Transcript Psychological Aspects of Obstetrics and Gynaecology

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
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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
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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
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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:•
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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