Repercussions in the Lifestyle of Oophorectomized Women

Results: The respondents were aged above 31 years, in 17.19% the cause that led to oopheroctomy was uterine leiomyoma. The age range for the procedure was 25-55 years, with prevalence among 36-45. 80.95% of women noticed changes after the procedure on quality of life with the presence of excessive heat, joint pain, weight gain, stress and decreased sexual pleasure, resulting in interference in sexual.


Introduction
The removal of the uterus, or hysterectomy, whether partial or complete, is the most common obstetric procedure realized worldwide [1].It is the second type of surgery performed on women, with quite significant estimates and often negative implications for a woman's life [2].
In the vast majority of cases, the surgical indication occurs for benign diseases.The procedure requires the specialized knowledge of physiology and pathologies that affect the organs of the female reproductive system, considering the clinical, psychological and social manifestations [3].
Just like any other procedure of the same complexity, hysterectomy generates a number of disadvantages.Some variables are quite considerable as urinary incontinence and pelvic organ prolapse when surgery is not total, sexual dysfunctions, distortion of body image, among others.However, we should consider the relief of symptoms caused by diseases that led to surgery, and the improvement of the quality of personal and social life [1].
Hysterectomy generates distressing feelings for women who undergo the procedure considered mutilating.Fear, anxiety, social and family isolation, in addition to the fear of the surgery itself, and the loss of a body representing the woman as a being donated to maternity, affect the female sexuality also [4].
To better accommodate women in such situations, the Ministry of Health, through the National Integral Attention to Women's Health Policy, formulated specific strategies actions for these patients.This policy clarifies that, in order to achieve the principles of humanization and quality of attention, the friendly reception in all levels of care assistance must be taken into account [5].
In this context, the presence of nursing aims to implement a differentiated and comprehensive assistance, guiding, comforting, ensuring respect and seeking the understanding of women's questions through a sensitive listening directed to professio-nal-patient interaction.Caring for hysterectomized patients provides the nursing staff the importance of providing clinical care to ensure them a comprehensive care, considering the patient as a whole being, who should be seen beyond the disease [6].
The rationale of this study occurs through understanding the problems experienced by women in this surgical intervention process.We believe that once distinguished the effects of surgery on the woman's life, it will be possible to expand tactics in which prevail the humanization of care.
Based on such assumptions, the following question was posed: which consequences women are brought to, before a procedure so striking as hysterectomy?What are the feelings experienced and the quality of life they have after surgery?Thus, the objectives of this research were to identify the factors that led women to hysterectomy in the municipality of Brejinho-PE; to check the consequences caused in the lives of women after hysterectomy procedure; and to understand the influence of hysterectomy on the quality of women's lives.

Methods
This research is a study exploratory, which aims to deepen the subject of detailed study, building concepts about the favorable and unfavorable aspects in relation to the nursing work, using more precise problems or hypotheses subject to further research [7].
The study was conducted in the Family Health Program III Village of Fatima, located in the town of Lagoinha, city of Brejinho-Pernambuco, Brazil.
All hysterectomized women enrolled in the Family Health Program above, constituted the study population, being a total of 26 women.The sample was randomized from the following inclusion criteria: women who had undergone partial or total hysterectomy and who are over 18 years old.These exclusion criteria were established: women who did not accept to participate in the survey; with mental disorders that make it impossible to respond to the questionnaire; single women who have never had sexual intercourse with men or women; who do not reside in the village anymore and have no record of accomplishment of hysterectomy in the medical records.
At the site of the research, the sample population consisted of 26 women, but 5 people were reluctant to cooperate with the research, refusing to respond to the instrument used, and so only 21 women participated in the study.
Data collection occurred in the months of January to February 2016, taking as instrument a semi-structured questionnaire containing issues related to the study objectives.This questionnaire has been used individually for each woman, being applied in a reserved manner to avoid any kind of embarrassment and to facilitate their freedom on answering the questions, with an average duration of 15 minutes.
Ethical approval collected before start of the study and Research Committee of the Patos Integrated College under number CAAE: 51417015.3.0000.5181, the collected data were analyzed based on the approach of quantitative and qualitative methods, and discussed in light of the relevant literature.It is appropriate to clarify that the implementation of this research followed the ethical principles inherent in research involving human subjects, such as anonymity, respect for the person, guarantee of maximum individual and community benefit, and equal consideration of the interests involved, as required by Resolution 466 / 2012, standardized by the National Health Council [8].
Quantitative data were statistically analyzed and clustered through software (Word).The quantitative method is characterized by the use of the quantification methods for information collection and in the treatment of them, by means of statistical techniques, since the simplest, as percentage, average, standard deviation, to the most complex, as coefficient of correlation and regression analysis [7].
Qualitative materials were analyzed through the Collective Subject Discourse (DSC) technique.This is a procedure that portrays the respondents' statements expressions, which enables the thought in summary form and allows interpretations to substantiate results.This technique follows the following principles: consistency, proper positioning and distinction between the types of speeches in which all ideas presented in the statements are taken advantage of, being used tables to show the subjects' discourse [9].

Results
Results are arranged in two groups: the first one represents the analysis of the quantitative data of the study through tables, and the second one is presented frame-like and corresponds to the analysis of qualitative data, for the analysis of the Collective Subject Discourse.However, before we enter the analysis of the material regarding the proposed objective, we will present a brief characterization of the sample group of this study.
The evaluation of socio demographic data on subjective character was based on four variables: age group, education level, marital status and salary.In the age group of 21 women who responded to the questionnaire, there was a predominance of women with 41 years of age or more, represented by a percentage of 90.48 and 2 (9.52%) in the age group of 31-40 years.As for the level of education, 14 (66.67%)women presented incomplete elementary school, followed by those with complete primary education and illiterate of 14.29% each one, and only 4.76% had completed higher education.
Regarding marital status variable, 12 (57.14%)women are married, 7 (33.33%)are widows, and single women and divorcees represented 4.76%.The economic situation, reflected in the salary variable, has a higher percentage to the minimum wage, with 9 (42.86%)women, followed by 8 (38.10%) of them

Discussion
The age of 10 to 49 years of women is of fundamental importance in regard to female fertility [5].
Although the majority of respondents are 41 years old or more, the hysterectomy of 7 of them was held between 25-35 years, 8 women were 36-45 years and 7 of them were 46-55 years.In a research conducted in Parana State, in Brazil, it was concluded that the surgery average was 48.3 years, justifying that the preservation of the uterus is required while the reproductive function is maintained [10].
The result showed certain proximity, although the highest prevalence occurred in the age group of 36-45 years.Although several studies show the realization of hysterectomy as an incident in older women, this study showed that gynecologic surgery comes early revealing complications in the female reproductive system.As for education, 66.67% of respondents had not completed elementary school, which corroborates to a study that shows an average of seven years of study among women undergoing gynecological surgery.The low level of schooling can be an aggravating factor to women health, and the Ministry of Health (MS) considers it as an obstetric and gynecological risk factor [11].It is noted, therefore, that the education factor has direct interference in the salary issue, since the lower the education level, the lower the salary, consistent with positions of basic school levels.
Table 1 showed that the main cause that led women to the hysterectomy was leiomyoma with prevalence of 16 (76.19%),Leiomyoma of uterus or uterine fibroids are very common benign tumors, affecting between 20% to 40% of women at some point in life, and these are developed in the muscular wall of the uterus (myometrium).They vary greatly in size over time, and when small they may not cause symptoms, but when they grow, cause a lot of pain and bleeding.It may include pain, heavy bleeding, menstruation prolongation, fertility reduction and pelvic pressure.In some cases, they grow so much that can make a woman appear several months pregnant.Usually they grow during pregnancy and get reduced after pregnancy [12].
The most commonly procedure performed is the total hysterectomy, in 13 (81.25%)women, and partial hysterectomy in 3 (18.25%)women, for such a cause.According to Muniz, the most frequent factors for hysterectomy performing indications include: uterine leiomyomas, dysfunctional uterine bleeding, genital prolapse and endometriosis.Other causes include adenomyosis, chronic pelvic pain, pelvic inflammatory disease, endometrial hyperplasia, intraepithelial neoplasia, invasive uterine cancer, massive postpartum hemorrhage and infection [13].It is evident that a total hysterectomy is the most chosen one.This may be associated with complications of the anatomical structures of the female reproductive system, determined by the clinical course of this disease.
As the uterus and ovaries help maintain hormonal balance.So it is not simple hystrectomy only but also with bilateral oophorectomy.Life can be full of physical and psychological challenges.Women may experience hot flashes or other menopausal symptoms after hysterectomy, also known as "surgical menopause" [12].Table 2, in turn, portrays precisely the changes that woman's body presented after total or partial removal of the uterus, and 17 of these women reported variables as excessive heat (35.29%), joint pain, weight gain and stress (41.18%).Pardini's study also revealed that excessive heat was also identified between 60% to 80% of women participating in the survey [14].
The loss of libido or sexual desire after total hysterectomy is quite common.The body's reaction to hysterectomy varies from woman to woman, depending on their age and general health condition.This fact was detected in this study, in which 8 women maintained their intercourse unchanged.However, 52.38% of the survey participants reported changes in sexual intercourse, such as, decreased sexual libido and lubrication, and pain during intercourse due to vaginal dryness.It was also noted that some women reported that post-surgery symptoms did not affect their partners.This event may have been omitted by shame of feeling this difference and be seen as rejected by the partner, or not wanting to expose their sexual life.
It's worth noting that hysterectomy is often made to improve women's quality of life.It also helps to eliminate menstrual problems.However, the lack of estrogen generates some hysterectomy side effect on the body, and these problems can be described as the loss of bone mass, increasing the chances of cardiovascular diseases, urinary tract tissues and impaired genital, vaginal dryness, night sweats, depression, insomnia, and the relatively fast aging process [15].
To counteract the lower estrogen levels in the body of women undergoing "surgical menopause", the HRT hormone-replacement therapy is performed.The loss of estrogen from the body is balanced by the administration of synthetic hormones of estrogen and progestin in the form of medication.Generally, both estrogen and progestin are recommended when ovaries were removed.If not, just estrogen hormone is considered.HRT is usually administered to patients by drugs prescription in the form of pills.Some experts also prescribe natural progesterone in the form of vaginal gel or pessary (inserted into the vagina) and suppository (inserted into the rectum).The purpose behind these inserts is that the required hormone is directly absorbed into the bloodstream through the vaginal walls or rectum.Since pills are easy to be used, they are mostly recommended by medical experts [16].
According to Table 4, we can see that only 3 women make use of HRT (use of menopax and cicloprimogyna), hence these will benefit with respect to reducing the risk of heart disease and co-lorectal cancer, particularly aged women.It was also found that the participants who received the necessary information about HRT, and joined the therapy, proved to be satisfied with the results.This demonstrates the importance of dialogue between the team and the patient, in search of the best interventions.In contrast, 80.95% of the interviewees said they did not make use of HRT.Among the reasons referenced by them, there is a lack of knowledge about the therapy, lack of guidelines given by health professionals and the difficulty of adherence to treatment.
Regarding the drawbacks of HRT, medical experts are critical about the fact that it is not the HRT treatment, which is responsible for all side effects.It is the particular health condition of women that should be kept in mind before recommending HRT.So, if a woman does not have severe symptoms of post-menopausal, she should avoid HRT.Postmenopausal complications can be improved by changing habits.Alternatives such as bioidentical hormone replacement therapy (TRHB) can also be considered after medical supervision.Women who suffer from liver diseases or other complex medical complications should avoid HRT.Medical studies also report that HRT increases the risk of heart attacks (when both estrogen and progesterone are taken), breast cancer and blood clots [16].
In Table 1, from the collective subject discourse, we got the central idea of "staying mostly performing oncotic cytology," referring to health professionals guidance on the health care of women after hysterectomy.Despite being a valuable care for the prevention of gynecological diseases, whether or not the woman has a history of hysterectomy, this study also shows that 28.57% of women spend more than three years without performing pap smears, followed by 28.57% who perform it every 2 years and 42.86% of them that perform it annually.
The woman's attitude regarding the frequency of Pap smear testing is brilliantly clear in a survey conducted in the Family Health Strategy-ESF in the municipality of Parnaiba-PI.They claim that despite the cytological examination be carried out in basic health units (UBS) -which further facilitated the access of women to its realization -many women still have resistance to cytological collection and sometimes they undergo the examination in a later phase.Factors such as shame, shyness, fear, lack of information, prejudice of partners and other cultural context are related to a low demand of women seeking health facilities for this examination [17].
As nursing professionals use their knowledge in an attempt to better understand women's intimacy in hysterectomy situation, it is possible that we come to the conclusion that promotion actions and properly implemented prevention can be effective in encouraging women to self-care, improving their lifestyle and adding value to a positive view of their body image [18].

Conclusions
The performance of hysterectomy is always surrounded by conflicts, stigmas and expectations.Issues such as fear, anxiety, pathology, the procedure itself, the reflection on the maternity and even sexuality, are present in the life of the woman until long after the completion of hysterectomy.
From the reports made by women in this research, it was concluded that the prevalent cause for the indication of hysterectomy was leiomyoma, although other pathologies have been mentioned, such as ovarian cancer, in which the main type of procedure used was total hysterectomy, culminating in the removal of the uterus and associated structures.
As for hysterectomy impacts on the quality of life of these women, it was found that there were changes and that these changes interfere negatively.For being regarded as a surgical menopause, hysterectomy causes the same physiological symptoms of menopause, even in those women who are not yet at end of reproductive life In this sense, women have decreased quality of life by the interference of symptoms, such as excessive heat, joint pain, weight gain and stress.
Given the sudden reduction of hormones, especially the estrogen, it was possible to conclude that women suffer consequences such as reduced libido, leading her to have impaired sexual life.The decrease in vaginal lubrication, with episodes of pain during intercourse, leads many women to guard against it, generating so more interferences in women's lives after performing the hysterectomy.
Whereupon, it reinforces the participation of nursing in the performance of health programs for women, turning the implementation of actions aimed at providing physical and emotional relief to hysterectomized women.

Table 5 .
Central idea and the collective subject discourse on the guidelines by health professionals on health care for women after hysterectomy.Village of Lagoinha, Brejinho-PE, 2016.

Table 4 .
Answers of respondents regarding the realization of Hormone Replacement Therapy (HRT), the justifications for the nonuse of HRT and the medications used.Village of Lagoinha, Brejinho-PE, 2016.