In this study, the key concepts and categorization of the initial codes were conducted and reported based on the predicted categorization in the RAM interdependence mode. The demographic characteristics of the participants have been summarized in Table 1. Data analysis led to the product of 537 initial codes from the experiences of the participants, by merging similar codes, 124 codes were obtained. Finally, the theme of growing interdependence emerged, which includes two categories and six sub-categories (Table 2).
Evolution of addiction and interaction with important people in life
Most of the participants in this study reported feeling a sense of loss after a hysterectomy, which affected their emotional state and their emotional relationships. In the present study, participants experienced a change in their relationships with important people in their lives after the hysterectomy. These changes ranged from increasing relationships to decreasing relationships. This category consists of three sub-categories.
Evolution in the spiritual relationship
Most participants experienced fear and unreliability after hysterectomy. Most participants said they sought refuge in a source of power to overcome this fear and uncertainty. They often improved their spiritual relationship with God as absolute power. One participant said that:
“My communication with God has been increased. I feel like he was by my side during this difficult time. I talk to him more. I relied on God. (P16)
A small number of participants diminished their relationship with God and complained to God about the loss of their womb. One of the participants said:
“I had so many problems after the hysterectomy. I complained to God. I was ungrateful…I lost my relationship with God…” (P21)
Fluctuating emotional dependence on offspring
Most participants reported losing their fertility after uterine surgery. Consequently, they became emotionally dependent on their children. They described knowing that current children are the only possible children for them to increase their dependency, intimacy with their children, and described their close relationship with their children. One of the participants said:
“I missed the opportunity to have children, so my dependency on my children increased dramatically. I only had these two children. (P22)
A small group of participants described their negative psychological experiences after hysterectomy and said these experiences reduced their dependence on their children. Participants described decreased attachment, efforts to reduce dependency, and reduced intimacy with children. One participant said:
“I blamed others, even my children in my hysterectomy. If I hadn’t gotten pregnant, I would have remained a whole, healthy person. I am not as attached to my children as before. (P28)
For many participants in this study, hysterectomy was the primary driver of child dependency. They were therefore more committed to caring for their children. Seizing every opportunity to express love and affection for her children was a behavior that these women displayed due to the loss of their fertility. They said they were more sensitive to the future and the health of their children. One participant said:
“I can’t have any more children, so I have to take more care of my children so that nothing happens to them…” (P1)
Change in the emotional relationship of the spouse
Most of the participants said that the hysterectomy had affected their emotional relationship with their partner. Most of the participants described the improvement in their emotional relationship with their partner because of the support they received from their partner after the hysterectomy. Some have said that being with their spouse can calm them down. Others indicated that the presence of their spouse during illness and treatment increased their interest. One group also described the need to be with one’s spouse. Some also wanted to have a more intimate relationship with their spouse. One participant said:
“After the hysterectomy, I had a better relationship with my husband than before. I have peace by his side. We spend more time together. (P14)
Some participants said the loss of the uterus made women feel empty and deficient. They worried about their partner’s reaction to their condition. This concern led some of these women to describe problems in their relationship with their husbands. They were reluctant to talk about their personal problems with their spouse. They did not accompany their spouse for work and leisure, they felt disinterested in their spouse and some said they wanted to be independent of their spouse. One participant said:
“After the hysterectomy, I try to get away from him…I worry about what he thinks of me. I won’t talk to him about myself anymore. (p13)
Some women did not receive enough support from their husbands after the hysterectomy and as a result they felt alone and abandoned. Lack of spousal support damaged women’s emotional relationships with their husbands and caused an emotional rift between them. One participant said:
“If I hadn’t been emotionally attached to my husband, his absence after a hysterectomy wouldn’t have upset me. I’m disappointed with him. I can’t easily communicate with him. (P7)
Some participants owed it to the affectionate behavior of their spouse. They tried to compensate for the affectionate behavior of their wives. They have strengthened their emotional relationship with their spouse. They tried to improve their emotional relationship with their spouse. They said the relationship between them has become friendlier than in the past. One of the participants said:
“I am indebted to my husband’s behavior. He was committed to me during the difficult surgical conditions. Now I appreciate my husband more. I like it better. (P15)
Reinforced support system
In this study, a support system including family, co-workers, friends, and healthcare providers was described that supported participants in the areas of physical, caring, emotional, and informational support. This category consists of three sub-categories.
The family as a refuge to receive emotional support and care
For most participants, family served as a refuge for emotional support and care. Many participants said that their family members had comforted them. Some women reported that after the hysterectomy, they welcomed their husband’s supportive and caring behaviors. Some participants also described financial support from spouses. A group of women described receiving family care, including husbands, parents, sisters and even relatives. They said that when they felt lonely, they found their partner by their side. Some participants said they sought refuge with family when they experienced complications such as anxiety and stress after a hysterectomy. Being with family members calms them down. They trusted to receive the support of their family in difficult times. Although they are hesitant to attend public gatherings, they prefer to attend family gatherings. One participant said:
“I have been stressed and anxious since the hysterectomy. So I take refuge in my family (father, mother and sisters). I am at peace with them. They comfort me. (P28)
Friends and supportive peers
Many women after a hysterectomy describe physical limitations, especially at work and in life. They said that after facing these limitations, they appreciated the support, encouragement and help from colleagues, friends and others to overcome these limitations. Some participants explained that because talking to men about female genitalia was taboo, they tried to hide the type of surgery in their work environment. They said that when co-workers realized how difficult it was to get around and get work done, they helped a lot by doing hard work without asking why. Additionally, some participants described their experience of being encouraged by co-workers and workplace officials to seek treatment. One participant said:
“After the hysterectomy, I couldn’t work hard anymore. Since most of my colleagues were men, I couldn’t tell them about my surgery. But they helped me. They made sure that I was not under pressure during work. (P6)
Many participants were concerned about the lack of information about hysterectomy and its complications. In this regard, they communicated with women who had previously undergone a hysterectomy. They have become a source of information for the participants. One participant said:
“I faced a lot of problems after my hysterectomy. I met several hysterectomized women. They guided me. I always get help from them. (P8)
Some participants pointed to their friends as a source of support. They said their friends gave them emotional support and post-hysterectomy care. A group of women said they were taking refuge with their friends and spending more time with them. One participant said:
“I hid my surgery from my family, only my friend came with me. She took care of me.” (P13)
Supportive care providers
A group of health care providers and several physicians provided emotional support to participants during treatment and follow-up visits. During post-hysterectomy care, receiving clinical care with expressions of affection from healthcare personnel, including pain relief, nutritional assistance, and mobility, were some of the things participants described. Some participants felt intense pain. They said they had no hope of recovery at the time, but the information and advice provided by the nurses was promising and eased their suffering. Some of the participants experienced fear combined with a feeling of loneliness in the recovery room. Fear and ignorance of what had happened caused some participants to feel insecure in the first hours after the operation. The loving behavior of the doctor and the nurse made them feel safe. One group of participants described receiving emotional support and encouragement from healthcare staff. They said the support went beyond the physiological care expected of a doctor or nurse during an illness. Some said that the caring behavior of the doctor and hospital health staff motivated them to deal with the situation. One participant said:
“After the hysterectomy, I was hospitalized in the intensive care unit. This atmosphere scared me. But the ICU staff were excellent. I will not forget the energy I received from them at the period (P7)
