consent is that the doctor should provide all information as this is important to the patient’s decision whether to have a hysterectomy or not (Maclean, 2009). Autonomy focuses on guiding where one is going, deciding where to go and in what activities to engage (May, 2002 as cited in Taylor, 2004). Beauchamp and Childress (2008) also supported the autonomy principle in the context of informed consent. Informed consent enhances the patient’s “freewill” (Taylor, 2004, p. 383). Autonomy also connotes treating an individual with informed consent (Varelius, 2007) as opposed to James Taylor’s contention that when a patient is being treated, the well-being of that person is the primary concern (Maclean, 2009).
Autonomy means the patient dictates her life’s direction. For a patient to be autonomous, specifically in her decision to undergo a medical treatment, the doctor should not stop her decision, or control her decision by selecting information about medical options.
Otherwise, the doctor would compromise the woman’s decision regarding her medical treatment. All information about other treatment options should be given to her. Healthcare professionals can refrain from taking over the patient’s autonomy by providing them with all information about the alternative courses of treatment that are at their disposal, including the advantages and disadvantages of those options (Taylor, 2004). Some medical scholars and researchers have recommended reducing variation in surgical procedures, which has ethical and economic effects on surgery rates. Patient autonomy can be elevated and she can choose to avoid it if there are no benefits to be derived from surgery (McCulloch et al., 2013).
Although attacked on both sides, the principle of informed consent has impacted the medical profession (Schneider, 2005 as cited in Laufer-Ukeles, 2011). The concept of providing necessary information and acquiring consent from the woman to be placed under the knife has become a benchmark for change from the traditional protectionist and patriarchal method of treatment and a benchmark for yearning of enhancing women’s rights. There may be shortcomings to this present trend but patients’ rights, hospital ethics, the need to provide appropriate medical information to patients, and the need to acquire patient’s consent are now ordinary procedures in medical institutions, hospitals, clinics, and doctors’ dealings with their patients (Laufer-Ukeles, 2011).
In North America, doctors performed some hysterectomies even if they were not necessary. Investigations were conducted in the United States and Canada, which found that there were unwarranted hysterectomies performed. The medical profession is not united on this medical procedure regarding the reasons for hysterectomies in women (Roos, 2007).
As mentioned, there are minor and serious complications in hysterectomy. The Hippocratic code on medical ethics states that the doctor will treat the patient according to his capability and knowledge but not to hurt or injure the patient (Hippocratic Corpus, 1923 as cited in Bhutta, 2004). Furthermore, if the patient can have a choice of another method of therapy, it is possible that the mode of therapy is less expensive than surgery (Taylor, 2004). The doctor has a big role to play in the woman’s decision, but the doctor can also influence the decision. This, however, depends on the provisions of the informed consent law.
Proponents of women’s autonomy argue that the woman has individual right, more valuable than the right of the fetus. They criticize and want to be free from government regulations and doctor’s intervention on reproductive issues because this comprised women’s autonomy (Laufer-Ukeles, 2011). Others argue that women’s autonomy is weakened because they are discriminated by men. With the principle of informed consent, any doctor who operates on a woman and removes something from the reproductive organ without the patient’s consent, commits an offense like physical injury or coercion (Laufer-Ukeles, 2011).
Patients’ consent is not the only thing necessary, rather, adequate information that can help in the patient’s promulgation of a logical decision should be provided by the doctor. Patients can also refuse any treatment indorsed by the doctor and the doctor can be unethical and may violate the law if he/she refused to provide information regarding the patient’s condition, including other options, risks, and complications because of the treatment (Laufer-Ukeles, 2011, p. 575).
Concerned organizations have provided guidelines, which include a case-to-case risk assessment based largely on the woman’s family history. Perera et al. (2013) conducted a study on women who underwent hysterectomy for the period from 2000 to 2010 and patients who underwent bilateral oophorectomy. The study identified 752,045 women who underwent hysterectomy wherein 403,073 patients had ovarian conservation while 348,972 underwent bilateral oophorectomy. The number of ovary removal has been controlled, particularly on women ages 45 to 49. This is shown in figure 3.
The study of Perera et al. (2013) suggests that ovarian conservation has been increasing. Procedural factors influenced this trend, such as the type of hysterectomy, which influenced the most for retaining the ovaries. Hospital characteristics influenced about 10 percent in the decision to conserve the ovaries, while 5 percent and 3 percent were attributed to patient decisions and physician characteristics, respectively (Perera et al., 2013).
The researchers noted the variation and group the participants according to age and for those who underwent vaginal hysterectomy or not. There were about 2,000 to 10,578 hospitals that admitted and subjected 68,022 women of this latter grouping. The percentage of ovarian conservation registered at 37.2 percent. The findings of the study suggested that the rate of ovarian conservation during hysterectomy for benign reasons for young women aged 50 years increased (Perera et al., 2013).
Hospitals across the United States have chosen to tread along the path of ethical practice by performing hysterectomy and bilateral oophorectomy only on extreme cases. The trend for ovarian conservation is influenced by data collected by hospitals regarding the relationship of oophorectomy and coronary heart disease and possibly mortality (Berek et al., 2010; Parker et al., 2009; Parker et al., 2005; Rocca et al., 2006 as cited in Perera et al., 2013).
A woman’s reproductive system is associated with gender identity. When this is removed by surgical means, the woman loses “the deepest sense of what one is” (Elson, 2002, p. 37). Medical sociologists argue that medical treatments like hysterectomies can affect people’s lives. When a woman undergoes hysterectomy, she loses one part of her identity as a woman and that is menstruation. Medical sociologists contend that “menstruation and female gender identity are strongly associated” (Elson, 2002, p. 38).
Martin (1992 as cited in Elson, 2002) found in a study that respondents described menstruation as something that defines a woman, and that it was like “a mark of womanhood”. Menstruation makes women different from men and they just would not like to give it up easily through hysterectomy. Menstrual periods provide “a symbolic and material bond between women” (McClintock, 1971 as cited in Elson, 2002, p. 38). Hysterectomy marks the end of a woman’s menstruation, which disturbs gender identity as this is closely related with womanhood (Angier, 1999; Martin, 1992 as cited in Elson, 2002).
Quality of Life (QoL)
The process of healing must be in several stages. Although painful as it may be, a woman who undergoes hysterectomy becomes a new individual. Healing stages must be experienced with care and positive attitude. The loss of one part must lead to the recovery of new life’s horizons. Long (2002) indicated that women who have undergone hysterectomy should develop a new way of looking at life and womanhood (Jung, 1958 as cited in Long, 2002).
Nursing care should be planned adequately to correspond to the various stages of the healing process. Specific nursing care should make the patient move from the stage where she was dependent through a stage where she becomes conscious, self-actualizing, and independent. The first stage should involve the patient to come out of isolation. Breaking free from hiding and numbness and accepting the innermost pains are significant movements that should be followed.
Second, the numbness must be resolved and transformed into feeling. According to Kora and Sato (1958 as cited in Long, 2002, p. 537), suffering is a part of life that sometimes cannot be avoided and acceptance of suffering is the best way to reduce the pain. Visits from a mental health nurse or a professional person who can provide meaningful counseling is essential. The next stage is releasing or emptying, which involves dealing with fear and accepting the reality of womanhood (Long, 2002, p. 537). Fox (1983 as cited in Long, 2002) provided the process of emptying in four vital steps:
- The patient must take hold of the pain like a pack of sticks to build a fire.
- The sticks have to be held in an embrace so that the person can move across the room to the fireplace.
- When reaching the fireplace, the individual can release the sticks and let them go.
- After all the steps, the individual feels warmed and happy from the sticks she has thrown out to the fire.
According to Long (2002), the individual who has undergone hysterectomy must embrace womanhood once again, after she has suffered from the medical event. Long (2002, p. 542) advised that one can accept the fact that suffering enables one to admire life, feel compassion for others of the same fate. A woman who chooses to undergo hysterectomy must learn to endure the pain because this can lead to an improved quality of life (QoL). QoL is multidisciplinary but its definition is not universal as it can be seen from different perspectives. Hysterectomy can lead to improved QoL if the woman knows how to deal with it, patiently and perseveringly. There are also several notions and concepts which are influenced by culture.
The World Health Organization classifies QoL into six broad areas: “physical, psychological, level of independence, social relationship, environment and spirituality, religion, or personal belies” (Bayram & Beji, 2010, p. 4). Each of these areas affects all the others while QoL covers the entirety and wholeness. The WHO definition highlights life’s goals, expectations, aims and anxieties of individuals as they go on and meet life’s sufferings. Health-related quality of life (HRQL) encompasses the person’s entire well-being. According to international experts, HRQL includes the physical, social, and emotional areas of a person’s functions, including awareness of a person’s quality of life and general life satisfaction (Bayram & Beji, 2010).
Positive and negative effects can be seen on women who undergo hysterectomy. With the loss of fertility, the woman may become anxious and afraid of the many personal issues surrounding her life and her relationships with the people around her, particularly her husband. Women complained of difficulties in uterine problems, to include physical and menstrual pain, emotional and sexual dysfunctions and the decline in general health.
Summary and Conclusion
This literature survey has explored the advantages and disadvantages in hysterectomy. The empirical studies provided the pros and cons and hysterectomies and the reasons why doctors recommend surgeries. The surgeon should provide the necessary information for the woman to choose what best suits their health. Like any other medical activity or event, doctors have varying views. There were patients who reported of improved life while others had negative feelings about hysterectomy. In other words, the subject needs more empirical studies to substantiate what is in the literature. The presence of informed consent law can also affect the outcomes.
This study will use a theoretical framework known as the Health Belief Model (HBM) to determine problems of behavior. Researchers use HBM to understand and predict how patients apply health prevention and services. HBM begins with a hypothesis that actions pertaining to health are influenced by factors like: the presence of adequate motivation to make problems of health significant; the idea that a person is at risk to a health issue or as a consequence of that health problem, or there is the perception of a health threat; and the belief that observing a doctor’s or a health worker’s recommendation would reduce the health issue at lesser costs.
Authors argue that HBM is linked with social cognitive theory (SCT) (Rosenstock, Strecher, & Becker, 1988). Rosenstock (1974 as cited in King, Singh, Bernard, Merianos, & Vidourek, 2012, p. 194) further expounds on the concept of HBM elements, such as “perceived benefits, perceived barriers, and cues to action.” Individuals exhibit certain behaviors when they feel that:
- benefits are derived in exhibiting the behavior,
- the benefits are greater than the barriers in displaying such behavior, and
- there are clues reminding them to display such behavior (Rosenstock, 1974 as cited in King et al., 2012).
This concept was later modified and combined with Howard’s (1989) model: individuals need a stimulant to enhance their decision-making process, or they need to be motivated with what is known as environmental cue (Howard, 1989 as cited in Risker, 1996). The combination of Howard’s (1989) model and HBM provides explanation of patient behavior relative to the subject of health services. The model further explores that when individuals look for information about their health, the motivation relies on how confident they are in understanding and providing excellent choice with regards their health. Self-belief and experience of an exact choice are relevant when the individual seeks information about availability of health service (Risker, 1996).
Rosenstock (1974 as cited in King et al., 2012) explained that for individuals to take action to avoid sickness, they have to believe that
- they are vulnerable to the disease;
- the disease can inflict a severe impact on some part of their lives;
- certain behaviors can reduce the severity of the disease whenever the disease inflicts upon them; and
- these behaviors cannot be hindered by aspects like expenses, pain, and humiliation, or the perceived barriers.
HBM has a predictive ability and we can expand this to include the concept of self-efficacy, which is the perception or belief in how competent an individual in possessing certain behavior (Bandura, 1977 as cited in Lin, Simoni, & Zemon, 2005).
HBM constructs assert that individuals make decisions based on their beliefs and perceptions. The individuals’ actions relate to surgeries, preventive care, and other form of treatment (Bellamy, 2004). HBM can provide explanation on theories regarding the experiences and treatment responses/reactions of Mississippi women who have undergone or will undergo hysterectomies. Some questions that need responses in this instance are: Does the absence of informed consent law affect Mississippi women’s decisions to undergo hysterectomies? Are the women well informed about the causes and complications of hysterectomy? What are the advantages and disadvantages of having informed consent law for Mississippi women?
This chapter of the dissertation explains the expected methods for conducting the research. Here, this section of the paper explains the data collection method, data analysis method, research design, research approach, and research strategy. Lastly, this section of the paper also explores the ethical considerations of the research.
Research Design and Rationale
The research questions for this paper were:
- What are the perceptions of women who have undergone hysterectomy without prior awareness of comprehensive informed consent law?
- What are the new themes that emerge from the lived experiences of women who have undergone hysterectomy in the absence of comprehensive informed consent law?
The central concept of this paper is to understand the influence of informed consent in shaping the lived experiences of women who have undergone hysterectomies. The research tradition for investigating this central concept is to use a qualitative approach for sampling the views of the respondents. The rationale for doing so is that the qualitative approach best samples people’s attitudes and perceptions.
Role of the Researcher
My role as a researcher is to interview the respondents and investigate emerging themes and patterns from their responses. There are no prior relationships between the researcher and the respondents.
Participant Selection logic
Eight respondents will take part in the study by outlining the respondent group. They will come from support groups around Hinds County, Mississippi. There will be no bias in selecting the respondents because the study will use a random sampling method to choose them. The questions posed during the interviews will be qualitative in nature (in line with the research strategy). They will have a non-directive structure, thereby allowing the interviewees to give whatever type of response they wish.
However, the researcher will encourage the respondents to give their full experiences regarding the research topic (no holding back). This attempt will also urge them to express their feelings, thoughts, sensations, memories (and such like attributes) that may explain their views on the research topic. More specifically, the researcher will encourage the respondents to give their lived experiences about hysterectomies. The researcher will also seek clarification in instances when there are unclear responses.
Seidman (2012) says that all researchers should adopt prudent ways of collecting data. Particularly, he draws our attention to data collection methods that give respondents the freedom to express themselves (Seidman, 2012). The main data collection method for this study is the interview method. The main disadvantage associated with using this data collection method is the time and cost of conducting them (Seidman, 2012). Travelling costs and the time for booking appointments are the main hurdles in this regard. Furthermore, there is a risk associated with the respondents giving false information, or the participants adopting a “group ideology” (since the study will interview a focus group) (Seidman, 2012). To mitigate this problem, the researcher will conduct isolated interviews for every respondent.
For Published Data Collection Instruments
Long, White, Friedman, & Brazeal (2000) evaluated different research strategies and said the choice between qualitative and quantitative research strategies depends on the nature of the research topic and its underlying knowledge. Furthermore, the researchers said the methods for knowledge construction and our understanding of reality should further inform the research strategy (Long et al., 2000). This paper considered these factors when choosing the qualitative research strategy. Furthermore, since the research involves “social” issues, the qualitative research approach would help to develop further hypothesis for testing.
For Researcher Developed Instruments
Bound (2011) says the qualitative research strategy has several types of designs. They include “inquiry, narrative, phenomenological, participatory action, grounded theory, ethnography, and case study” designs (Bound, 2011, p. 1). The proposed study will use the phenomenological research design. This design is right for this paper because it focuses on people’s experiences and life conditions (Martyn, 2010; Hague, 2004). Furthermore, it provides researchers with an opportunity to measure the perceptions of those experiences. This way, the phenomenological design will help to distinguish different phenomena (from the respondents’ views) and noumena (how we construct reality) (Bryman & Bell, 2007).
This research design also merges with the main data collection method (interview) because it interprets facts, depending on people’s assertions. This way, the participants’ subjective opinions provide the framework for forming the research findings. Through this understanding, Bound (2011) says, “Phenomenology (is) focused on the subjectivity of reality, continually pointing out the need to understand how humans view themselves and the world around them” (p. 1). The main drawback of using the phenomenological research design is the difficulty of preventing researcher bias. Furthermore, since this research design mainly depends on subjective data, it is difficult to guarantee the validity and reliability of the findings obtained (Martyn, 2010).
Procedures for Recruitment, Participation and Data Collection
Besides factoring in the interview responses given by the research participants, this study merges theory and data. The theory part would mainly come from the findings obtained from other researchers. Amalgamating these findings with raw interview responses would highlight the need to include deductive and inductive approaches in the study. Since interviews outline the main data collection technique, an inductive approach would suffice.
This paper chooses the inductive research approach because it can condense raw data into easily comprehensible summaries (Nargundkar, 2003). Furthermore, this research approach easily establishes the link between the raw data obtained from the interviews and the research objectives. From this process, it is easy to develop a framework for understanding all the different sets of raw data obtained from the interviews (Panneerselvam, 2004). Based on the above competencies, Thomas (2006) says, “The general inductive approach provides an easily used and systematic set of procedures for analyzing qualitative data that can produce reliable and valid findings” (p. 237).
Some researchers have criticized the inductive research approach for failing to provide a strong analytical focus for theory, or model, development (Panneerselvam, 2004; Nargundkar, 2003). However, this study uses it because it provides a simple evaluation of direct interview questions. Indeed, as Panneerselvam (2004) and Nargundkar (2003) say, many researchers find the inductive approach easier to use than other data analysis methods.
Data Analysis Plan
Waters (2014) says that the best data analysis method should resonate with the nature of the data collected. This chapter has already shown that the interview method is the main data collection technique. This paper will use the thematic data analysis method as the main data analysis tool. It works by picking out unique themes from the responses given by the research participants (Waters, 2014). To do so, the themes will represent essential experiences of the respondents.
Collectively, these themes would represent abstract concepts of the research questions. Waters (2014) says there are two types of themes that would emerge in such kinds of analyses. The first type is the collective theme, which represents unique concepts that represent the views of two, or more, people. The second one is the individual theme, which only applies to the views of one respondent (Waters, 2014). Both categories would outline the data analysis method.
Issues of Trustworthiness
Since this study uses human subjects, trust issues are bound to emerge. To gain the researchers’ trust, there will be no mention of the researchers’ names or personal contacts. All the participants will take part in the research anonymously. This requirement is important because the research involves investigating the lives of women who have undergone hysterectomies. Some of them would like to keep this information private. Lastly, the study will make sure that the respondents understand that the proposed study will not expose their personal information because it aims to meet academic goals only.
Before conducting the interviews, the researcher will make sure the research participants take part in the study, voluntarily. Therefore, there will be no bribery, payment, or deception.
This chapter describes the methodology for the dissertation. The qualitative research approach will mainly guide the process of data collection and analysis. It describes the research design, instrumentation, and data analysis procedures. Since human subjects will provide information for the study, there will be a keen emphasis on observing all ethical considerations related to their involvement in research.
Altman, D., Granath, F., Cnattingius, S., & Falconer, C. (2007). Hysterectomy and risk of stress-urinary-incontinence surgery: Nationwide cohort study. The Lancet, 370(1), 1494-1499.
Bayram, G. &Beji, N. (2010).Psychosexual adaptation and quality of life after hysterectomy.Sex Disability, 28(1), 3-13. Web.
Beauchamp, T. L. & Childress, J. F. (2008). The principles of biomedical ethics. New York: Oxford University Press.
Bellamy, R. (2004). An introduction to patient education: theory and practice. Medical Teacher, 6(4), 359-365.
Berg, J., Appelbaum, P., Lidz, C., & Parker, L. (2009). Informed consent: Legal theory and clinical practice (2nd ed.). New York: Oxford University Press.
Bhutta, Z. A. (2004). Beyond informed consent. Bulletin of the World Health Organization, 82(10), 771-777.
Boosz, A., Lermann, J., Mehlhorn, G., Loehberg, C., Renner, S., Thiel, F.,…Mueller, A. (2011). Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH).European Journal of Obstetrics & Gynecology and Reproductive Biology, 158(1), 269-273. Web.
Bound, M. (2011). Qualitative Method of Research: Phenomenological. Web.
Bower, J., Schreiner, P., Sternfeld, B., & Lewis, C. (2009).Black-white differences in hysterectomy prevalence.The CARDIA study.American Journal of Public Health, 99(2), 300-307.
Brahams, D. (2009). Unwanted hysterectomies.The Lancet, 342(8867), 361.
Brett, K. & Higgins, J. (2007). Hysterectomy prevalence by Hispanic ethnicity: Evidence from a national survey. American Journal of Public Health, 93(2), 307-312.
Brett, K. &Madans, J. (2005). Hysterectomy use: The correspondence between self-reports and hospital records. American Journal of Public Health, 84(10), 1653-1655.
Broder, M. Kanouse, D., Mittman, B., &Berstein, S. (2000). The appropriateness of recommendations for hysterectomy.Obstetrics and Gynecology, 95(2), 199-205.
Brown, J., Sawaya, G., Thom, D., & Grady, D. (2009). Hysterectomy and urinary incontinence: A systematic review. The Lancet, 356(1), 535-539.
Bryman, A., & Bell, E. (2007). Business research methods. New York, NY: Oxford University Press.
Butt, J. L., Jeffery, S. T. & Van DerSpuy, Z. M. (2012). An audit of indications and complications associated with elective hysterectomy at a public service hospital in South Africa. International Journal of Gynaecology and Obstetrics, 116(2), 112–116.
Carlson, K., Nichols, d., & Schiff, I. (1993).Indications for hysterectomy.New England Journal of Medicine, 328(43), 856-60.
Cofey, N. (2013). Hysterectomy: Hands off my uterus.
Darwish, M., Atlantis, E., Mohamed-Taysir, T. (2014). Psychological outcomes after hysterectomy for benign conditions: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 174(1), 5-19. Web.
Dueholm, M., Langfeldt, S., Mafi, H., Eriksen, G., &Marinovskij, E. (2014). Re-intervention after uterine leiomyoma embolisation is related to incomplete infarction and presence of submucousleiomyomas. European Journal of Obstetrics & Gynecology and Reproductive Biology, 178, 100-106.
Editorial staff and contributors. (2014). Hesterectomy – open surgery (Surgical removal of the uterus [or womb]; abdominal hysterectomy; vaginal hysterectomy). Consumer Health Complete.
Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2012). Separation, failure and temporary relinquishment: Women’s experiences of early mothering in the context of emergency hysterectomy. Journal of Clinical Nursing, 21(2), 1119-1127. Web.
Elson, J. (2002). Menarche, menstruation, and gender identity: Retrospective accounts from women who have undergone premenopausal hysterectomy. Sex Roles, 46(1/2), 37-48.
Farquhar, C. & Steiner, C. (2002). Hysterectomy rates in the United States 1990-1997. Obstetrics and Gynecology 2002, 99(1), 229-234.
Forsgren, C. & Altman, D. (2013). Long-term effects of hysterectomy: A focus on the aging patient. Aging Health, 9(2), 179-187. Web.
Gimbel, H. Zobbe, V., Andersen, B., Filtenborg, T., Gluud, C., & Tabor, A. (2003).Randomised controlled trial of total compared with subtotal hysterectomy with one-year follow up results. British Journal in Obstetrics and Gynaecology, 110(21), 1088-1098.
Graaff, A., D’Hooghe, T., Dunselman, G., Dirksen, C., Hummelshoj, L., WERF EndoCost Consortium, &Simoens, S. (2013). The significant effect of endometriosis on physical, mental and social wellbeing: Results from an international cross-sectional survey. Human Reproduction, 28(10), 2677-2685. Web.
Greenberg, J. (1983). The meaning of menorrhagia: An investigation into the association between the complaint of menorrhagia and depression. Journal of Psychosomatic Research, 17(1), 209-214.
Guler, H., &Taskin, L. (2001).The effect of planned education on coping with problems in post-hysterectomy period.Journal of Cumhuriyet University School of Nursing, 5, 9–18.
Gupta, S. &Manyonda, I. (20 14).Hysterectomy for benign gynaeological disease.Obstetrics, Gynaecology and Reproductive Medicine, 14(5), 135-140.
Hague, P. N. (2004). Market Research in Practice: A Guide to the Basics. London, UK: Kogan Page.
Hall, H., Jamison, P., Coughlin, S., &Uhler, R. (2004).Breast and cervical cancer screening among Mississippi Delta women.Journal of Health Care for the Poor and Underserved, 15(3), 375-389.
Harvard Women’s Health Watch. (1994). For many, happiness is a hysterectomy. Harvard Women’s Health Watch, 1(11).
Harvard Women’s Health Watch. (1996). Hysterectomy alternative.Harvard Women’s Health Watch, 3(11).
Harvard Women’s Health Watch. (1998). Treating fibroids. Harvard Women’s Health Watch, 5(8).
Harvard Women’s Health Watch. (2001). Alternatives to hysterectomy.Harvard Women’s Health Watch, 4(2) 5-7.
Harvard Women’s Health Watch. (2004). Hysterectomy vs. medication for abnormal uterine bleeding.Harvard Women’s Health Watch, 1(1), 7-8.
Harvard Women’s Health Watch. (2007). Alternatives to hysterectomy.Harvard Women’s Health Watch, 4(2), 1-2.
Harvard Women’s Health Watch. (2009). Routine ovary removal during hysterectomy ill-advised for most women.In the Journals, 1(1), 7-7.
Hawighorst-Knapstein, S., Fusshoeller, C., Franz, C., Trautman, K., Schmidt, M., Pilch, H.,…Vaupel, P. (2004). The impact of treatment for genital cancer on quality of life and body image—Results of a prospective longitudinal 10-year study. Gynecologic Oncology, 94, 398–403. Web.
Haynes, P., Hodgson, H., Anderson, A., & Turnbull, A. (1977).Measurement of menstrual blood loss in patients complaining of menorrhagia.British Journal of Obstetrics and Gynaecology, 84(3), 763-768.
Higham, J. & Shaw, R. (1990).Measured menstrual blood losses – normal population and ‘menorrhagic’ patients.In R. Shaw (Ed.), Dysfunctional uterine bleeding: Advances in reproductive endocrinology, (pp. 195-218).Carnforth: Parthenon Publishing Group, Inc.
Jones, D. E., Shackelford, P. &Brame, R. (1999). Supracervical hysterectomy: Back to the future? American Journal of Obstetrics and Gynecology, 180(3), 513-515.
Justia US Law: Brown v. Mladineo. (1987).
Keys, H., Bundy, B., Stehman, F., Muderspach, L., Chafe, W., Suggs, C.,…Walker, J. (2005). Cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage IB cervical carcinoma. The New England Journal of Medicine, 340(15), 1154-1161.
King, K., Singh, M., Bernard, A., Merianos, A., &Vidourek, R. (2012). Employing the health belief model to examine stress management among college students.American Journal of Health Studies, 27(4), 192-203.
Kinnick, V. G. &Leners, D. W. (2005). Impact of hysterectomies on women’s lives: A prospective study. Journal of Women & Aging, 7(1-2), 133-144.
Lambert, L., Straton, J., Knuiman, M., & Bartholomew, H. (2003).Health status of users of hormone replacement therapy by hysterectomy status in Western Australia.Journal of Epidemiology and Community Health, 57(4), 294-300.
Laufer-Ukeles, P. (2011). Reproductive choices and informed consent: Fetal interests, women’s identity, and relational autonomy. American Journal of Law & Medicine, 37(4), 567-623.
Lin, P., Simoni, J., & Zemon, V. (2005). The health belief model, sexual behaviors, and HIV risk among Taiwanese immigrants. AIDS Education and Prevention, 17(5), 469-483.
Long, A. (2002).The healing process, the road to recovery and positive mental health.Journal of Psychiatric and Mental Health Nursing, 5(1), 535-543.
Long, R. G., White C. M., Friedman W. H., & Brazeal D. V. (2000). The Qualitative versus Quantitative research debate: A question of metaphorical assumptions. International Journal of Value-based Management, 13(1), 189-197.
Maclean, A. (2009). Autonomy, informed consent and medical law: A relational challenge. New York: Cambridge University Press.
Magon, N. & Chauhan, M. (2012). Editoreal. Sutotal hysterectomy: Has it come a full circle? International Journal of Clinical Cases and Investigations, 4(1), 1–4.
Marks, N. &Shinberg, D. (2007). Socioeconomic differences in hysterectomy: The Wisconsin Longitudinal study. American Journal of Public Health, 87(9), 1507-1514.
Martyn, D. (2010). The Good Research Guide: For Small-Scale Social Research Projects: for small-scale social research projects. London, UK: McGraw-Hill International.
Materia, E. Rossi, L., Spadea, T., Cacciani, L., Baglio, G., Cesaroni, G., …Perucci, C. (2005). Hysterectomy and socioeconomic position.Journal of Epidemiology and Community Health, 56(6), 461-465.
May, T. (2004). Social restrictions on informed consent: Research ethics and medical decision making. HEC Forum, 16(1), 38-44.
McCulloch, P., Nagendran, M., Campbell, W. B., Price, A., Jani, A., Birkmeyer, J. D., & Gray, M. (2013). Strategies to reduce variation in the use of surgery.The Lancet, 382, 1130-1139.
McPherson, K., Herbert, A. & Judgeetal, A. (2005). Psychosexual health 5 years after hysterectomy: population-based comparison with endometrial ablation for dysfunctional uterine bleeding. Health Expectations, 8(3), 234–243.
Nargundkar, R. (2003). Research Methods and Design – Additional Inputs and Questionnaire Design- a customer-centric approach in Marketing Research – Text and Cases. New Delhi, IN: Tata McGraw-Hill.
Owens, D. (2009). Informed consent.Journal of the American Society of CLU &ChFC, 51(6), 34-35.
Panneerselvam, R. (2004). Data Collection and Presentation in Research Methodology. New Delhi, IN: PHI Learning Pvt.Ltd.
Parkinson-Hardman, L. (2007). The complete guide to hysterectomy. London, UK: Lulu.
Perera, H., Ananth, C., Richards, C., Neugut, A., Lewin, S., Lu, Y.,… Wright, J. (2013). Variation in ovarian conservation in women undergoing hysterectomy for benign indications.Obstetrics & Gynecology, 121(4), 717-726. Web.
Phung, T., Waltoft, B., Laursen, T., Settnes, A., Kessing, L., Mortensen, P.,…Waldemar, G. (2010). Hysterectomy, oophorectomy and risk of dementia: A nationwide historical cohort study. Dementia and Geriatric Cognitive Disorders, 30(1), 43-50. Web.
Pinar, G., Okdem, S., Dogan, N., Buyukgonenc, L., &Ayhan, A. (2012).The effects of hysterectomy on body image, self-esteem, and marital adjustment in Turkish women with gynecologic cancer.Clinical Journal of Oncology Nursing, 16(3), E99-E104. Web.
Polk, H. (2006). The evolution of guidelines toward standards of practice.The American Surgeon, 72(11), 1133-1148.
Prior, A. Stanley, K. Smith, A., & Read, N. (1992). Effect of hysterectomy on anorectal and urethroversical physiology.Gut, 33(1), 264-67.
Qamar-Ur-Nisa, H., Memon, F. & Shaikh, T. A. (2011). Hysterectomy: an audit at a tertiary care hospital. The Professional Medical Journal, 18(1), 46–50.
Risker, D. (1996). The health belief model and consumer information searches: Toward an integrated model. Health Marketing Quarterly, 13(3), 13-26.
Roos, N. (2007). Hysterectomies in one Canadian province: a new look at risks and benefits. American Journal of Public Health, 74(1), 39-46.
Rosenstock, I., Strecher, V., & Becker, M. (1988). Social learning theory and the health belief model.Health Education Quarterly, 15(2), 175-183.
Ruuskanen, A., Hippelainen, M., Sipola, P., &Manninen, H. (2010). Uterine artery embolisation versus hysterectomy for leiomyomas: Primary and 2-year follow-up results of a randomized prospective clinical trial. European Radiology, 20(1), 2524-2532. Web.
Schollmeyer, T., Elessawy, M., Chastamouratidhs, B., Alkatout, I., Meinhold-Heerlein, I., Mettler, L.,…Weigel, M. (2014). Hysterectomy trends over a 9-year period in an endoscopic teaching center. International Journal of Gynecology and Obstetrics, 126(1), 45-49. Web.
Scutiero, G., Nappi, L., Matteo, M., Balzano, S., Macarini, L., & Greco, P. (2013). Cervical pregnancy treated by uterine artery embolisation combined with office hysteroscopy. European Journal of Obstetrics & Gynecology and Reproductive Biology, 166(2), 104-106.
Seidman, I. (2012). Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences. New York, NY: Teachers College Press.
Sheth, S. (2013).Vaginal hysterectomy in women with a history of 2 or more cesarean deliveries.International Journal of Gynecology & Obstetrics, 122(1), 70-74.
Singh, S., Ryerson, A. B., Wu, M., &Kaur, J. (2014).Ovarian and uterine cancer incidence and mortality in American Indian and Alaska native women, United States, 1999-2009.American Journal of Public Health, 104(S3), S423-S432.
Sparić, R., Hudelist, G., Berisava, M., Gudović, A., &Buzadzić, S. (2011). Hysterectomy throughout history. ActaChirurgicaIugoslavica, 58(4), 9-14.
Stam, P. (2012). Woman’s right to know act: A legislative history. Issues in Law & Medicine, 28(1), 3-67.
Sutton, C. (1997). Hysterectomy: A historical perspective. Baillière’s Clinical Obstetrics and Gynaecology, 11(1), 1-22.
Tapper, A., Hannola, M., Zeitlin, R., Isojärvi, J., Sintonen, H., &Ikonen, T. (2014). A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions. Journal of Obstetrics & Gynecology and Reproductive Biology, 177(1), 1-10. Web.
Taylor, J. C. (2004). Autonomy and informed consent: A much misunderstood relationship. The Journal of Value Inquiry, 38(1), 383-391. Web.
Thakar, R., Ayers, S., Clarkson, P., Stanton, S., &Manyonda, I. (2002). Outcomes after total versus subtotal abdominal hysterectomy. The New England Journal of Medicine, 347(17), 1318-1325.
Thomas, D. (2006). A General Inductive Approach for Analyzing Qualitative Evaluation Data. American Journal of Evaluation, 27(2), 237-246.
University of Maryland: Mississippi appendectomy. (n.d.).
Varelius, J. (2007). On Taylor on autonomy and informed consent.The Journal of Value Inquiry, 40(1), 451-459. Web.
Waters, J. (2014). Phenomenological Research Guidelines.
Weber, A. & Lee, J. (1996).Use of alternative techniques of hysterectomy in Ohio, 1988-1994.The New England Journal of Medicine, 335(7), 483-489.
Wilcox, L., Koonin, L. Pokras, R., Strauss, L., Xia, Z., & Peterson, H. (2005).Hysterectomy in the United States, 1988-1990.Obstetrics and Gynecology, 83(3), 549-555.
Wong, C., Jim, M., King, J., Tom-Orme, L., Henderson, J., Saraiya, M.,…Espey, D. (2011). Impact of hysterectomy and bilateral oophorectomy prevalence on rates of cervical, uterine, and ovarian cancer among American Indian and Alaska native women, 1999-2004.Cancer Causes Control, 22(1), 16812-1689. Web.
Woolcott, C., Maskarinec, G., Pike, M., Henderson, B., Wilkens, L., &Kolonel, L. (2009). Breast cancer risk and hysterectomy status: the multiethnic cohort study. Cancer Causes Control, 20(1), 539-547. Web.
Wu, J. M., Wechter, M. E., Geller, E. J., Nguyen, T. V. & Visco, A. G. (2007). Hysterectomy rates in the United States, 2003. Obstetrics and Gynaecology, 110(5), 1091–1095.
Yeh, J., Cheng, H., Hsu, P., Sung, S., Liu, W., Fang, H.,…Chuang, S. (2013). Hysterectomy in young women associates with higher risk of stroke: A nationwide cohort study. International Journal of Cardiology, 168(3), 2616-2621. Web.
Zhang, C., Havrilesky, L., Broadwater, G., Di Santo, N., Ehrisman, J., Lee, P.,…Valea, F. (2014). Relationship between minimally invasive hysterectomy, pelvic cytology, and lymph vascular space invasion: A single institution study of 458 patients. Gynecologic Oncology, 133(1), 211-215. Web.