Lived experiences of hysterectomy and its effects on the physical, psychological, social and marital life of women under 40 years of age: a qualitative phenomenological study conducted in Lahore, Pakistan

Hysterectomy, the surgical removal of the uterus, is one of the most common gynaecological procedures performed worldwide to treat various medical conditions, including uterine fibroids, endometriosis and abnormal uterine bleeding. 1 2 While the physical outcomes of hysterectomy are well-documented, its broader effects on the psychological well-being, social interactions and marital relationships of women remain an area of ongoing research, particularly in culturally specific contexts. 3 4 Recent studies have explored the multifaceted experiences of women post-hysterectomy. A qualitative study conducted in Iran found that women experienced a heightened need for emotional and social support from family members, particularly their spouses and healthcare providers, highlighting the importance of a strong support system for postoperative adaptation. 5 Similarly, research in Turkey has shown that hysterectomy significantly influences self-perception, body image and emotional well-being, with some women reporting feelings of incompleteness and perceiving the loss of the uterus as a loss of a symbol of womanhood and of femininity, experiences which are often shaped by cultural and social norms. 6 While studies from Iran and Turkey have explored women’s experiences following hysterectomy, these studies are situated within distinct socio-cultural and healthcare contexts. In many such settings, experiences were shaped primarily by concerns related to femininity, sexual functioning and bodily identity. However, in Pakistan, reproductive expectations are deeply embedded within patrilineal family systems, strong son preference and multi-generational (joint) household structures, where fertility is closely tied to a woman’s social status, marital security and acceptance within the marital family. 7 8 Hysterectomy in this context may therefore carry distinct psychosocial implications, as these women are perceived to have lost their reproductive potential prematurely. In South Asian contexts, particularly in Pakistan, the prevalence of hysterectomy is increasing alarmingly 9 ; however, limited research has examined the psychological and social consequences of the procedure. While studies on menopause, a related reproductive health transition, have found high levels of anxiety, depression and stress among postmenopausal women in Pakistan, underscoring the mental health challenges associated with reproductive health changes. 10 11 Furthermore, research suggests that hysterectomy may impact marital relationships, affecting intimacy and sexual function, which can lead to distress in relationships. 12 13 In Pakistan, societal norms and cultural perceptions surrounding the health of women, particularly reproductive health, can significantly impact their psychological well-being. Understanding these perceptions helps in addressing the stigma and misconceptions related to hysterectomy. Women in Pakistan often face societal expectations regarding their roles as mothers and wives, and deviations from these roles can negatively affect their health and self-worth. 14 Hysterectomy, which affects fertility, can alter how they are perceived and treated within their families and communities, especially when women undergo hysterectomy during their fertile period. The experiences of women aged under 40 years of age undergoing hysterectomy in Pakistan can be better understood through a gendered and intersectional lens. Feminist theory highlights how women’s bodies are socially regulated and valued in relation to reproduction, reinforcing patriarchal norms that associate women’s social value and gender identity with fertility and reproductive capacity. 15 Within such systems, reproductive capacity becomes central to women’s social legitimacy. Goffman’s theory of stigma 16 further provides a useful framework for interpreting how the loss of reproductive ability may lead to perceived social discrediting, particularly in contexts where fertility defines marital worth. In Pakistan’s patrilineal and multi-generational (joint) family structures, women’s experiences are shaped not only by gender but also by age, marital status and position within the household hierarchy, reflecting an intersectional pattern of disadvantage. 17 Applying these theoretical perspectives allows for a deeper understanding of how surgically induced menopause intersects with cultural expectations, gender norms and power relations within the family system. Given the interplay of cultural, social and psychological factors, this study aimed to explore the lived experiences of women aged under 40 years of age following hysterectomy within the socio-cultural context of Pakistan. In particular, it sought to understand how women interpret and construct meaning around their hysterectomy experience, how surgically induced menopause influences their sense of identity, marital relationships and social positioning within the family and how broader socio-cultural expectations regarding fertility shape their post-hysterectomy experiences. Understanding these dimensions is crucial for developing culturally sensitive support systems and interventions tailored to the unique challenges faced by this population.

No patient or public was involved in the present study.

A total of seven women were included in the present study, with all women ranging in the age group of 30s at the time of hysterectomy. About half of the women included in the present study were working (four out of seven), while half were housewives (three out of seven). The characteristics of the participants involved and interviewed in the present study are given in table 1 . Four major themes emerged during the data analysis process that included 1) physical and psychological effects, 2) family and communal dynamics, 3) effects on marital life and 4) role fulfilment. Themes with their sub-themes are illustrated in figure 2 . A hysterectomy, the surgical removal of the uterus, can have various physical and psychological effects on individuals. These effects can vary depending on the reason for the surgery, the individual’s overall health and individual factors. Based on the experiences and stories of the participants, the present theme has been categorised into three sub-themes that are discussed below. Hysterectomy procedures can have a significant recovery time depending on the type and method of hysterectomy. During the recovery period, patients’ everyday routines are disrupted. This is because the recovery process is exhaustive and makes the patient unable to perform their usual tasks, imposing a significant physical and psychological effect on them. For our study participants, who were relatively younger than the demographic who undergo hysterectomies, the recovery period was also substantially less. All the participants reported becoming physically active within 3 weeks of the procedure. However, after the recovery period, the procedure leaves behind physical after-effects that manifested for months or even years after the procedure. When asked about the physical changes and pains, the majority of the participants reported experiencing fatigue, hot flashes and body aches. Most complaints were consistent with the symptoms of early onset menopause that hysterectomies bring on. Some participants highlighted their discomfort as: I constantly feel drained and fatigued since my hysterectomy (H1) After my hysterectomy, it is very difficult for me to get up in the morning. I stay in bed for about 30 to 45 min after getting up. Due to the fatigue and body aches, I find it difficult to get up and start my day (H3) Since my hysterectomy, it is not easy for me to stay standing up for more than fifteen minutes while cooking in the kitchen. I feel like my whole body is stuck, stiff and cold and I find it unable to move (H7) However, another participant highlighted her uneasiness while bending and said: I started to realize after my surgery that I cannot bend. I first noticed this while bending to tie my daughter’s shoelaces. It was very painful for me. I felt a sharp irritation in my lower back and felt unable to do it. Now I avoid bending anyway as it is very uncomfortable and unmanageable for me (H6) This exhaustion, persistent fatigue and generalised body aches are some of the various symptoms of early-onset menopause. The sudden onset of menopause that occurs after a total hysterectomy brings many changes in a female’s body. The response of the participants clearly shows that it is difficult for them to get used to menopause, especially as it affects them before the usual age, and they feel many physical symptoms. Exhaustion, fatigue and body aches can impede the performance of daily duties, including household chores and job performance. Hysterectomies do not cause visible external physical change that, for instance, procedures like mastectomies do. The anatomical change is internal, and women physically look more or less the same after recovery. However, sometimes this appearance of normalcy leads to others forgetting about the procedure they had undergone. However, women who have had hysterectomies do feel the loss of an organ, that a part of their body has been removed. Participants mentioned: Sometimes I do feel like I went through a tragedy. Not just because my uterus was removed, but because one of my organs was removed (H2) I feel as if something is missing in my body (H3) For all of the participants, there had been initial fear and apprehension when they were informed that they needed to undergo hysterectomy. This fear was associated with the procedure itself, stemming from a trepidation towards surgery. Many of them did not carry forward these feelings and felt relief that the procedure had been done without complications. However, the feelings of losing a part of their body remained with them. Following hysterectomy, participants perceived that individuals within their primary social circles lacked a comprehensive understanding of the significance of their experience. Instead, these women were often viewed as occupying a socially constructed ‘sick role’ limited to the immediate post-recovery phase. There was little recognition of the lasting effects the women might continue to experience beyond that period, effects that often emerged over several months. This lack of awareness may be partly attributed to the fact that the women themselves did not necessarily identify themselves with the sick role either. As one of the participants succinctly put it, I try to live as normally as possible, but even when I do not hide my pain, people fail to recognize that I have gone through something significant (H5) This highlights that, although the participants did not seek attention or sympathy, they still expected others to show a certain level of sensitivity towards them, given that they had undergone a surgical procedure. Yet another participant shared: If I compare myself with a patient of hypertension, I can realize that people tend to be considerate of their condition and often avoid anything that might bother or upset them. But, in the case of hysterectomy, the behavior of people does not change and they act as if nothing has happened (H6). This conscious comparison with other people in the sick role reveals that though participants did not see themselves as ‘ill’ or ‘sick’, they still wish for some consideration or concern given to other people with better recognised medical conditions. Gleaning from the interview data, all participants felt emotionally distressed following their hysterectomy. Most of them tried to put on a brave face and display ‘sabr’ (an Urdu term that refers to perseverance/patience in the face of trials, hardships or delay, while maintaining faith and trust in Allah’s (God) wisdom) with religious underpinnings of rewards associated with it. Some participants described resuming their daily lives after physical recovery from the surgery, making an effort to suppress any emotional distress they experienced. They emphasised fulfilling domestic and professional responsibilities without visibly expressing vulnerability, often prioritising family stability over personal emotional processing. This return to normalcy was not necessarily indicative of emotional recovery but rather reflected a culturally reinforced expectation that women must endure silently and maintain household equilibrium. Others, however, felt unable to articulate their need for extended emotional support. In the words of one of the participants: I do not how to say it, I do not know how to show it. But there is a part of me that sometimes wishes for some special treatment, some protocol. I do not know how to ask for it (H6). Her reference to ‘special treatment’ and ‘protocol’ suggests a longing not for material assistance but for recognition of the significance of her experience. The hesitation in her words reflects both emotional suppression and uncertainty about the legitimacy of her needs. Within many Pakistani households, overt requests for emotional validation may be perceived as weakness or unnecessary dramatisation, particularly once physical healing appears complete. Similarly, other participants mentioned: I wish my family members could understand what I feel (H4) Sometimes I do wish that someone would talk to me about this. My family, my friends…I wish they would just speak to me about it (H7). These statements do not only highlight the hesitancy felt by participants in admitting to their need for extra emotional support and understanding but also reflect the isolation experienced by women and the communication gap that exists even in intimate relationships regarding hysterectomy and sexual and reproductive health. Further, while interviewing participants, it was asked how the participants had coped with the emotional stress as a result of this surgery. Religious coping emerged as a central adaptive mechanism. The participants added: The negative response and comments of my in-laws regarding my condition helped me get closer to my religion and Allah (God). I used to be a very outgoing person and was not so religious but after my hysterectomy, I felt very isolated. I was losing my hope to recover mentally then I decided to talk to Allah and ask help from Him and it actually helped me to get back to my normal life and cope up with stress (H2). I decided to rely on Allah (God) for comfort (H7) This indicates how the participants sought comfort through faith and prayers when the absence of comfort was felt in their social relationships. Here, faith functioned not as passive resignation but as an active psychological resource. The concept of sabr (patience with faith) provided moral meaning to suffering, reframing hysterectomy as divine testing rather than personal failure. This demonstrates how emotional resilience in this context is culturally mediated through spiritual frameworks An important factor deeply linked to emotional distress is having severe mood swings. A female’s body experiences multiple hormonal changes throughout her life. After this major surgery, hormonal changes occur which cause serious mood swings. These mood swings caused emotional highs and lows, unexpected emotional responses and over-sensitivity. The majority of the participants reported feeling over-sensitive about seemingly innocuous stimuli. Participants, while highlighting the emotional highs and lows characteristics of mood swings, mentioned the following: Some days I feel a butterfly passing by and overjoyed, and on other days I feel consumed with dark, depressing thoughts while doing routine things; like this morning while driving to work (H1). At one minute I am happy while in another minute I feel like crying (H2). I have noted that I may overreact over things which are not such a big deal and at the same time, there are very little things which suddenly make me happy. Or sometimes I will not feel anything over a big issue (H5). I used to be a very calm person but now I myself feel that things are not as serious as I take them to be. Things get on my nerves too easily. I feel that I overreact in many situations that most of the times initiate argument with my husband (H4) These statements highlight the over-sensitivity among the participants and an intense, unexpected emotional response over ordinary stimuli. Such reactions can lead to or worsen arguments with a husband and family members. Further, a theme persistent throughout each interview was the feeling of having a lack of emotional support among the participants. Participants mentioned: When I go through emotional twist and turns, people around me just are not considerate (H6). My family, my husband, my in-laws all supported me physically, financially, socially, in every way. But I was not given an emotional pillow. I was not given an emotional space. Nobody thought that if she’s angry, depressed or just emotionally not well (H7). This is depictive of something that most participants felt: that they were not given any special consideration or leeway regarding any post-hysterectomy effects they faced. Family is one of the most important and primary support systems for an individual, and everyone expects a positive response from family in hard times. While discussing the reaction of family after hysterectomy, we came across some harsh experiences of participants. Taunting and harsh comments have been experienced by all the participants. While the intensity and frequency of such experiences varied, many described feeling emotionally unsupported within their marital homes. Instead of understanding the loss of a woman, in-laws and husband in some cases have been found to be unsupportive in bringing them out of the mental trauma and physical pain. When asked about the response of in-laws and specifically her mother-in-law, one participant mentioned that she had experienced varying complications during her pregnancies from the start. When she had her first miscarriage, which she described as being due to ‘stones in the uterus’ (a term she used to refer to uterine fibroids), she returned home after spending a week in the hospital. She then heard her mother-in-law saying that ‘ she can only produce stones, not a child (H6)’. This statement is indicative of the psychological distress and lack of empathetic response from the in-laws, specifically the mother-in-law. For the participant, it was extremely painful as the participant had tears in her eyes while narrating: I only have one daughter. After surgery (hysterectomy) when I came back to home, my mother in-law started to taunt me and used to ask me to allow my husband to marry someone else because I was unable to give him a son and now it is my moral duty as a wife to set him free for second marriage. I was lucky as my husband did not choose to have a second wife (H2). The participant further expressed that she found it disappointing that a woman could not understand the pain of another woman. This indicates a lack of empathy from the mother-in-law. In most cases, the mothers-in-law did understand the need for a hysterectomy but afterwards were not concerned with their daughter-in-law’s health. Rather, their concern turned to how well their daughter-in-law could perform her wifely duties and whether or not she could bear a ‘grandson’. Another participant described the emotional weight of taunts from her mother-in-law in a similar manner: After my hysterectomy, she would say that I was useless now because I could not give this family a son. She told my husband that he should think about his future and his lineage. I felt as if I was no longer a person but just someone who had failed at her duty. (H1) These statements reveal more than interpersonal insensitivity and lack of empathy; they reveal how reproductive capacity is embedded within patrilineal expectations. In the socio-cultural context of Pakistan, fertility is not merely a private matter between spouses but a collective family concern. The participant’s language, ‘failed at her duty’, demonstrates the internalisation of patriarchal norms that equate womanhood with reproductive success, particularly the production of a male heir. The hysterectomy thus symbolised not only a medical procedure but also a perceived disruption of lineage continuity. Many participants felt that if their mothers-in-law had been more emotionally supportive, it would have helped them cope better with the physical and emotional pain. The majority of the participants described their natal families, including their parents and siblings, as being comparatively more emotionally supportive throughout the surgery and recovery period, particularly in contrast to their experiences within marital households. In every case, women spent a significant period of their recovery time at their parent’s house because they felt they would be better looked after and comforted there. However, we observed in multiple cases that there still existed a gap in the understanding and empathy offered to women who had undergone hysterectomy, even by their own family. One participant noted how her operation had been extremely traumatising as she had been in a life-or-death struggle during it. However, after 6 months of her operation, she spoke to her sister and narrated: She seemed to have forgotten the ordeal I went through 6 months ago. I was so hurt that she did not even ask me if I was alright, (pause), she did not even ask me how I felt (H6). This shows that participants still felt that sometimes their family members fell short of the emotional support and sensitivity they expected. However, all the participants mentioned that their families had been extremely concerned about their health and had been a great help during the healing process. The participants’ families did look after them and focus on the health of the patient; however, they somehow failed to understand the mental trauma they had experienced. This privation of emotional support remained a concurrent theme among the majority of participants. Out of our seven participants, four were working women. These women described relatively open and informal relationships with close friends and selected female colleagues. Compared with the tensions reported within marital households, friendships were generally characterised as supportive; however, this support was often shaped by limited understanding of hysterectomy and its long-term implications. One participant recalled: After my surgery, one of my close friends visited me in the hospital. She was surprised to see me looking quite well and said so. I responded, ‘I am fine, but what were you expecting?’ She then explained that she had heard hysterectomy was a very serious procedure and was surprised to see me looking well (H3). This interaction illustrates the gap between public perceptions of hysterectomy and lived reality. The friend’s surprise suggests that hysterectomy is often imagined either as a catastrophic, visibly debilitating event or as a routine medical procedure with no lasting impact. The participant’s rhetorical response, ‘what were you expecting?’, subtly reveals her awareness of these exaggerated or misinformed narratives. While the visit itself was supportive, it also exposed widespread misconceptions about postoperative recovery and embodied change. Another participant described how medical advice influenced social conversations: My doctor told me that I am young, and perhaps that is why I was able to cope with this issue quickly. Some of my friends asked whether I had tried hormone therapy or any other treatment to recover faster. I replied that I had not undergone any therapy or sessions. However, I do carry an internal fear that, as I grow older, I might face serious health problems (H4). Here, external reassurance about youth and resilience coexisted with internalised anxiety. Although friends expressed concern through practical questions about therapy or medication, deeper emotional fears remained unspoken. The participant’s ‘internal fear’ highlights how visible recovery does not necessarily equate to psychological security. In a socio-cultural context where reproductive organs are often symbolically associated with womanhood, fertility and vitality, concerns about ageing, hormonal imbalance and future illness may persist quietly beneath outward composure. Workplace reactions were generally described as neutral but emotionally distant. Participants noted that hysterectomy was rarely discussed openly in professional settings, as reproductive health is often considered a private or sensitive matter. Once women resumed their duties and appeared physically functional, colleagues assumed full recovery. This limited engagement reflects broader cultural discomfort surrounding gynaecological issues. In formal work environments, identity is typically framed around productivity rather than personal well-being. Because hysterectomy leaves no visible marker and topics such as fertility and sexuality remain culturally restrained, women’s internal struggles often go unrecognised. Participants described returning to work and appearing ‘normal’, while privately coping with fatigue, mood changes and lingering anxieties. Although friendships and workplaces were less overtly judgemental than marital homes, support often remained surface-level. Deeper conversations about emotional or identity-related changes were largely absent, reinforcing a subtle but persistent sense of isolation. These lapses in empathetic understanding can reinforce feelings of loneliness and induce serious mental stress, which can lead to many other issues. In Pakistani society a woman’s marital life comprises her relationship with and responsibilities towards her husband. It includes sexual partnership, childbearing and rearing and household duties. The marital relationship can undergo some pressure after hysterectomy, as one of the partners goes through emotional upheavals due to mood swings, and the sexual relationship and intimacy may also be affected. Following hysterectomy, a woman’s sexuality can be affected. In many cases, sexual intercourse becomes painful, but sometimes sexual activities might actually improve. Among all our participants, there was a reported psychological stress associated with resuming sexual activities post-hysterectomy. Sexuality is a part of married life, and if it becomes painful for the woman, the relationship between her and her partner faces strain. Most participants felt hesitant to discuss the particulars of their sexual relationship. However, two of the participants had very contrasting experiences. According to one of them, her sexual life improved after her hysterectomy as she “no longer feared an unplanned pregnancy” (H6 ), so she was mentally at ease. However, for another participant, sexual intercourse became very painful following her total hysterectomy. Research shows that there are some women who are not able to satisfy the sexual needs of their partners post-hysterectomy, as it becomes a painful experience for them. Our participants reported feeling pain during sexual intercourse, which also led to a total loss of desire for sexual intimacy on her part. This led to both her and her husband feeling frustrated. One participant explained: It was really painful for me to pursue sexual activity like before. I clearly feel the distance between me and my husband. And it is not only physical (H3). This participant also discussed that she has observed a clear difference in her husband’s behaviour. He speaks very little and prefers to stay out of home even after working hours. She added that initially she had felt extremely disturbed and upset over this situation, but now she had grown used to it. Emotional disconnect within the marriage, which is perceived as one of the most intimate relationships and sources of support, can contribute to feeling distress post-hysterectomy. While talking about this feeling, one participant added: At times I look at my husband and wonder if he ever thinks of what I have been through (H4). Such narrations reveal a perceived lack of empathy, as well as a communication gap. Further, the interviews also revealed that participants who lived in multi-generational/joint family systems had experienced more strains and challenges in their marital relationship as compared with women who lived in nuclear families, post-hysterectomy. Couples living in nuclear families experienced less involvement of the in-laws, and many issues faced by the couples remained between themselves. This provided the couple a degree of privacy, whereas couples in multi-generational/joint families felt that the entire household took a stake in their problems. In relationships where there was a perceived communication gap between the husband and wife, there was a higher degree of feelings of disconnectedness, occurrence of arguments and insecurity felt by the wives regarding their desirability. The participants also felt that as soon as their recovery period was over, their husbands expected them to return to normal routines. However, beyond the recovery time there was no concept of providing extra support, whether emotionally or practically. All participants except one said that they felt their husbands could have provided them with better emotional support and empathy post-hysterectomy. Most of the participants felt that if they had received the empathetic understanding and support from their husbands, it would have decreased or altogether avoided some of the minor arguments and issues in their marital lives. This indicates the importance of communication and understanding between the husband and wife and how the absence of it can adversely affect the marital relationship. It was observed that due to misinformation or lack of information, many of the times people thought that hysterectomies left women unable to have sexual intercourse. This seemed like an open invitation to many members of the participants’ and their husbands’ social circle to jump in with comments and jokes about second marriages. In the legal context of Pakistan, a man can legally marry up to four wives, given the permission of the wife. However, socially, polygamy is still stigmatised and is secretly practised under conventional circumstances. A woman undergoing a hysterectomy is seen as one of the unusual and stigmatised circumstances where her husband taking on a second wife is socially justified. The possibility of a second marriage looms large, especially if the woman has no children at all or only daughters. In many cases, insensitive jokes and comments followed the women very soon after the procedure, especially about husbands remarrying. This is reflective of a disregard for what the participants had gone through (in one case, a life-and-death situation). One participant mentioned: A week after my operation, my husband’s friend visited him. He jokingly said to him that now he could marry again and find a younger “piece”. I was shocked. How had he even dared say such a thing, barely days after my operation? My husband and I got in an argument afterwards. He had to reassure me multiple times that he had no intention of remarrying (H6). These and other seemingly dismissive remarks that participants encountered following the procedure carry multiple implications. They reflect not only a lack of empathy and understanding of women’s experiences with hysterectomy but also a broader cultural disregard for women’s identities and roles. Such attitudes can undermine women’s self-esteem and create feelings of insecurity. In this socio-cultural context, women may be perceived as dispensable or replaceable, particularly when unable to bear children or meet their partner’s sexual expectations, further intensifying psychological vulnerability. Almost all participants expressed that the idea of their husbands remarrying contributed to deep feelings of unease and insecurity, particularly among those who had only daughters. In our sample, four participants had sons, while three had only daughters. Within Pakistani society, sons are highly valued. The cultural ideals of the ‘complete family’ make having a son almost essential. Patriarchal norms dictate that lineage, family name and inheritance are preserved through male heirs, which in turn places immense social pressure on women. This expectation often legitimises a husband’s right to remarry for the sake of male progeny, leaving women vulnerable to the perception that they are replaceable if they cannot produce sons. For instance, one participant recalled that her husband, after returning from work, repeated a remark made by his colleagues that, “They were joking with him, saying that now he was free to marry another woman to have a son (H5).” Such casual comments reinforced her sense of insecurity and highlighted how normalised remarriage becomes under cultural pressure for male heirs. Another participant described overhearing her mother-in-law tell her husband: “Your wife is unlucky for our family because she cannot give us a son to continue our family name and look after you in your old age (H1).” The use of the word ‘us’ in this remark is particularly revealing. It demonstrates that the expectation of a son was not confined to the couple themselves but was seen as a collective concern of the wider family, especially the husband’s relatives. These narratives illustrate how women’s identities and self-worth are often tied to their reproductive capacity and, specifically, to their ability to bear sons. For participants who had undergone hysterectomy, such remarks carried even greater weight, intensifying feelings of insecurity and reinforcing the perception that their social value could easily be diminished. Our interview data showed that out of the many socially assigned roles that the participants held, a few underwent noticeable effects. The most prominent roles to be affected were those of a wife and child-bearer, their domestic role, their professional role and their personal self-view versus the social expectations. When asked about their sense of self after hysterectomy, participants generally stated that while they felt a significant alteration in their physical state, they did not perceive a noticeable change in their personality or sense of womanhood. They emphasised that womanhood was not reduced to menstruation or childbearing alone; their internal sense of being a woman was too deeply rooted to be shaken by the surgery. As one participant said: I am like any other woman. Yes, I cannot bear children anymore, but I have already got 3 children, that is enough. I also have some future career plans (H3). This reflects the broader trend of how women with children, particularly those who had fulfilled the cultural expectation of motherhood, were able to draw on alternative identity anchors such as career aspirations and existing family roles. For them, the loss of reproductive ability did not diminish their self-worth or disrupt their womanhood but rather was understood as a health setback. However, the data also reveal important differences based on whether participants had male children. The cultural valorisation of sons meant that women with male children were somewhat insulated from stigma, yet not entirely exempt from social comparison. One participant reflected: I cannot help but think that people want me to feel inferior for not being able to produce children anymore, even though I have a son. Women in particular can be harsh and I wonder how they can be that way towards another woman. I feel that my sisters-in-law felt themselves better than me for having more children than I have (H2). This account highlights the paradox that even women with sons were not free from feelings of inadequacy. Although the presence of a male child provided some degree of social validation, fertility and the number of children continued to be used as a yardstick of worth within family networks. The sense of inadequacy was even more pronounced among women who had only daughters, shaping how they interpreted their own womanhood post-hysterectomy. As one participant admitted: I have a daughter and sometimes I wish I had a son and then I feel ashamed of being a woman who herself wishes for a son to be respected by her in-laws. I feel like it’s not my thinking, people around me forced me to think this way (H5). Such reflections highlight how socio-cultural norms about the necessity of sons are internalised, affecting women’s perception of themselves. While women with sons were more likely to frame their self-perception around resilience, future plans and the sufficiency of their existing children, women without sons tended to struggle more with societal expectations and stigma, sometimes adopting the very narratives that devalued them. Ultimately, these findings reveal that self-perception after hysterectomy is not uniform; it is mediated by cultural constructs of lineage and gender and especially by whether or not a woman has a male child. The role of women in Pakistani society is deeply embedded within a male-centric framework, reflecting the broader dynamics of patriarchy and patrilineal lineage structures. A woman’s value as a wife is commonly assessed by her ability to please her husband emotionally and physically, maintain the household responsibilities, bear and nurture children and uphold the family’s honour. Within this socio-cultural framework, reproduction is not merely biological but symbolic; it affirms marital stability, lineage continuity and social legitimacy. As reflected in earlier themes, the birth of a son carries particular significance, as sons are traditionally associated with inheritance, family name continuation and long-term security within the marital home. All participants in this study were married, making their perceptions of their spousal roles central to understanding post-hysterectomy adjustment. While many retained a strong sense of self, some participants expressed feelings of inadequacy tied to cultural expectations of reproduction. The inability to bear additional children—especially sons—was experienced not only as a medical outcome but also as a perceived disruption of their socially assigned role. Notably, two of the three women without sons reported that they would allow their husbands to remarry if he desired. One participant expressed this with visible restraint: If he wants to, of course he can marry again. It is his right. How can I stop him from wanting what every man wants? (H5 ) This statement illustrates an internalisation of patriarchal norms, where the possibility of a husband’s polygamy is not only normalised but quietly accepted as a ‘right’ and as something that ‘every man wants’, despite the profound emotional cost. The participants framed this acceptance as a consequence of their perceived inability to conform fully to societal ideals of womanhood and wifely duties. In particular, the absence of a son was seen as a failure to meet the culturally constructed standards of being a ‘complete wife’. The participant does not describe external pressure; rather, she anticipates and legitimises the possibility herself. Such acceptance suggests that marital security is perceived as conditional on reproductive fulfilment. The absence of a son, in particular, was subtly equated with incompleteness. Even when husbands did not explicitly express dissatisfaction, participants internalised the belief that they had fallen short of idealised standards of womanhood. The notion of being a ‘complete wife’ thus extended beyond companionship and partnership to include reproductive performance. Such narratives highlight how women’s self-perceptions are shaped less by explicit confrontation and more by deeply entrenched structural norms. Rather than resisting or openly challenging these expectations, participants often adopted a stance of resignation or quiet accommodation, which reflects the weight of patriarchal conditioning in shaping women’s sense of worth within marriage. In this context, hysterectomy becomes more than a medical intervention; it symbolically reconfigures a woman’s perceived position within marriage. Even when emotionally supported by their spouses, participants navigated an internal negotiation between personal worth and culturally prescribed ideals of fertility, lineage and obedience. Hysterectomy, like any other major surgical procedure, requires careful post-operative care and adequate time for recovery. However, in the socio-cultural context of Pakistan, where women are primarily responsible for managing household tasks, it becomes particularly challenging for them to prioritise their own health following such a procedure. The absence of visible bodily changes after hysterectomy often leads others to assume that recovery should be swift and uncomplicated. This perception overlooks the fact that hysterectomy, much like the removal of vital organs such as a kidney or liver, represents not only a physical loss but also an emotional and psychological adjustment that requires time and support. As one participant expressed: I am a working woman and I am very active. My family often blames me for being too careless and says this happened to me because of my careless behavior towards my health but it is not like that. What had happened to me was decided by God and was not my fault at all (H4). This account highlights the tendency of families to attribute women’s health issues to personal negligence rather than recognising structural or biological factors beyond their control. Such blaming not only disregards the complexity of the surgery but also intensifies women’s sense of isolation. Following a major operation, participants expected empathy, support and care from family members; instead, criticism or blame created feelings of being misunderstood and emotionally unsupported. The impact of hysterectomy on women’s roles varied significantly depending on whether these roles were professional or domestic. Out of the sample, four participants were working women. When asked about disturbances in their professional duties post-surgery, they reported that their work life was largely unaffected, apart from the leave required for surgery and recovery. They did not experience insensitivity from colleagues, and some even described their coworkers as ‘open-minded and supportive’. Despite occasional fatigue or emotional stress, their professional performance remained stable, indicating that the workplace provided a comparatively neutral or even supportive environment. In contrast, women’s domestic roles were more heavily disrupted by the physical consequences of hysterectomy. Household chores and caregiving responsibilities became difficult to manage, which created frustration and feelings of inadequacy among participants. One woman shared: During the recovery time of one and half month, I was totally dependent on my sister-in-law. She was really nice to me and my daughters but somewhere inside me being unable to perform my duties bothered me a lot. For a very active woman like me, it was really difficult to depend on others (H1). This sense of inadequacy was compounded by cultural expectations that place women at the centre of household management. Unlike in the professional domain, where support and understanding were available, the domestic sphere often magnified women’s vulnerabilities. Some participants chose to stay at their mother’s home till their complete recovery, as they feared neglect or criticism from in-laws who were unwilling to provide the necessary care. Such experiences highlight how patriarchal family structures reinforce women’s burden of domestic responsibility while simultaneously denying them adequate support during illness or recovery. Thus, while professional spaces appeared more accommodating, domestic spaces often intensified women’s distress, underlining the gendered nature of recovery experiences after hysterectomy.

A principal strength of this study is its qualitative depth, foregrounding women’s lived experiences and cultural context. By integrating narratives across physical, psychological, social and marital domains, the study offers a holistic and contextualised understanding rarely captured in quantitative studies. Additionally, the focus on patriarchy, son preference and marital relations adds unique cultural nuance to the literature on hysterectomy. Nonetheless, limitations must be recognised. Participants were recruited through purposive sampling within a specific geographic area, which may limit transferability to other regions of Pakistan with differing socio-cultural dynamics. As with most qualitative research, findings reflect the perspectives of women who were willing to participate and may not capture the experiences of those who declined, potentially introducing self-selection bias. Additionally, the sample was limited to married women who have at least one child, which restricts applicability to women who do not have any children, are unmarried or are from different socio-economic contexts. Similarly, while a recurring pattern in our findings suggested comparatively greater emotional support from natal families than from in-laws, this observation should be interpreted cautiously. Family structures, socio-economic contexts, urban-rural differences and regional cultural norms may significantly influence post-hysterectomy experiences. Future research involving more diverse populations would be valuable in examining variability across contexts. Finally, reliance on retrospective self-reporting introduces potential biases, particularly regarding sensitive topics like marital intimacy or remarriage. While the study provides in-depth insight into lived experiences, the findings should be interpreted as context-specific rather than statistically generalisable. Future research would benefit from longitudinal, multi-site and cross-cultural designs and from broader samples that include rural populations to better understand how socio-cultural variability shapes post-hysterectomy experiences.

This study sheds light on the multifaceted experiences of women in Pakistan following hysterectomy, exploring the interplay of physical recovery, psychological resilience, marital dynamics and socio-cultural expectations. Unlike much of the existing literature, largely centred on biomedical or individual psychological outcomes, this research embeds women’s narratives within the cultural framework that ascribes significant social weight to reproductive capacity and gendered roles. Physically, participants reported fatigue, pain and disruptions in mobility. These findings are consistent with prior studies noting increased postoperative stress, anxiety and depression among hysterectomy patients. 21 22 However, in the Pakistani context, these physical limitations were deeply interwoven with everyday domestic expectations. Women’s inability to perform household tasks became a source of emotional distress, amplifying feelings of inadequacy within a cultural setting where domestic competence equates to moral worth. In contrast, many Western settings emphasise domestic flexibility during recovery, with societies more likely to share or defer household chores to accommodate convalescing individuals, reflecting a gradual shift in gendered caregiving norms. 23 Consequently, while physical symptoms after hysterectomy remain universal, in Pakistan the distress is intensified by cultural obligations and limited domestic support options. Interestingly, working participants reported minimal disruption beyond recovery leave and described workplaces as supportive or neutral. This contrast with domestic life highlights how the structured, task-oriented nature of formal employment, underpinned by sick leave policies and productivity measures, buffers women from the stigma they face at home. 24 In professional spaces, recovery is framed as a temporary medical need, while at home, women’s incapacity disrupts culturally ascribed domestic roles tied to moral worth, intensifying distress. 24 25 This divergence echoes feminist scholarship showing that paid work is legitimised and bounded, while unpaid domestic labour remains invisible yet morally loaded. 26 The finding underscores that recovery is not only biomedical but also socially mediated. 25 Addressing these inequities requires family-level awareness and redistribution of household labour to reduce the psychosocial burden of recovery. Psychological outcomes were similarly complex. While participants reported mood swings, anxiety and reduced sexual desire, most did not report a diminished sense of womanhood or personal identity following hysterectomy. Instead, many reaffirmed womanhood through motherhood, caregiving or professional roles, anchoring identity in reproductive achievement (number of children) and social performance rather than uterine status. 25 27 28 This aligns with qualitative syntheses showing that women use coping strategies such as self-adjustment, role redefinition and seeking support. 27 Systematic reviews, likewise, note mixed sexual outcomes, highlighting that the overall function often remains stable, though subgroups, such as younger women or those undergoing oophorectomy, report declines in desire or arousal. 29 – 31 These patterns highlight the resilience of cultural identity frameworks while underscoring the need for context-specific counselling and sexual health support. The interplay between hysterectomy, marital relationships and son preference emerged as a critical insight. Compared with qualitative findings from other countries, where hysterectomy experiences are often framed primarily in relation to womanhood, sexual identity, bodily integrity and the symbolic meaning of femininity attached to the uterus, the present study highlights a stronger emphasis on fertility-related social value and familial positioning within the Pakistani context. In Turkey and other countries, studies of women undergoing hysterectomy, concerns have largely centred on marital intimacy, self-perception, coping and adaptation following surgery, 6 27 while a qualitative study conducted in Brazil reported that the uterus was often viewed as having already fulfilled its reproductive role, and its removal did not appear to interfere with how women perceived their sexuality and sense of womanhood. 32 However, in Pakistan, reproductive capacity, particularly childbearing and son preference, remains closely tied to social legitimacy within patrilineal and multi-generational/joint family systems. In South Asian cultures, where sons are considered essential for lineage, inheritance and social standing, the absence of a male child amplified women’s fears of marital instability. 33 34 Women with male children often experienced relief, some reporting improved intimacy due to the elimination of pregnancy anxieties, while those without male children expressed deep insecurity, fearing rejection or polygynous arrangements. Hysterectomy cannot be separated from gendered norms, as it reshapes not only bodies but also social value and marital security. The notion of the ‘patriarchal bargain’ 35 captures this dynamic: women assert agency within structural constraints, yet remain bound by expectations of reproduction and male offspring. By altering reproductive capacity, hysterectomy may ease physical burdens but also heighten insecurity where sons are prized, reflecting a persistent tension between resilience and self-doubt. Collectively, this suggests that the psychosocial impact of hysterectomy among women under 40 years of age operates through a socio-cultural pathway in which gender norms, fertility expectations and household hierarchy collectively shape women’s experiences. The reproductive capacity of women influences marital security and family positioning, which in turn affects psychological well-being and social identity following hysterectomy. This model underscores the interconnected nature of biological change and socio-cultural structures in shaping lived experiences. This study also underscores the lack of empathetic support from extended families, particularly in-laws. Participants frequently described feeling unsupported or misunderstood by unsympathetic caregivers or compelled to relocate to their maternal homes during the recovery period. These experiences mirror findings from Goudarzi and colleagues, 25 who emphasised the importance of familial and healthcare support in adapting post-hysterectomy (especially the need for emotional support from husbands, families and colleagues). Moreover, the public health dimension cannot be ignored. South Asian gynaecological health remains under-prioritised, as highlighted in a roundtable discussion calling for expanded attention to women’s reproductive well-being across the life course, beyond maternal health. 36 In contexts where unnecessary hysterectomies are reportedly rising, even among younger women, in part due to medical overuse and limited fertility-preserving alternatives, 37 the psychosocial consequences identified in this study call for urgent reform. In sum, this study illustrates that while hysterectomy is a common surgical procedure, its implications are profoundly shaped by cultural norms around gender, marriage and motherhood. Physical recovery cannot be understood without considering domestic expectations; emotional resilience is rooted in cultural identity and social roles and marital security is deeply influenced by son preference. These insights contribute a culturally grounded perspective to the existing literature and have relevance for clinical practice, public health policy and feminist scholarship.

Conclusively, the present study found that women who have undergone hysterectomy before the age of 40 years have adverse physical, psychological, social and marital effects in their lives due to lack of societal support and acceptance related to the anatomical procedure. Though some women reported having better sexual relations with their partner, the fear and insecurity of deteriorating marital relations remain constant with the wish and preference of having a male child as the underpinning cause of the fear and insecurity. The findings suggest that structured counselling and family-oriented educational interventions may be beneficial, particularly in addressing misconceptions and culturally rooted beliefs surrounding womanhood, fertility status, son preference and marital expectations and reducing marital and familial tensions observed among participants. Integrating psychosocial counselling within pre- and post-operative care could help women and their families better understand the physical and emotional changes associated with surgically induced menopause.

The present study uses a qualitative framework to explore how self-perception and social experiences are influenced by an anatomical procedure—hysterectomy—particularly in contexts where the uterus may be viewed as a symbol of womanhood, fertility, identity or social value and where stigma or shame may be associated with reproductive loss. For this study, it was imperative to tap into the subjective, personal experiences of the participants. The study explores the lived experiences of hysterectomy and its effects on the physical, psychological, social and marital lives of women under 40 years of age in the socio-cultural context of Pakistan using a phenomenological approach. This approach enabled the researchers to understand the internal states of the women, combined with their perception of selves and their relationships. Using this approach, researchers were able to gain insight into the essential meanings of lived experiences of participants following hysterectomy and therefore a deeper understanding of their long-term physical, social and psychological well-being. To report the findings of the present study, consolidated criteria for reporting a qualitative research (COREQ) checklist 18 were used. The present study has been conducted at Sheikh Zayed Hospital, a tertiary care public hospital located in Lahore, Pakistan. Data of patients who have undergone hysterectomy in the last 2 years were recruited from the hospital. These patients were reached by telephone with the reference of the physician and were requested to be a part of the study. All the participants were selected using pre-defined inclusion and exclusion criteria through purposive sampling. Participants were selected using purposive sampling to capture variation in age (under 40 years of age), parity, time since hysterectomy and socio-economic background. Efforts were made to include participants from diverse family structures (multi-generational/joint and nuclear households) to ensure representation of varying socio-cultural dynamics. The inclusion criteria included married women who had undergone hysterectomy prior to natural menopause and were residing in Lahore, Pakistan, along with the confirmation of hysterectomy through hospital reports, duplex ultrasonography reports, age under 40 years at the time of hysterectomy, hysterectomy in the last 2 years, at least one child and informed consent. While the exclusion criteria included declined consent. In Pakistan, the majority of the hysterectomy cases are reported among women aged between 40 and 45 years, many of whom are in either the perimenopausal or natural menopausal transition phase. However, to better inspect the effects of hysterectomies among relatively younger women, we specifically chose women under 40 years of age to be part of our sample. This allowed us to focus specifically on women who underwent hysterectomy during their reproductive years. Keeping in mind socio-cultural limitations and social stigma attached to the subject matter, we only opted for married women as our interview population. Further, to minimise any recall bias, only those women were selected who had their hysterectomy in the last 2 years. Initially, the patients were identified from the hospital records, and those meeting the eligibility criteria were then reached by telephone with the reference of the physician to be invited to be a part of the study. The researcher/author (RBS) introduced herself, explained the purpose of the study and emphasised that participation would be entirely voluntary. Following this, the researchers/authors (MMA and HS, both medical doctors) examined the reports of the patients for the confirmation of hysterectomy. In total, 10 patients were identified and reached to potentially be a part of the study; however, 3 of the women declined to participate due to personal reasons. Data collection continued until thematic saturation was achieved. Data collection and analysis were conducted concurrently. After each interview, transcripts were reviewed and coded, and emerging themes were compared with previous interviews. Saturation was considered to be achieved after the fifth interview, when no new codes, categories or conceptual insights emerged in subsequent interviews and when existing themes were sufficiently developed in depth and variation. Two additional interviews confirmed thematic redundancy. This resulted in a total sample of seven women in the present study. For data collection, a semi-structured interview guide was developed and used. The developed interview guide was pilot tested on one participant that was not included in the final sample. Findings from the pilot interview guided modifications to the interview guide by identifying overlapping questions, reorganising the flow for better coherence and incorporating targeted probing questions. The final interview guide (attached as online supplemental annexure 1 ) had two sections, that is, (1) socio-demographic profile and (2) formal interview questions. In socio-demographic characteristics, age, age at the time of hysterectomy, number of children and profession of the participant were recorded. However, for maintaining the anonymity of the participants, only age at the time of hysterectomy and profession of the women have been given as indirect identifiers in the results section. Interviews were conducted between September and December 2024 at the hospital premises in private, face-to-face settings involving only the participant and the interviewer. All interviews were conducted by the researchers/authors HS (MD) and NNE (MD), each of whom was provided an extensive 2-day training on conducting qualitative interviews, asking probing questions and taking field notes. During this session, mock interviews were conducted to familiarise the team with the interview guide and to ensure consistency in the interviewing approach. To minimise cultural and gender bias, only female researchers conducted the interviews, as all the participants of the present study were women. Each interview session began with an informal interaction, during which the researchers introduced themselves and explained the study objectives. This initial rapport-building phase helped establish trust and facilitated open communication, encouraging participants to share their experiences openly. It also assisted researchers in understanding the complexities associated with hysterectomy and in identifying appropriate probing questions for the formal interview. To minimise personal bias, researchers maintained reflective diaries for field notes and remained focused strictly on the study objectives. Probing questions were used to explore participants’ emotions, perceptions and experiences regarding the physical, psychological, social and marital impact of hysterectomy. All interviews were audio-recorded with the participants’ consent and lasted between 45 and 60 min. Data saturation was achieved after the fifth interview, with two additional interviews conducted to confirm saturation. The adequacy of data saturation was also discussed in a collective meeting among all authors. Interviews were transcribed verbatim immediately after each session. Transcripts were returned to participants for member checking; three participants provided feedback, and follow-up interviews were conducted where necessary to validate the data and ensure credibility. Additionally, the researcher/author (RBS) conducted two repeat interviews for the validation of data. Data were analysed using Braun and Clarke’s thematic analysis framework. 19 20 Given the phenomenological orientation of the study, analysis was conducted manually without the use of qualitative data analysis software in order to maintain close engagement with participants’ narratives and preserve contextual meaning. Manual coding allowed the researchers to remain immersed in the data and engage in iterative reflexive interpretation. Both inductive and deductive approaches were employed to ensure rigour in the analysis. The inductive approach enabled themes to emerge organically from participants’ accounts, while the deductive approach ensured that the analysis remained aligned with the study objectives and relevant theoretical constructs. This combined strategy facilitated a nuanced understanding of the physical, psychological, social and marital effects of hysterectomy among women who had undergone hysterectomy before 40 years of age. The analysis followed a systematic six-step process: First of all, the data collected from the interviews were initially transcribed verbatim and subsequently compiled into narrative form in English. Since interviews were conducted bilingually, in English and Urdu (local language) depending on the participant’s preference, all transcripts were translated into English to facilitate uniform analysis. To ensure linguistic accuracy and preserve contextual meaning, translated transcripts were cross-checked against the original audio recordings. Three researchers/authors (MMA, RBS and SA) independently read each transcript multiple times to gain deep familiarity with the data. Reflexive notes and preliminary impressions were recorded in analytic memos. Additionally, all the translated interviews were presented to the participants and discussed with them in order to ensure trustworthiness of the data and that the essence of the verbatims had not been lost during the process of translation. Minor issues were identified, primarily involving clarification of wording and contextual phrasing; these were addressed through discussion with participants and incorporated into the final transcripts. No substantive changes to meaning or thematic content were required. Each transcript was coded manually, line-by-line, by researchers/ authors MMA, RBS and SA. Codes were generated inductively from participants’ narratives while remaining theoretically sensitive to concepts related to stigma, gender norms and role expectations. After coding the first three transcripts independently, the researchers compared codes and developed a shared codebook. Discrepancies were discussed in analytic meetings until consensus was achieved. Inter-coder agreement was calculated on the first three transcripts using percentage agreement, which demonstrated 87% concordance between coders. Disagreements were resolved through discussion and refinement of code definitions. From the codes, dimensions were extracted and recorded along with their frequency of occurrence. These dimensions were then organised into sub-themes based on conceptual clarity, which were subsequently grouped to form overarching themes reflecting patterned meanings across the dataset. This iterative process allowed both participant-driven insights (inductive) and theory-informed categorisation (deductive) to guide the development of themes. Multiple meetings among all the authors were conducted to finalise the themes. At the fifth step, the final themes were reviewed against the original transcripts to ensure internal coherence, conceptual distinctiveness and alignment with participants’ lived experiences. Additionally, all the data and the finalised themes were presented to a colleague, unrelated to the study, to ensure the credibility of the findings and to gain an external perspective. This approach made sure that no personal potential biases have affected the data analysis and interpretation process. During this stage, refinements were made to enhance analytic clarity and thematic accuracy. Initially, ‘Physical Effects’ and ‘Psychological Effects’ were developed as two separate overarching themes. However, on iterative review of the coded data, it became evident that participants consistently described physical symptoms (eg, fatigue, pain, hormonal changes) alongside emotional distress and mood disturbances in an intertwined manner. The data demonstrated substantial conceptual overlap between bodily changes and psychological responses, reflecting the inseparable embodied nature of their experiences. Therefore, these two themes were merged into a single overarching theme titled ‘Physical and Psychological Effects’. Additionally, the second theme was originally labelled ‘Social Dynamics’. Following peer debriefing and thematic review, this title was revised to ‘Family and Communal Dynamics Post-Hysterectomy’ to more accurately capture the culturally embedded and relational nature of participants’ experiences, particularly within marital households and extended family systems. This renaming enhanced contextual specificity and better reflected the socio-cultural framework of the study. These refinements ensured that the final thematic structure remained grounded in participants’ narratives while accurately representing patterned meanings across the dataset. At the final step, the process of member checking was conducted, and the findings of the present study were presented to the participants of the present study. Three participants provided feedback. The changes suggested were very minor and primarily related to clarification of wording rather than substantive reinterpretation of data. No major thematic restructuring or re-coding was required. For example, the description within the sub-theme on emotional distress was slightly refined to better reflect religious coping as a source of resilience rather than silent suffering. This adjustment did not alter the thematic structure but enhanced the accuracy of representation. Overall, member checking confirmed that the themes accurately reflected participants’ lived experiences. Overall, all these steps ensured the credibility of the findings and that the interpretation aligns with the perspective of the participants. The complete steps of the data analysis are illustrated in figure 1 . The final themes were organised into four major categories: physical and psychological effects, family and communal dynamics, role fulfilment and effects on marital life as the impacts of hysterectomy on women’s lives, corresponding to the core research question of the study. Additionally, specific attention was paid to women’s self-perception following hysterectomy and the effects on their interpersonal and social relationships. Given the interpretive nature of phenomenological inquiry, reflexivity was integral to the research process. The research team comprises professionals trained in public health and clinical medicine, with prior engagement in women’s health issues within the Pakistani socio-cultural context. Our professional experiences have sensitised us to issues such as patriarchy, son preference, reproductive decision-making and marital power dynamics. While this background enhanced our contextual understanding, we acknowledged that it could also predispose us to particular interpretive lenses during data collection and analysis. To address this, we engaged in systematic bracketing. Prior to data collection, each researcher documented personal assumptions, expectations and preconceptions regarding hysterectomy, gender norms and women’s health decision-making. These reflexive accounts were maintained in research diaries and revisited throughout the study. During interviews, we consciously adopted an open and exploratory stance, using probing questions grounded in participants’ narratives rather than our prior knowledge. We also reflected on positional dynamics between researchers and participants. Shared gender identity facilitated rapport and encouraged open discussion of sensitive and embodied experiences. However, we remained attentive to the possibility of assumed shared understanding and took care to avoid projecting our interpretations onto participants’ accounts. Throughout data analysis, regular reflexive meetings were conducted to critically examine emerging interpretations. Field notes, analytic memos and reflexive diaries were systematically reviewed to distinguish participants’ meanings from researchers’ presuppositions. These documents captured evolving impressions, methodological decisions and points of interpretive tension. Repeated revisiting of these materials helped ensure that themes remained firmly grounded in participants’ lived experiences. This ongoing reflexive engagement, combined with peer debriefing and member checking, enhanced the credibility, transparency and trustworthiness of the findings.