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Psychological Aspects of Obstetrics and Gynaecology Dr Chris Cordle Clinical Psychologist Leicester General Hospital Obstetrics & Gynaecology • OBSTETRICS That branch of medicine and surgery dealing with the care of women during pregnancy, childbirth and puerperium • GYNAECOLOGY The science of physiological function and diseases of women – particularly of the pelvic organs and genital area • Prevalence rates of psychological distress in women attending gynaecology clinics consistently show that on average 50% are estimated to be psychiatric cases • This is higher than in other hospital OP clinics (GHQ and PSEQ) Female Reproductive Cycle • Puberty • Onset of menarche • The menstrual cycle and a women’s experience of menstruation are known to be influenced by psychological factors • Some of the most commonly encountered complaints at the GP surgery are related to menstruation and the menstrual cycle Disorders of the Menstrual Cycle • • • • Amenorrhoea Menorrhagia Premenstrual tension Dysmenorrhoea Premenstrual Syndrome • Concept is ill-defined in terms of nature and duration of symptoms • Prevalence rates vary from 25% to 90% • Most commonly reported symptoms: – Headaches, breast tenderness, bloating, irritability, depression, tension, concentration difficulties Premenstrual Syndrome • General emotional problems co-exist with reports of PMS in women attending medical services Premenstrual Syndrome • Important to carry out a careful analysis of the nature of the problem • Daily diary over 2-3 months can help to clarify whether the problems are chronic and associated with life stresses or with the menstrual cycle Psychological factors which may influence reporting of menstrual symptoms 1. Personal History E.g. Age of menarche Early experience of menstrual pain Preparation for menstruation Mother’s attitude towards menstruation Mother’s own behaviour when menstruating 2. Attitudes Towards menstruation and the feminine role and self Psychological factors which may influence reporting of menstrual symptoms 3. Stressful life events 4. Personal coping strategies for dealing with pain Psychological Approaches to the Management of Pre-Menstrual Symptoms • Promoting health behaviours, improved diet and exercise • Relaxation • Cognitive restructuring • Psychotherapy/ Counselling • Self-help groups Female Reproductive Cycle Puberty Onset of menarche Sexual Experience Wanted Enjoyable Or Unwanted or Problematic Female Psychosexual Problems 1. 2. 3. 4. 5. 6. Vaginismus Dyspareunia Sexual arousal disorder Orgasmic dysfunction Loss/ lack of sex drive Recurrent discharges/ infections Female Reproductive Cycle Puberty Onset of menarche Sexual Experience Wanted Or Unwanted Enjoyable or Problematic Conception Infertility TOP Infertility • Affects 10% of couples of childbearing age • Estimated that 1 in 6 can be expected to seek specialist help at some time in their lives (UK figures) • Almost 75% are trying for their first baby • Infertility is unexplained in approximately 28% of couples Infertility The relationship between infertility and psychological functioning is complex 1. It may be causal a. Neuroendochrine perspective Stress Reduced efficiency Irregular activity of pituitary gland of ovaries Infertility • Supportive evidence from case histories • Conception following adoption • Conception on holiday Infertility b. Sexual problems Accounts for 5.5% of cases of infertility (Dubin and Amebarr, 1972) • Vaginismus • Erectile failure • Retarded ejaculation The relationship between infertility and psychological functioning 2. Consequential a) The Emotional response to infertility has been likened to a grief reaction and includes stages of • • • • • • Surprise/ shock Denial Anger Isolation Guilt Acceptance/ resolution b) c) d) e) Depression and Anxiety are common amongst infertile couples Tests and treatment stress ++ Can have detrimental effect on relationship Social pressures to become parents Feelings of isolation and shame/ low self-worth Psychological intervention with Infertile couples Grief Work a. For loss of fertility and its effect on sexuality, loss of pregnancy experience, loss of control – may be actual bereavement, eg miscarriage b. Explore links between past events and current reactions, eg previous bereavement or TOP Psychological intervention with Infertile couples Relationship/ Sexual Counselling • Sexual/ marital difficulties may be preexisting or reactive • Strengthen support and communication Stress management • Cognitive/ behavioural techniques Termination of Pregnancy In 1991, approximately one sixth of pregnancies in the UK were terminated. The main reason was psychosocial risk to the woman. Termination of Pregnancy • Approximately 5% of women experience significant psychological disturbance after a termination – Guilt – Anxiety and depression – Relationship difficulties • Very difficult to establish a causal relationship. May be reflecting general problems in living. Poor psychological outcome related to:• Past psychiatric history (Zolese & Blacker, 1992) • Medical or genetic reason for termination (Elder & Laurence, 1991) • Abortion taking place during second trimester (Donnai et al, 1981) • Pressure/ coercion in decision making (Dunlop, 1978) • Guilt beforehand/ negative attitude to TOP (Belsey et al, 1977) • Poor social support/ poor quality relationships (Moseley et al, 1981) • Indecisiveness about termination (Shusterman, 1979) • Upset at first discovering the pregnancy – anger, anxiety (Shusterman, 1979) Puberty Onset of menarche Sexual Experience Wanted Or Unwanted Enjoyable or Problematic Conception Infertility TOP Pregnancy Miscarriage Hyperemesis Anxiety Miscarriage or Spontaneous Abortion • Spontaneous loss of a pregnancy within the first 24 weeks • Occurs in approximately 20% of all known pregnancies Common Reactions • • • • • • Guilt and self blame Grief reaction Intense sadness and sense of loss Anger Anxiety Depression Factors affecting grief following early miscarriage • 1st trimester – narcissistic stage – Growing foetus is experienced as an integral part of the mother – losing part of oneself • May find herself mourning a ‘fantasy’ child whose sex she may never know • Mourning may seem inappropriate for someone who has never ‘existed’ • Normal rituals associated with bereavement – lost. The baby is rarely seen – no funeral • Possible lack of normal supportive features as people may not have been aware of pregnancy • Sudden nature precludes anticipatory grief work • Mother loses foetus and role as patient – follow up appointments not common • Lack of clear-cut explanations, leading to parental guilt Stray-Pederson & StrayPederson (1984) Control Group N = 24 Women who concurrently Miscarry (no identified Abnormality) Experimental Group N = 37 Optimal psychological Support TLC Stray-Pederson & StrayPederson (1984) • Control Group successful pregnancies • Experimental Group successful 33% had 86% had pregnancies Puberty Onset of menarche Sexual Experience Wanted Or Unwanted Enjoyable or Problematic Conception Infertility TOP Pregnancy Miscarriage Hyperemesis Anxiety Childbirth Stillbirth S.C.B.U. Trauma Post Natal Depression Puberty Onset of menarche Sexual Experience Wanted Or Unwanted Enjoyable or Problematic Conception Infertility TOP Pregnancy Miscarriage Hyperemesis Anxiety Childbirth Stillbirth S.C.B.U. Trauma Post Natal Depression climacteric Menopause • For the majority of women, menopause is not a major stress • Previous depression and social factors, eg stressful life events appear to be more important than menopausal status Gynaecological Surgery • E.g. Hysterectomy • Cancer • Chronic Pelvic Pain Hysterectomy • Levels of psychological morbidity are high in women who have a hysterectomy • Pre-operatively, levels of psychological morbidity in women who have a hysterectomy are almost five times higher than in women in the general population (Gath & Cooper, 1982) Chronic Pelvic Pain • Chronic pelvic pain is usually defined as non malignant pain in the lower abdominal region of at least 6 months duration • It is distinguished from dysmenorrhoea and dyspareunia Chronic Pelvic Pain • Laparoscopic assessment of women with CPP reveal that approximately 60% have no apparent pelvic pathology Common diagnoses:• • • • • Pelvic Inflammatory disease Endometriosis Adhesions Fibroids Irritable Bowel Syndrome Aetiology of chronic pelvic pain without obvious pathology • Undetected pathology eg lacerations of uterine ligaments • Psychophysiological theories eg pelvic congestion theory • Musculoskeletal dysfunctions rg overstretched muscles and ligaments, weakness, faulty posture • Psychogenic theories eg. Sexual abuse, trauma Detailed Psychological Assessment • Pain history and pain analysis – ABC and daily diaries rating symptoms and mood together • Pain beliefs and attributions • Examination of psychological and social factors occurring before and since symptoms, eg bereavement, divorce/ separation, chronic relationship problems, other emotional trauma • Current and past mental state • Sexual functioning including any history of sexual abuse • Robert Gooch in 1829 recommended a life confined to the sofa for women with chronic pelvic pain “At first it is tedious, but she soon learns to amuse and occupy herself in this position” Psychological Management of Chronic Pelvic Pain • Education – psychological model of pain • Pain management – CBT • Stress management – Anxiety and anger management – Assertiveness training • Psychosexual therapy – couple work • Psychotherapy for women who have been sexually and/or physically abused