Symptom Experience in
Women After Hysterectomy
Kimberly H . Kim, RN, PhD, Kathryn A. Lee, RN, PhD
= Objective: To review the literature addressing
the symptom experience of women after hysterectomy.
Data Sources: Computerized searches in
MEDLINE and CINAHL, as well as texts and refer-
ences cited in articles. Key concepts in the searches
included hysterectomy, sleep disturbance and pain,
hysterectomy and fatigue, hysterectomy, depres-
sion, and depressed mood.
Study Selection: Articles and comprehensive
works relevant to key concepts and published after
1970, with an emphasis on new findings from 1990
to 2000. Sixty-four citations were identified as use-
ful to this review.
Data Extraction: Data were organized under
the following headings: women and hysterectomy,
biopsychosocial perspectives, common symptoms
after hysterectomy (pain, disturbed sleep, fatigue,
depressed mood, anxiety), and significance of
review (implications).
Data Synthesis: Literature suggests that after a
hysterectomy, women experience complications
during the postoperative recovery period that may
vary with the type of surgical procedure. During this
period, the quantity and quality of sleep as well as
other symptoms (pain, fatigue, anxiety, and depres-
sion) are influenced by various physiologic, psycho-
logic, and social factors. Despite limited evidence
that sleep problems may occur frequently during the
recovery period, only a few researchers have sys-
tematically examined sleep patterns in women after
hysterectomy. None of these studies, however, used
objective sleep measures or examined multiple
dimensions of these women’s lives.
Conclusions: This review conceptualized the
women‘s symptom experience as the experience of
specific symptoms (pain, sleep disturbance, fatigue,
depressed mood, and anxiety) that were influenced
472 JOGNN
by biopsychosocial factors. JOGNN, 30,472-480;
2001.
Keywords: Anxiety- Biopsychosocial fac-
tors - Depressed mood- Fatigue- Hysterectomy-
Pain-Sleep disturbance-Symptom experience
Accepted: March 2001
Hysterectomy is the most frequently performed
surgery for women of reproductive age in the
United States. Although hysterectomy relieves pre-
operative symptoms, including heavy bleeding and
pain related to endometritis, uterine fibroids, and
cancer in women, it carries a substantial risk of mor-
bidity. It is reported that 40% to 50% of women
who undergo a hysterectomy experience complica-
tions in the postoperative period (Gould & Wilson-
Barnett, 1985; Schofield, Bennett, Redman, Wal-
ters, & Sanson-Fisher, 1991). Hemorrhage, injury
to the urinary tract, perforation of the bowel, infec-
tion, and a threefold increase in coronary artery
disease are some of the immediate postoperative
complications of this surgery (Clarke, Black,
Rowe, Mott, & Howe, 1995; Dicker et al., 1982;
Easterday, Grimes, & Riggs, 1982; Harris, 1997).
A posthysterectomy syndrome (Richards, 1974)
includes a loss of libido in some patients and is
characterized by fatigue, depression, headache,
hot flushes, and sleep disturbance.
This review comprised computerized searches
in MEDLINE and CINAHL and included articles
and texts in published works. The literature
reviewed describes women’s symptom experiences
after hysterectomy and the relationships between
their symptom experiences and biopsychosocial
factors in their lives. In addition, the severity of
symptoms after surgery were compared between
Volume 30, Number 5
the two frequently performed procedures, total abdom-
inal and laparoscopic vaginal hysterectomy.
Women and Hysterectomy
The most prevalent non-pregnancy-related surgical
procedure for women in the United States is hysterecto-
my: Approximately 650,000 hysterectomies are per-
formed annually (Meeks & Harris, 1997). The most
common diagnosis that indicates the need for a hys-
terectomy is uterine leiomyoma, followed by
endometriosis, prolapse of the uterus, and cancer of the
reproductive tract. Although most hysterectomies are
performed as elective procedures, the likelihood of hav-
ing a hysterectomy varies according to a woman’s age,
the diagnosis, and other characteristics such as income,
ethnicity, and education (Bachmann, 1990; Steege, 1997).
Education level is an important predictor for out-
comes in women treated for chronic pelvic pain.
Women with higher educational levels prefer nonsurgi-
cal pain management, whereas women with less educa-
tion prefer hysterectomy (Carlson, Miller, & Fowler,
1994). Women who have only a high school education
are about 4 times more likely to have undergone hys-
terectomy than women with a college degree or
advanced education (Harlow & Barbieri, 1999).
The rate of hysterectomy peaked at 100.5 hysterec-
tomies per 10,000 women ages 30 to 54 years during
the years 1988 to 1990, and the total rate of hysterec-
tomy was slightly higher for African American than for
white women (Wilcox et al., 1994). The hysterectomy
rates by age also differ for African American and white
women. Compared t o whites, African American
women have hysterectomies at a younger age for most
diagnoses (Lewis, Groff, Herman, Mckeown, &
Wilcox, 2000).
Chandra (1998) reported that rates increase particu-
larly among women who are less advantaged socioeco-
nomically and are ages 15 to 44 years. Women who
have borne children and are no longer fertile more fre-
quently undergo hysterectomy rather than nonsurgical
therapy (Carlson et al., 1994).The overall prevalence of
hysterectomy in Canada (16.3’70)is much higher than
in the United States and increases sharply to 30% for
women ages 35 to 55 years (Snider & Beauvais, 1998).
Canadian women of lower income and education also
have a higher rate of hysterectomy (Snider & Beauvais,
1998).
The abdominal surgical procedure (70%) is used
predominantly. Harris and Olive (1994) report that
50% of women who have had a hysterectomy also had
bilateral oophorectomy (removal of ovaries), which is
higher in abdominal compared with laparoscopic hys-
terectomy. Oophorectomy is recommended to prevent
the occurrence of ovarian cancer; however, it increases
SeptemberlOctober 2 001
the risk of osteoporosis and cardiovascular disease
(Wilcox et al., 1994). The balance of risks and benefits
from oophorectomy depends on whether exogenous
estrogen is used after surgery. This is consistent with
current knowledge of estrogen’s beneficial effects on
lipid profiles, vascular endothelium, and thrombotic
mediators (Carlson, 1997). All researchers agree that
concomitant removal of the ovaries leads to a signifi-
cant increase in psychosexual dysfunction in the pre-
menopausal woman (Harris, 1997). Whether hormone
replacement therapy can reverse this trend remains
unclear (Harris, 1997). Symptoms of psychosexual dys-
function may include anxiety, depression, fatigue, and
disturbed sleep.
Use of either the abdominal or the laparoscopic pro-
cedure appears to depend on the diagnosis and the
physician’s preference. Uterine leiomyoma and
endometriosis are the primary diagnoses for two thirds
S l e e p disturbance and fatigue are anxiev-
producing symptoms for women after
hysterectomy and are related to
multidimensional aspects of their lives.
of the women who have hysterectomies for noncancer-
ous conditions. Abdominal hysterectomy is performed
more commonly for myomas and the presence of malig-
nancy (Wilcox et al., 1994). Several studies suggest that
although the laparoscopic procedure has advantages
and disadvantages, when it is performed by well-trained
physicians the complication rate does not exceed that of
abdominal hysterectomy (Meeks & Harris, 1997; Van
Den Eeden et al., 1998). The advantage of laparoscop-
ic hysterectomy is the ability of physicians to observe
the tissue with laparoscopy once the vaginal cuff clo-
sure is completed.
The effect of abdominal versus laparoscopic proce-
dures on patients’ health care costs also has been ana-
lyzed. Spiritos and colleagues (1996) reported higher
costs associated with the surgery and length of hospi-
tal stay in the abdominal group ($19,158 versus
$13,988). The laparoscopy group had a shorter length
of hospital stay (2.4 days versus 6.3 days) and returned
to their normal activities sooner (2.4 weeks versus 5.3
weeks). An average operating time for laparoscopic
hysterectomy is 115 minutes, compared with 87 minutes
for abdominal cases (Meeks & Harris, 1997; Meikle &
Orleans, 1997).The increased time required for laparo-
scopic hysterectomy compared with abdominal hys-
JOGNN 473
terectomy is due to the more complex nature of the Biopsychosocial Influences
laparoscopic surgery.
Physiologic Psychologic Social Factors
Factors Factors Age
Biopsychosocial Perspectives Temperature Fear Ethnicity
Hysterectomy affects many aspects of a woman’s Surgical History of Marital status
health. The outcomes of interest for a woman consider-
ing hysterectomy may include its effectiveness for relief
of symptoms; duration of hospitalization and recupera-
tion; and long-term effects on quality of life, including
biopsychosocial function. For the purpose of this
review, a woman’s symptom experience after hysterec-
tomy is conceptualized as a complex interaction among
procedure
Blood pressure
Hemoglobin
Hematocrit
Hormonal
changes
\ I
depression

J
Education
Income
Support
system

physiologic, psychologic, and social factors. The con- Symptom Experience

ceptual model (see Figure 1)that guides this review was
developed and refined from previous empirical data on
women’s health and fatigue research (Lee, Lentz, Tay-
lor, Mitchell, & Woods, 1994; Lee, Portillo, & Mira-
montes, 1999).
Compared with women undergoing abdominal sur-
gery for other reasons, women undergoing hysterecto-
my have additional physiologic, psychologic, and social
factors to consider. The physiologic factors may differ
in women who have had a hysterectomy because of the
removal of the uterus, the hormonal imbalance related
to ovarian failure (even when the ovaries are preserved),
and possible negative consequences of the surgery. The
psychologic factors these women experience also may
differ from those of women without hysterectomy, with
negative outcomes reported, such as depressed mood
and anxiety. Social factors may vary depending on fam-
ily relationships and support systems in the woman’s
community. The factors in women’s relationships with
their partners and the long-term effects on their quality
of life may vary owing to the surgical procedure.
Physiologic Factors
Several physiologic factors may contribute to
women’s symptom experience after hysterectomy. An
elevated body temperature is seen commonly in postop-
erative patients and is associated with decreased rapid
eye movement (REM) sleep and increased deep sleep
(Kent, Price, & Satinoff, 1988). It is unknown, howev-
er, if the fever-induced sleep disturbance is mediated by
hormones.
The surgical trauma can induce a complex physio-
logic stress response involving the endocrine-metabolic
system as well as a local inflammatory response.
Endocrine-metabolic hypermetabolism, with increased
plasma concentrations of catabolic hormones and
reduced anabolic hormones, leads to acceleration of
most biochemical reactions, including muscle protein
breakdown that results in a negative nitrogen balance
(Kehlet, 1988). This response may last for a few days or
weeks (Rosenberg-Adamsen, Kehlet, Dodds, & Rosen-
Disturbed sleep
Pain
Fatigue
Depressed mood
Anxiety
FIGURE 1
Symptom experience in women after hysterectomy.
berg, 1996), depending on the patient’s response to the
surgical trauma.
The increased postoperative sympathetic activity
with increased catecholamines may contribute to post-
operative sleep disturbances, as high levels of noradren-
ergic activity maintain wakefulness (Aakerlund &
Rosenberg, 1994; Hilakivi, 1987). Postoperative fever,
hypertension, tachycardia, anemia, infection, and pain
are all examples of physiologic factors associated with
disturbed sleep. Furthermore, the postoperative sleep
disturbance could be a contributing factor in the phenom-
enon of postoperative fatigue (Christensen & Kehlet,
1993), although the relationship between postoperative
fatigue and sleep disturbance remains unknown.
Outcomes from laparoscopic hysterectomy and
abdominal hysterectomy were compared by Olsson,
Ellstrom, and Hahlin (1996) in a prospective random-
ized trial. Although the rate of complications did not
differ between laparoscopic hysterectomy and abdomi-
nal hysterectomy, the postoperative fall in hematocrit
was significantly greater after abdominal hysterectomy.
Postoperative pain assessed by the patients 2 days after
surgery on a visual analog scale was significantly high-
er after abdominal hysterectomy (Olsson et al., 1996).
Psychologic Factors
In women, fear of having cancer, prior mental health
status, and history of depression are related to psycho-
logic sequelae after hysterectomy. Some researchers sug-

474 JOG” Volume 30, Number 5

gest that women with preoperative depression are at
increased risk for depression after surgery (Lalinec-
Michaud & Engelsmann, 1984; Naughton & McBee,
1997). Moore and Tolley (1976) reported that 32% of
their 47 patients were depressed 3 months after abdom-
inal hysterectomy; however, 64% of these women were
depressed before surgery. Fear of having cancer after
hysterectomy may affect women’s psychologic health.
Luoto, Auvinen, Pukkala, and Hakama (1997) investi-
gated a subsequent risk of cancer in women, using a ret-
rospective cohort of 25,382 women who had hysterec-
tomies and a similar number of women who did not
have the surgery. They found that hysterectomy was not
associated with any substantial protective or promo-
tional effect on cancer in women.
Hysterectomy itself or removal of the ovaries at the
time of hysterectomy may have a detrimental effect on
psychologic well-being after surgery. Bachmann (1990)
reported that most psychologic symptoms after hys-
terectomy are associated with the decline of estrogen
that occurs when either the ovaries are removed in con-
junction with the hysterectomy or they are partially
removed by the surgery. This may be due to a lack of
estrogen replacement therapy after surgery. The effects
of estrogen differ for individual women, however, and
how estrogen alters women’s psychologic health
remains unknown.
Social Factors
Education, income levels, ethnic and cultural back-
grounds, support systems, and age at the time of a hys-
terectomy are strong social influences for women’s
responses after experiencing a hysterectomy. Women
younger than age 30 who undergo a hysterectomy for
pelvic pain and endometriosis are more likely than
older women to report a sense of loss and disruption in
their lives (MacDonald, Klock, & Milad, 1999).Women
who are younger than age 40, less educated, have a con-
flict about childbearing, and undergo oophorectomy
are at higher risk of depression after hysterectomy
(Bachmann, 1990). Hysterectomy did not relieve symp-
toms for women with low incomes or who were in ther-
apy at the time of hysterectomy (Kjerulff et al., 2000).
Furthermore, women who receive less social support
are more likely to report unpleasant symptoms.
Primomo, Yates, and Woods (1990) reported that
social support from the partner and family was signifi-
cantly associated with less depression, higher marital
quality, and better family functioning. Low levels of
social support also are associated with negative psycho-
logic sequelae in women after hysterectomy. Webb
(1986) reported that women who received professional
information, as a form of social support, reported fewer
symptoms of anxiety, depression, fatigue, and hostility
and more vigor than did women who did not receive
SeptemberlOctober 2001
support. Thus, health care providers who educate
women before surgery about side effects and how to
manage recovery at home can have a positive effect on
women’s postoperative symptom experience. Full-time
housewives were in particular need of support from
nurses because of their relative isolation from other
sources of support and information.
Common Symptoms After Hysterectomy
A hysterectomy is considered to be effective for
symptom relief, morbidity reduction, and rehabilitation
for work. Despite the success of this procedure and
extensive literature on outcomes, little has been report-
ed on women’s symptom experience and the social
sequelae of surgery and the rehabilitation process.
Compared to women undergoing
abdominal surgery for other reasons,
women undergoing hysterectomy have
additional physiologic, psychologic,
and social factors to consider.
Reports suggest that as many as 50% of all women who
undergo hysterectomy will encounter one or more
symptoms as complications (Dicker et al., 1982;
Schofield et al., 1991). For this review, symptom expe-
rience is conceptualized as the experience of specific
symptoms (pain, sleep disturbance, fatigue, anxiety, and
depressed mood), with the level of severity influenced
by physiologic, psychologic, and social factors as well
as the surgical procedure performed.
Pain
Postoperative pain after hysterectomy can lead to a
wide range of undesirable consequences. These include
reduced mobility that may lead to deep vein thrombo-
sis, respiratory difficulties, reluctance to mobilize, sleep
disturbance, and fatigue (Closs, 1992). Pain also may
accelerate tissue breakdown, impair bladder and bowel
function, and increase the likelihood of long-term pain.
Pain in the abdominal incision is one of the most com-
mon reasons cited for dissatisfaction after hysterectomy
(Tay & Bromwich, 1998). Carlson and colleagues
(1994) report that with hysterectomy 72% of women
experience medium to high levels of pain postopera-
tively for 14 days. During the 1st week after surgery,
women may experience more pain and a reduction in
their ability to perform daily activities. Chronic pelvic
/OGNN 475
pain persisted after surgery in 22% of cases (Stovall,
Ling, & Crawford, 1990). It also is clear that postoper-
ative pain at night has a detrimental effect on sleep
(Closs, 1992; Jones, Hoggart, Withey, Donaghue, &
Ellis, 1979; Murphy, Bentley, Ellis, & Dudley, 1977).
Disturbed Sleep
One of the prevalent symptoms of postoperative
recovery is reduced or fragmented sleep. Indicators of
disturbed sleep range from self-report measures of decreas-
es in total sleep time to number of awakenings during
the night. Previous studies in patients undergoing major
abdominal surgery found that total sleep time is reduced
by up to 80% on at least one of the first postoperative
nights (Ellis & Dudley, 1976;J. Rosenberg, Wildschiodtz,
Pederson, Von Jessen, & Kehlet, 1994). Sleep also is
fragmented with numerous arousals and spontaneous
awakenings (Knill, Moote, Skinner, & Rose, 1990) that
contribute to complications and prolonged convales-
cence (Bisgaard, Kjaersgaard, Bernhard, Kehlet, &
Rosenberg, 1999). As sleep disturbance increases, sleep
effectiveness decreases (Knapp-Spooner & Yarcheski,
1992). In a study of 175 women with abdominal hys-
terectomy, Schofield and colleagues (1991) found that
48% of women who had preoperative sleep disturbance
also experienced the same or worse sleep disturbance
postoperatively and 9% ( n = 15) of women reported
sleep disturbance as a new symptom after hysterectomy.
Sleep disturbance during the postoperative period also
may produce undesirable effects, such as impaired tissue
restoration (Adams & Oswald, 1983) and negative mood
states (Shaver, Giblin, Heitkernper, & Paulsen, 1989).
Changes in sleep are influenced by the surgical inter-
vention and recovery from surgery, as well as the hos-
pital environment. Hospital noises and frequent inter-
ruptions for monitoring and treatments have been
W o m e n ’ s prevalent postoperative
symptoms must be explored and evaluated, in
conjunction with the biopsychosocial aspects
of their lives, so that targeted strategies can be
used to reduce their symptom experience.
implicated as causes of sleep fragmentation (Redeker,
Mason, Wykpisz, & Galica, 1996). The greatest change
in sleep experienced by patients having surgery
occurred from the time of preadmission to their 3rd
postoperative night (Knapp-Spooner & Yarcheski,
1992). Regular sleep cycles and REM sleep were absent,
476 JOGNN
and deep sleep was markedly reduced during the first 2
postoperative nights in patients having open heart sur-
gery (John, Large, Masterton, & Dudley, 1974). Rosen-
berg and colleagues (1994) concluded that postopera-
tive sleep is severely disturbed, with early suppression
of REM and deep sleep and rebound of REM sleep on
the 2nd and 3rd nights, consequently resulting in
fatigue and depression.
Sleep quality in postoperative patients is markedly
decreased during the first 1 or 2 nights, but it improves
for most patients before discharge. Studies based on
staff observations have shown that during the 1st night,
most patients (56%) experience disturbed sleep with
respect to total sleep time (Helton, Gordon, & Nun-
nery, 1980). The duration of the operative procedure
was related to the duration of postoperative sleep dis-
turbance, and anesthetic use was not significantly relat-
ed to postoperative sleep patterns (Meeks et al., 1997).
Fatigue
Fatigue, a prominent complaint in women after hys-
terectomy, often interferes with daily activities. Fatigue
is defined as an indicator of how a person is responding
to internal and external environmental demands (Lee
et al., 1994). Acute physical fatigue may occur as inter-
nal demands for energy expenditure exceed energy
reserves. Physiologic conditions, including the surgical
procedure, may deplete energy reserves by creating an
unrelenting physical demand for energy expenditure.
Carlson and colleagues (1994) found that 91% of 271
women who had abdominal hysterectomy reported
postoperative fatigue for 21 days; 35% reported fatigue
at 3 months, and 20% reported persistent fatigue at 12
months. The fatigue experienced by women with hys-
terectomy is related to postoperative pain and frag-
mented sleep that may lead to negative psychologic
health sequelae such as depressed mood.
Depressed Mood
In an early retrospective study, Richards (1974)
found that depressed mood, disturbed sleep, headache,
and fatigue occurred in approximately 70% of women
who had hysterectomy. In a longitudinal study of 63
women of low socioeconomic status who underwent
hysterectomies, most (73YO)reported sometimes having
negative symptoms (i.e., being depressed, irritable,
nervous, or having “blue spells”) that were associated
with their hysterectomy (Bernhard, 1992). Fifty-nine
percent of women revealed postoperative symptoms
they thought were either worse or caused by hysterec-
tomy (Raphael, 1978). In a study of 418 women ages
25 to 50 years, Carlson and colleagues (1994) found
that depressed mood was one of the new problems
reported by women after their hysterectomy. Similarly,
Lalinec-Michaud and Engelsmann ( 1984) found that
Volume 30, Number 5
persistent depression was more apparent after surgery
(31%versus 9%’) in a group of women who had a hys-
terectomy compared with patients who had a cholecys-
tectomy. Incidence rates of depressed mood after hys-
terectomy vary, however, ranging from 5%’ to 70%,
depending on the measurement criteria, hormonal ther-
apy, and length of follow-up after surgery.
Depressed mood may result from the stress of hys-
terectomy or from hormonal deficiency. Kritz-Silver-
stein, Wingard, Barrett-Connor, and Morton (1994)
examined the association of hysterectomy and
oophorectomy status to depression after surgery. The
rates of depression, as measured by the Beck Depression
Inventory, were significantly higher in the group who
had a hysterectomy with bilateral oophorectomy than
among the group who had a hysterectomy with unilat-
eral oophorectomy (Kritz-Silverstein et al., 1994).
Khastgir and Studd (1998) reported that ovarian
hormone deficiency after hysterectomy is responsible
for the negative effect on mood. This may be due to a
lack of estrogen replacement therapy (ERT) postopera-
tively in women having oophorectomy. Therefore, ERT
has been recommended for most women who undergo
hysterectomy with oophorectomy for noncancerous
conditions. Estrogen replacement therapy after hys-
terectomy with or without bilateral oophorectomy has
been shown to reduce the incidence of depressed state
(Khastgir & Studd, 1998). In a clinical trial of women
who had hysterectomies, women who had oophorec-
tomies and received ERT reported anxiety and depres-
sion similar to women whose ovaries had been pre-
served, but less than those who had oophorectomy
without ERT (Nathorst-Boos, von Schoultz, & Carl-
strom, 1993). It appeared that the ERT ameliorated the
psychologic symptoms of the women who had both
hysterectomy and oophorectomy.
However, several studies indicate that women may
stop taking daily ERT because of headache, irritability,
breast soreness, or risk of cardiovascular disease (Keat-
ing, Manassiev, & Stevensen, 1999; Rako, 1998).
Estrogen replacement therapy users are younger and
more likely to be white women with higher incomes and
educational levels (L. Rosenberg, Palmer, Rao, &
Adams-Campbell, 1998). Many women who are pre-
scribed ERT express dissatisfaction with the side effects
and dosages, whereas many other women have not even
heard of ERT (Mingo, Herman, & Jasperse, 2000).
Only small numbers of women receive ERT, owing to a
number of factors, including fear of potential complica-
tions and adverse side effects (Keating et al., 1999). Of
women who do receive ERT, compliance with the ther-
apy is low (Keating et al., 1999). Without routine
endocrinologic monitoring of follicle stimulating hor-
mone (FSH) levels, the need for ERT after hysterectomy
is often missed (Khastgir & Studd, 1998).
SeptemberlOctober 2001
Anxtety
High rates of anxiety and depression have been
reported in women after hysterectomy in retrospective
studies. Several prospective studies, however, suggest
that hysterectomy for benign disorders does not cause
anxiety and depression but may decrease distressful
symptoms in women. The improvement in preoperative
symptoms of depression and anxiety is consistently seen
in prospective studies of women undergoing hysterecto-
my (Alexander, Naji, & Pinion, 1996; Carlson, 1997;
Khastgir, Studd, & Catalan, 2000).
Significance of This Review
Although hysterectomy relieves the preoperative
symptoms of heavy bleeding and pain related to
endometriosis and cancer in women, it carries a sub-
stantial risk of morbidity. After hysterectomy, women
may experience complications in the postoperative
recovery period that may vary with the type of surgical
procedure. During this period, the quantity and quality
of women’s sleep are influenced by various factors,
including the type of surgery, postoperative pain, anxi-
ety, and fatigue.
Despite limited evidence that sleep problems occur
frequently during the recovery period, only a few
researchers have systematically examined the sleep pat-
terns in women who have had a hysterectomy. None of
these studies, however, used objective sleep measures or
examined multiple dimensions of these women’s lives.
A woman’s experience of postoperative symptoms must
be reviewed within the context of complex biopsy-
chosocial influences. To understand the woman’s symp-
tom experience, her prevalent postoperative symptoms
must be explored and evaluated in conjunction with the
biopsychosocial aspects of her life, so that targeted
strategies can be used to reduce her symptoms.
Implications
There is a growing body of biomedical and psychi-
atric literature on the effects of hysterectomy although
only a small number of studies were found in the nurs-
ing literature. Nursing research is needed to ascertain
women’s symptom experience after hysterectomy. This
review has implications for further nursing research on
this topic. As discussed, the conceptual framework of
symptom experience associated with a biopsychosocial
perspective can provide a model for nursing research in
women’s symptom experience after hysterectomy. Such
research can build upon recent advances in understand-
ing and managing acute and chronic symptoms such as
pain, sleep disturbance, fatigue, anxiety, and depression.
Although hysterectomy relieves unpleasant preoper-
ative symptoms, the literature indicates that women
JOG” 477
experience varying degrees of consequences, from posi-
tive to negative, depending on the surgical procedure
performed, the method of measurement, use of hor-
monal therapy, and women’s biopsychosocial differ-
ences. The consequences of hysterectomy in women’s
lives are not well understood. Therefore, more research
is needed to examine women’s symptom experiences
after hysterectomy in relation to their lives, using the
conceptual framework provided. A woman’s perception
of pain, disturbed sleep, fatigue, anxiety, and depressed
mood must be considered within the context of her
complex environment. To understand women’s symp-
tom experience, researchers must focus on multidimen-
sional aspects of women’s lives, including the physio-
logic, psychologic, and sociologic environments.
Future research also should include women from
diverse cultures.
In practice settings, health care providers who work
with women undergoing hysterectomy need to be aware
of the symptoms that women are experiencing on a
daily basis, any changes in those symptoms, and the
effect that the changes in symptoms may have on
women’s well-being. It is not always possible to affect
the symptoms associated with hysterectomy. However,
it is possible to ascertain the sources and levels of symp-
toms and provide a woman with the self-care skills she
needs to cope more effectively and to reduce the distress
associated with these symptoms after hysterectomy.
Health care providers caring for women after hys-
terectomy should not attribute the negative symptoms
entirely to physiologic factors. They should consider the
psychologic and sociologic factors in women’s lives
when planning interventions. Provider education is
needed to integrate the biopsychosocial aspects of care
for women. Education programs also must be conduct-
ed in community settings to teach families and
women’s support systems about hysterectomy. Such
programs can provide current information about
women’s gynecologic health and the available alterna-
tives to hysterectomy.
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480 JOG"
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Kimberly H. Kim is an assistant professor, Department of
Nursing & Health Sciences, California State University,
Hayward.
Kathryn A. Lee is a professor and James & Marjorie Liv-
ingston Chair, School of Nursing, University of California,
Sun Francisco.
Address for correspondence: Kimberly H . Kim, RN, PhD,
Department of Nursing & Heafth Sciences, California State
University, Hayward, Hayward, CA 94542-3086. E-mail:
kimhyek@aol.com.
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