International Research Journal of Social Sciences______________________________________ ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci. International Science Congress Association 15 Hysterectomy among Premenopausal Women and its’ impact on their Life- Findings from a study in rural parts of India Sardeshpande Nilangi N. Tata Institute of Social Sciences, Mumbai, INDIAAvailable online at: www.isca.in Received 24th December 2014, revised 6th February 2015, accepted 24th March 2015 Abstract Hysterectomy among premenopausal women is an area of concern as early menopause exposes women to a host of health problems. In India, there have been several news reports from different parts of the country about hysterectomies among young women. This study is based on in depth interviews conducted with 44 women who had undergone hysterectomy and were less than 45 years in age at the time of interview. The study was conducted in the state of Maharashtra which is one of the economically developed states of India. The study delves into the reasons for accepting hysterectomy and understanding women’s perceptions about how hysterectomy has impacted their health. Using Feminist methodology, the study probes the decision making processes before undergoing surgery and the ways in which women cross the gender barriers in accessing health care services. The study found that on one hand women felt relieved from the health problems, but they were also unhappy about losing their body part. In the rural agriculture setting, the gender division of labour is such that women have to perform several tasks to run the household as well as manage the agricultural work. Several women complained about the decline in their work capacity and also regretted the decision of undergoing surgery. Women blamed their circumstances such as obligations of working in fields which could not allow them to take adequate rest after surgery. Yet, it was seen that women were unwilling to share their negative experiences of surgery with other women who were contemplating about hysterectomy. In the rural settings, woman’s contribution to the family labour is essential; however hysterectomy at young age reduces this contribution as it decreases women’s capacity to work. In the context, where spate of hysterectomies is being reported from different parts of India, this study highlights that hysterectomy in premenopausal women is going to become major public health problem in India as all these women are being pushed into early menopause and related health problems. Catering to the needs of these women is going to be a daunting task for the health system in India which is still battling for providing access to basic services such as access to safe abortion services or safe delivery services. Keywords: Hysterectomy, premature menopause, impact on health, India. Introduction Hysterectomy which is the surgical removal of uterus is one of the commonest surgeries in women all across the globe. It is estimated that by the age of 60 years, approximately one third of women in the USA have had a hysterectomy. Of these, 75% surgeries are among the women between the ages of 20 and 49 years. In the United Kingdom , in 2001, 21% of women aged 55– 59 were estimated to have had a hysterectomy whereas in Australia, 14% of women aged 18 years or above had had a hysterectomy. Of late, hysterectomy among pre-menopausal women in India is being raised as a matter of concern by women’s health activists. Several news reports and few studies have substantiated that women are being subjected to hysterectomy in an unscrupulous manner for the health conditions which do not warrant surgical treatment. At present, there is no national level survey which gives prevalence of hysterectomy in India. Conceding to the persistent demand from health activists, Government on India has recently included questions on hysterectomy in the national level health survey. Though the data on prevalence of hysterectomy is not available, there are studies which have identified premature menopause that is menopause before the age of 40, as an emerging area of concern in the field of women’s health in India. A 2005 study found the prevalence of premature menopause in India to be around 11%, far higher than levels recorded in Western countries, which range from 1 to 4%4,3. The study revealed that premature menopause disproportionately affects rural and less-educated women. Recent most round of National Family Health Survey had also found that for 18% of women in the age group 30 to 49 years, the last menstrual period had occurred six or more months preceding the survey. These women included women who had undergone hysterectomy though separate data for hysterectomy was not available. Hence, women in India are facing dual situation, where on one hand, accessing good quality health care within physical proximity is still challenging for several women, on the other hand, unnecessary surgical interventions for gynaecological International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 16 morbidities is also becoming a norm. Hysterectomy among premenopausal women is a major public health problem as a sizeable proportion of women in the reproductive ages are now moving into menopausal stage, catering to their health needs will pose a dual burden of providing services for tackling the problem of reproductive health problems including services required for safe delivery. This premature induction of menopause in women has very grave consequences on women’s bodies as the hormones produced by ovaries play crucial role in maintaining women’s health. So after the hysterectomy, women may temporarily be relieved of the gynaecological problems for which they sought treatment but a host of other problems arising due to surgery or hormonal imbalance occur subsequently. Given the fact that several news reports have highlighted the spate of hysterectomies in different parts of country, it is important to understand the context in which women are accepting hysterectomy as the option for the treatment. It is essential to understand the impact of this surgery on women’s lives because sometimes the surgeries are conducted even in early twenties. In a study conducted in the state of Andhra Pradesh, average age at which hysterectomies were done was 28.5 years. It is important to note that these hysterectomies are taking place in the same milieu where several women are not able to access basic services such as access to safe delivery or access to safe abortion. Analysis of the women’s health situation in India reveals that the inferior status accorded to women has deleterious effects on their health and limits their access to healthcare. This paper is based on a study undertaken in Maharashtra which is one of the larger states of India. The study looks in to the ways in which women overcome the cultural and financial barriers before undergoing hysterectomy and the impact of hysterectomy on women in premenopausal age group. Study setting: Maharashtra is the second most populated state in India, which houses around 112 million people. Around 45% of the population in the state resides in urban area. Mumbai, which is the capital of the state, is the hub of economic activity in the country. The state contributes about 14.4% of the national GDP. As per India Human Development Report 2011, Maharashtra ranked 5th in the country with a Human Development Index of 0.572. Despite high Gross State Domestic Product, Maharashtra’s poverty ratio was 30.7% indicating the inequitable distribution of resources in the state. Resources in health sector are mostly concentrated in the private health sector. The utilization of health services from the public health sector is very low. Despite the cost implication, even poor families seek services from private health sector as they are perceived to be of better quality than the public health services. The implementation of laws and policies regarding private health sector regulation is abysmal in the state, thus large number of unnecessary surgical interventions such as deliveries by Caesarean Section or hysterectomies are reported from different regions of the state. Various studies have highlighted the barriers faced by women in accessing health care services. However, with increasing irrational interventions, it has become necessary to study the quality and rationality of services that women are receiving. Also, it is important to understand the ways in which women are overcoming the barriers in health care access such as financial barriers or cultural barriers. Hence, this study was undertaken to investigate the phenomenon of hysterectomy in premenopausal women. Methodology The study uses qualitative approach using in-depth interview as the research method. Women with hysterectomy and less than 45 years in age at the time of interview were included in the study. Primary objective of the research was to study hysterectomy as an illustration of women’s health care access to understand the ways in which women overcome the barriers in accessing health care. The study also looked into women’s perceptions about reproductive morbidities and the influence of these perceptions on the acceptance of hysterectomy, the process of decision making within the household before undergoing hysterectomy. Another aspect of the study dealt with the ways in which the financial barriers were overcome for undergoing hysterectomy and importantly, the study documented the experiences of women regarding effects of hysterectomy on their physical health. Limitations of the research: This study exclusively focuses on the perspectives and experiences of women who have undergone hysterectomy, whereas the perspectives of health care providers have not been taken in to account. Another limitation is that given the limited geographical coverage of the study, the findings of the study are not generalisable. Locale of the study: The study covered 14 villages from two districts viz. Pune and Satara in the state of Maharashtra. From Pune district, Velhe and Purandhar blocks were included in the study, whereas, from Satara district, Wai and Khatav blocks were included. The data for the qualitative study was collected between June 2013 to November 2013. Prior to conducting this qualitative study, a household survey was conducted in the state where information regarding hysterectomy was sought from all women above age of 15 years. The districts which reported highest number of hysterectomies were selected for subsequent qualitative study. Sampling: Selection of districts and blocks was done using systematic random sampling method. The state of Maharashtra consists of five geographical regions viz. North Maharashtra, Vidarbha, Marathwada, Konkan and Western Maharashtra. The International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 17 districts from these five geographical regions of the state were given ranks on the basis of the score obtained by using indicators such as Level of urbanization, Hospital beds per hundred thousand population, Under 5 mortality rate, Female literacy rate and District Domestic Product. After ranking districts from each region, they were divided into two categories based on the development status. In each region, one district from category of high development and one from the category of low development was selected randomly. Further, within each selected district, the blocks (sub-districts) were ranked on the basis of level of urbanisation and then divided in to two strata (blocks with higher and lower urbanisation). One block from each of the stratum was randomly selected for the study. In the selected blocks, villages were selected purposively to cover villages near to the block town as well as far from the block town. In the selected villages, women who fitted the criteria of selection i.e. age less than 45 years at the time of interview and with history of hysterectomy were interviewed. Information regarding women who have undergone hysterectomy was generated with the help of local health functionary. Sampling size was not decided a priori. Saturation sampling was used and interviews were continued till no new information was being generated. Total 44 interviews were conducted in 14 villages. Tools for data collection: For conducting in depth interviews, an open-ended guide was used where broad areas of enquiry included knowledge of role of reproductive organs and attitudes about menstruation, information about previous reproductive events such as deliveries, use of contraceptives and history of sterilisation, questions related to the gynaecological problems for which hysterectomy was done, regarding acknowledgement of woman’s problems by other family members, regarding permission from the family for seeking care, about interactions with the health care providers consulted, experience of the surgery and health problems faced after surgery and the financial implications of the surgery. All the interviews were recorded and subsequently transcribed and translated into English. Data was analysed thematically. The study was conducted conforming to ethical principles. Written informed consent was sought from all the participants prior to starting the interview. The study was reviewed and certified by the Institutional Ethics Committee. Results and Discussion Findings: Socio-demographic profile of the respondents: Out of the 44 respondents, maximum number of respondents (20) belonged to the age group 36 to 40 years at the time of interview. Lowest age of the respondent was 30 years and highest age at the time of interview was 45 years. In the study, lowest age at which hysterectomy was performed was 22 years whereas majority of the respondents (33) got operated between 31 to 40 years of age. Almost one fourth of the respondents reported that they got operated before the age of 30 years. 41 respondents were married at the time of interview, two were widows and one was separated from husband. Regarding educational status, it was seen that one fourth (11) had never been to school, seven had completed primary education. More than half of the respondents (26) had studied beyond primary level. More than two third (30) of the respondents were engaged in agricultural work. Six respondents were home makers, whereas remaining were either working as village level health functionaries or were self-employed. Several of the respondents were members of self help groups. One of the reasons for better access to health services could be their participation in self help groups. Studies have demonstrated that women’s involvement in decision making increases due to their participation in the SHGs. History of deliveries and contraceptive usage among the participants: Total 130 pregnancies were reported by the respondents. Out of 44 respondents, two had no children, 22 respondents had two children each, 15 respondents had three children and five respondents had four children. Information regarding place of delivery, reasons of home delivery and delivery related complications was sought for 113 deliveries which includes 4 neonatal deaths. Remaining 27 include MTPs and natural abortions. In most of the cases, first delivery was before the age of 18 years. Deliveries among young women are known to have adverse pregnancy outcome10. Most of the respondents had undergone sterilisation before hysterectomy. Reproductive morbidities reported by the respondents: Total 97 different symptoms were reported by 44 respondents. Menstrual problems such as prolonged menses, frequent menstruation and heavy bleeding during menses were reported by majority (24) of the respondents. Second most complaint was pain in abdomen which was reported by 22 respondents. One fourth (12) of the respondents reported that they suffered from prolapsed uterus at the time of surgery. Due to the recurrent blood loss, menstrual problems were associated with weakness in case of seven respondents. White discharge was reported by 15 respondents. Out of these 44 women, 32 hysterectomies were performed by abdominal route and 12 were performed by vaginal route. Cochrane review which compared the three surgical approaches i.e. abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy for conducting hysterectomy, has indicated that vaginal hysterectomy is the best surgical approach as it results into quicker return to normal activities, fewer infections and episodes of raised temperature after surgery, and a shorter stay in hospital compared to abdominal hysterectomy11. This finding is also endorsed by Johnson, N. et.al 12. In the study area, however abdominal route was seen to be preferred by the surgeons. International Research Journal of Social Sciences__ Vol. 4(4), 15-22, April (2015) International Science Congress Association Reproductive health problems for which hysterectomy was done Reasons for undertaking hysterectomy: In the study, it was seen that none of the respondents had any knowledge about why women get menses and about the role of different reproductive organs in the body. The common perception was that the function of uterus is only producing children. Hence, uterus was considered dispensable once desired family size was achieved. Fear of cancer, failure of medical treatment, pract in living with reproductive health problems, fear mongering by the doctors and belief in the hysterectomy as the best treatment, these were the reasons for which women accepted hysterectomy13 . It is true that cancer is more common among w omen as compared to men in India, and cervical cancer constitutes one of the major reasons for cancer in India However, in the study it was seen that doctors instilled the fear of cancer in cases like fibroids of uterus which rarely turn cancerous. Mos t of the hysterectomies were conducted in private health sector which had its financial implications on the respondents. Studies have shown that in absence of robust public health infrastructure in rural areas, the poor have to rely on private health facil ities and the rise in the cost of private health care poses serious concern to the poor15. Impact of hysterectomy on physical health of women: Removal of ovaries at the time of hysterectomy has been one of the important issues of concern given the import by ovaries in performing hormonal functions. Studies have shown that women with long- term oestrogen deficiency face increased risk of osteoporosis and heart disease, stroke, hip fracture, depression and anxiety3, 16.  Sciences__ ______________________________________ ____________ Science Congress Association Figure-1 Reproductive health problems for which hysterectomy was done In the study, it was seen that none of the respondents had any knowledge about why different reproductive organs in the body. The common perception was that the function of uterus is only producing children. Hence, uterus was considered dispensable once desired family size was achieved. Fear of cancer, failure of medical treatment, pract ical difficulties in living with reproductive health problems, fear mongering by the doctors and belief in the hysterectomy as the best treatment, these were the reasons for which women accepted . It is true that cancer is more common among omen as compared to men in India, and cervical cancer constitutes one of the major reasons for cancer in India 14. However, in the study it was seen that doctors instilled the fear of cancer in cases like fibroids of uterus which rarely turn t of the hysterectomies were conducted in private health sector which had its financial implications on the respondents. Studies have shown that in absence of robust public health infrastructure in rural areas, the poor have to rely on private ities and the rise in the cost of private health care Impact of hysterectomy on physical health of women: Removal of ovaries at the time of hysterectomy has been one of the important issues of concern given the import ant role played by ovaries in performing hormonal functions. Studies have term oestrogen deficiency face increased risk of osteoporosis and heart disease, stroke, hip Immediate post- operative health problems: surgery, injuries to organs such as bladder, ureters and bowel, post- operative bleeding, retention of urine, urinary infection, wound infection, fever are some of the known complications after hysterectomy17 . Along with problems related to physical health, depression after hysterectomy was also reported in one of the studies. Economic stress faced due to surgery was one of the main reasons for the depression 18 In the present study, out of 44 respo respondents had reported immediate post operative health problems. Difficulty in passing urine and severe pain in abdomen, these were the main health problems reported by several respondents. Problems like giddiness, weakness, lo appetite, headache, nausea, vomiting, back ache were reported by eight respondents out of forty four. Some of the respondents also complained about diarrhoea, numbness in legs and infected stitches which required treatment for longer duration. Neglig ence on part of doctors was evident in two cases which led to intra- operative or post operative health problems. In one case, due to inadequate effect of anaesthesia, the respondent could feel pain even at the time of surgery. In another case where the sur gery was done through vaginal route, the doctor had forgotten to remove the vaginal pack. Due to the obstruction caused by this pack, the respondent could not pass urine for a very long time, later on when the doctor removed the pack, the problem was allev iated. Most of the respondents were hospitalised for a week after surgery. There was variation in the advice given regarding period for which rest was required. The suggested period for rest varied from one month to six months. The doctors had forbidden wo men from doing strenuous work after hysterectomy. However, in the rural agricultural setting, women do not have the luxury to take rest for such a long  Amenorrhoea Menstrual problems Pain in abdomen Prolapsed uterus White discharge Backache Itching in vagina Problem with passing urine Weakness Miscellaneous ____________ ISSN 2319–3565 Int. Res. J. Social Sci. 18 operative health problems: Bleeding during surgery, injuries to organs such as bladder, ureters and bowel, operative bleeding, retention of urine, urinary infection, wound infection, fever are some of the known complications . Along with problems related to physical health, depression after hysterectomy was also reported in one of the studies. Economic stress faced due to surgery was one of 18 . In the present study, out of 44 respo ndents, almost half of the respondents had reported immediate post operative health problems. Difficulty in passing urine and severe pain in abdomen, these were the main health problems reported by several respondents. Problems like giddiness, weakness, lo ss of appetite, headache, nausea, vomiting, back ache were reported by eight respondents out of forty four. Some of the respondents also complained about diarrhoea, numbness in legs and infected stitches which required treatment for longer duration. ence on part of doctors was evident in two cases which operative or post operative health problems. In one case, due to inadequate effect of anaesthesia, the respondent could feel pain even at the time of surgery. In another case gery was done through vaginal route, the doctor had forgotten to remove the vaginal pack. Due to the obstruction caused by this pack, the respondent could not pass urine for a very long time, later on when the doctor removed the pack, the iated. Most of the respondents were hospitalised for a week after surgery. There was variation in the advice given regarding period for which rest was required. The suggested period for rest varied from one month to six months. men from doing strenuous work after hysterectomy. However, in the rural agricultural setting, women do not have the luxury to take rest for such a long Amenorrhoea Menstrual problems Pain in abdomen Prolapsed uterus White discharge Backache Itching in vagina Problem with passing urine Weakness Miscellaneous International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 19 period. Most of the respondents started with household chores within fifteen days of surgery. However, in the immediate post operative period they tried to refrain from intense physical activities and limited themselves to activities like cooking which could be done by sitting in one place. Health problems faced in long term: Out of 44 respondents, 39 respondents reported that they were facing health problems after surgery as well. In fact in some cases there was no relief from the problems like pain in abdomen which existed prior to the surgery and did not get alleviated even after surgery. In such cases, women were very unhappy because they had considered that surgery would relieve them from the health problems, but in reality new problems had started after surgery. Back pain was the commonest health problem reported by the respondents. Women believed that uterus is attached with strings which also provide support to the back and thus once uterus is removed, this support is lost. Hence, the ability to lift weights or take heavy loads goes down. Some of them also related back pain to the spinal anaesthesia given at the time of surgery. Another common problem women reported was significant weight gain after surgery. Respondents felt that their agility has reduced after surgery. Increased weight hampered their ability to do work in the field. In rural set up in India, agriculture is main occupation for many of these respondents which involves doing work in bending position and hence back ache was perceived as major hindrance to work. Along with back pain, several other respondents complained about other musculoskeletal disorders such as muscle pain and joint pain. Hot flushes were reported by some of the respondents. Respondents were certainly unhappy about their decreased capacity. In the study, it was seen that in the pre-surgery counselling sessions where the doctor is expected to give information about the possible consequences of surgery, the doctors did not speak about hormonal problems that women would face after surgery. Barring one or two cases, women were not aware about menopausal problems. None of these respondents were given hormone replacement therapy. One of the respondents said that when she went to see another doctor for her frequent aches and pains, he said that calcium in her body has gone down and that it was a mistake to do hysterectomy. However, none of these doctors speak about these health problems prior to the surgery. Listening to such comments after surgery, women regret their decision of hysterectomy but in vain. Women’s perceptions about self image after hysterectomy: Almost one fourth of the respondents did not have any particular feeling associated with loss of uterus. Out of the remaining respondents, some expressed sadness or regret over losing uterus whereas some felt relieved after surgery. As far as perceptions about physical health are concerned, the respondents described that they felt feeble after surgery; they felt as if their strength has gone down. Many of the respondents narrated that when they were getting menses, they felt light and agile; however, as they are not getting menses anymore, their body has become heavy. Respondents expressed their feeling of emptiness inside the body after surgery. They said woman with her bag inside feels full. One of them said that now it feels like a pit inside. One of the respondents articulated that she feels that she has lost balance of her body. She said that the uterus must be attached in the body with the help of strings, now after surgery; the strings may have loosened so she can’t maintain balance. One of the respondents expressed that she felt that she is permanently disabled now after the bag is removed. Few other respondents expressed the regret about removing uterus at early age. Most of them feared death if surgery is delayed. More than their own health, the priority for surgery was given so that they can look after children and husband. Fear of cancer was also quite gripping, as several of them mentioned that once a person gets cancer, no amount of money can cure it. Women were worried that if they deny surgery and face fatal complications then the children would become orphans. However, there were few women who were happy about the surgery. They felt good and relieved. They said that they felt relieved because now they don’t have to think about any complication of the health problem. Some of the respondents had expressed that even after hysterectomy, for few months they could feel the changes before the date of menses like heaviness in the breast, which waned subsequently. Further to the question about how women felt after surgery, a specific probing question was asked about what positive changes they experienced after surgery. Interestingly, several women were happy about not getting menses. In India, menstrual taboos exist and women are disallowed from participating in religious rituals if they are menstruating. Many times women take pills to postpone the menses if any religious festival is coming up. Thus, women were very happy that now they don’t need to bother about menses coming during festival period. In rural areas, use of sanitary napkins is rare. Mostly women use rags during menses. Several women complain discomfort at the useof rags because due to frequent use, these rags become hard and cause peeling of the skin. Women who were suffering from problems like heavy bleeding were feeling very relieved after surgery as now they didn’t have to manage bleeding problems. Respondents felt relieved that now they don’t have to wash the blood soaked clothes. Respondents were happy that the health problem is gone, one of them also called it as the bug is gone. International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 20 Some of the respondents were happy because they don’t have to worry about cancer now. Most of the respondents were worried about the complications of their gynaecological problems and after surgery they were feeling relieved that now they will not have to face any complications. Implications of hysterectomy on family life: Some of the respondents expressed that since their strength and ability to work has reduced, the family is getting affected. Husbands at times disapproved that the wife is not working as much as they expected. Since after surgery, women were not allowed to lift heavy weights, hence the husband had do tasks like fetching water. Women also said that in rural set up, most of the work requires lifting loads, hence the husband felt burdened. One of them reported that there were clashes between her and the mother in law when she could not work. The mother in law did not allow taking rest and she had to do all the work including fetching water, washing clothes and such. Only few of them spoke about how the surgery affected their sexual life. Dyspareunia i.e. painful sexual intercourse, dryness in vagina and decreased libido were the symptoms reported by some other respondents. Most of the respondents said that they refrained from sex at least for 5 to 6 months. Some of them also reported that surgery did not affect their sexual life. Discussion: Although the implications of hysterectomy on physical health and mental health have been well established through various studies, the social impact of this surgery varies with the social context. In the rural agrarian society where this study was undertaken, women’s role in economic production is of immense importance for the family. In the study, out of 44 respondents more than one third of the respondents were single-handedly managing the farming activity as their husbands were self-employed and were not engaged in agricultural work. In these families, women’s illnesses are treated without delay as the family couldn’t afford to keep women out of agricultural activities. Similarly post-surgery health problems also impact families seriously as it is difficult for the families to visit health care provider recurrently. It was seen that women feel burdened that the family has already spent huge sums for surgery and hence do not talk about the post operative health problems. Study conducted by Jean Elson in New England which is a different social context than India had shown that women placed significant value on ovaries as the source of female normality19. Women considered uterus as merely an organ important for producing children, but the ovaries were considered as organ responsible for producing female sex hormones. Women identified removal of ovaries with losing something essential to their sense of femaleness. Removal of uterus was considered essential for relief from bleeding and pain; however, women felt grief and anger for removal of ovaries. Women in the study conducted by Elson had discussed femaleness with regard to hormonal balance and sex drive, and femininity in terms of the ability to display appropriate sexual attractiveness. Whereas in the present study, it was seen that women were not aware about the role of ovaries. In fact, women were never been given any information about the reproductive organs and their functions. In the area where the study was conducted, women often referred to uterus as ‘bag’ and believed that the role of uterus is to carry child. The patriarchal system, which is the dominant form of social system in the study area, places high value on the reproductive role of uterus. Thus certain rituals are followed to celebrate menarche as menarche is an indication of functional reproductive system. In the same patriarchal system, women who have sons are given more value than women who have only daughters. Hence women aspire to have at least one son and consider their family to be complete only when they have achieved this goal. In the present study also it was seen that out of 44 respondents, 42 had either one or two sons, which confirms that only when women have given birth to sons they consider the option of hysterectomy. However, the connection between presence of ovaries and femaleness in the mind of respondents was not evident in the present study. In another study, Elson J. had looked into whether premature termination of menstrual function negatively affects women’s subjective gender identities20. In her study, women acknowledged that since the time of their menarche, women closely associated menstruation with their gender identity. Hence though on one hand they found hysterectomy as a great rescue as it relieved the pain and discomfort they were suffering on the other hand women regretted losing the menstrual cyclicity as it was a regulator of their daily lives. They found menstrual cycles as a feeling of connection to other menstruating women; and considered menstruation as important for their own emotional needs. Whereas in Indian context, women mostly consider menstruation to be a problem, because there are several taboos associated with menses which hinder women’s daily activities during menses. Women are forbidden from taking part in any religious activity if they are menstruating. Also sometimes they are segregated during the days of menses. During menses women are not allowed to cook or mingle with other family members. They sit in one designated corner of the house, where food and water is provided to them. They are not allowed to touch anywhere in the house as they are considered to be polluting in those days. Due to these restrictions, women often view menses as unwelcome especially during festivals. In this context, women in fact feel relieved after hysterectomy as it saves them from this rigmarole of segregation. They feel free to participate in the social and religious functions. Another study conducted by Cabness J. had looked into psychosocial dimensions of hysterectomy. In this study, web based questionnaire was administered to 74 women who had undergone hysterectomy to elicit the responses21. In the study done by Cabness, women had described their pre-surgery emotional experiences as “irritable,” “moody,” “depressed,” and International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 21 “scared” or “fearful” and said that the physical conditions were alleviated after surgery. Women felt being more sociable after surgery and had much improved sexual relations post hysterectomy. There was improvement in the emotional domain as women expressed relief at not having concerns about pregnancy or birth control. In the present study, most of these women had already done sterilisation surgery, hence concerns about pregnancy were not applicable in their situation, however; as mentioned in previous section women certainly felt relieved that now they don’t have to worry about cancer or other life threatening complication of reproductive illness. Another study conducted by Galavotti C. and Richter D. looked into women’s experiences with as well as attitude towards menopause, hysterectomy, and hormone replacement therapy (HRT) 22. In this study, in-depth qualitative interviews and focus groups were conducted at four sites, Alabama, New Mexico, South Carolina, and Texas. Information was also gathered on women’s concerns and what experiences they have had or expect to have with healthcare providers and what they perceived their friends’, families’, and sexual partners’ attitudes are toward hysterectomy. The study found that women definitely were relieved of the symptoms for which they underwent hysterectomy. Women relied on prayers and spiritual help to overcome their fear, anxiety and depressions before surgery, however, no medical help was offered to them by the physician. Women expressed need for more information prior to surgery like different types of surgery or other options for treatment. In some cases, women sought support from their male partners and in some cases from other friends or relatives. Women did not receive adequate information about removal of ovaries and its implications such as need for hormonal treatment thereafter.In the present study also it was seen that women had no knowledge about whether the ovaries were retained or removed. None of them were given hormonal replacement therapy after hysterectomy. Conclusion It is seen that the doctors often tout hysterectomy as a superior treatment option in case of reproductive health illnesses; however, the study shows that this surgery negatively impacts women’s physical health and results in loss of work capacity. Hence, though clinical studies substantiate the benefits of hysterectomy, practically women may not always be benefitted from it. While considering hysterectomy as a treatment option, it is important to consider the background of the patient. In some cases, there was hardly any medical justification for surgery; however, at present there is no mechanism to assess whether unnecessary surgeries are taking place. There is a need to constitute audit mechanisms to ensure that hysterectomies are performed only when they are absolutely necessary. Given the widespread private health sector in India, these audit mechanisms have to be made part of the regulatory frameworks. On the other hand, there is a need to educate women about the physiology of reproductive system and relevant information to make informed decision about hysterectomy should be readily available. Acknowledgement Funding support for this study was received from IDRC, Canada. References 1.Babalola E., Bharucha A., Schleck C., Gebhart J., Zinsmeister A. and Melton J., Decreasing utilization of hysterectomy: a population-based study in Olmsted county, Minnesota, 1965-2002. Am J Obstet Gynecol. 196 ): 214.e1–214.e7. doi:10.1016/j.ajog.2006.10.390 (2007) 2.Markovic M., Manderson L. and Warren N., Pragmatic Narratives of Hysterectomy Among Australian Women. Sex Roles (58) 467–476 (2008) 3.Conway G., Premature Ovarian Failure. British Medical Bulletin S6 (3) 643-649 (2000) 4.Syamala T. and Sivakami M., Menopause: An Emerging Issue in India, EPW 4923-4930 (2005) 5.International Institute for Population Sciences (IIPS) and Macro International National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS 2007) 6.Kameswari S.V. and Vinjamuri P., Medical Ethics: A case study of Hysterectomy in Andhra Pradesh Downloaded from http://kicsforum.net/kics/setdev/hysterectomy-ethics-in-S-T-for-setdev-final-1.pdf on 11-02-2012 (2007 )7.Kamalapur S.M. and Reddy S., Women Health in India: An Analysis, Int. Res. J. Social Sci.2(10), 11-15, October (2013)8.Economic Survey of Maharashtra 2012-13. Directorate of Economics and Statistics: Planning Department, Government of Maharashtra, (2013) 9.Reena, Rajdeep Kaur and Nikita, Impact of SHGs on the level of Participation of the Women in Decision- Making Process: A Comparative Analysis, Int. Res. J. Social Sci., 3(5), 29-31, (2014)10.Gogoi M., Association of Maternal Age and Low SocioEconomic Status of Women on Birth Outcome, Int. Res. J. Social Sci., 3(10), 21-27, (2014)11.Nieboer T. E., Johnson, N., Lethaby, A., Tavender E., Curr L., Garry R, van Voorst S, Mol BWJ and Kluivers KB, Surgical approach to hysterectomy for benign gynaecological disease, Cochrane Database of Systematic Reviews, Issue (). Art. No.: CD003677 (2009) 12.Johnson N., Barlow D., Lethaby A., Tavender E., Curr L. and Garry R., Methods of hysterectomy, systematic review International Research Journal of Social Sciences____________________________________________________ISSN 2319–3565Vol. 4(4), 15-22, April (2015) Int. Res. J. Social Sci.International Science Congress Association 22 and meta-analysis of randomised controlled trials, bmj.com330, 1478 (2005) 13.Sardeshpande N., Why do young women accept hysterectomy? Findings from a study in Maharashtra, India, International Journal of Innovation and Applied Studies, (8), 579-585 (2010) 14.Manjunatha S., A Sociological Study on the Women Cancer Patients in Bangalore City, India, Int. Res. J. Social Sci., 2(7), 8-13, (2013) 15.Poddar S., A Study of Spatial Variation of Women Health Status in Hugli district of West Bengal in India, Int. Res. J. Social Sci., 3(11), 20-26, (2014)16.Sharma S. Prophylactic Bilateral Oophorectomy: Does Benefits Outweigh Risks? (Editorial) JK Science (13), 1, 1-2 (2011) 17.Brummer T., Jalkanen J., Fraser J., Heikkinen A., Kauko M., Makinen J., Seppala T., Sjöberg J., Tomas, E. Härkki and P. FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors. Human Reproduction, 26(7), 1741– 1751 (2011)18.Wang X., Lambert C. and Lambert V. Anxiety, Depression and Coping strategies in post-hysterectomy Chinese women prior to discharge, International Nursing Review,54, 271–279 (2007) 19.Elson, J. Hormonal Hierarchy: Hysterectomy and stratified stigma, Gender and Society, 17(5), 750-770 (2003)20.Elson J. Menarche, Menstruation, and Gender Identity: Retrospective Accounts from Women Who Have Undergone Premenopausal Hysterectomy, Sex Roles., 46 1/2), 37-48 (2002) 21.Cabness J., The Psychosocial Dimensions of Hysterectomy: Private Places and the Inner Spaces of Women at Midlife, Social Work in Health Care, 49(3),211-226 (2010) 22.Galavotti C. and Richter D., Talking about Hysterectomy: The Experiences of Women from Four Cultural Groups. Journal of women’s Health and Gender-based Medicine, (9), S- 63 to S-67 (2000)