Psychological Aspects of Obstetrics and Gynaecology

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Psychological Aspects of Obstetrics and
Gynaecology

• Dr Chris Cordle
• Clinical Psychologist
• Leicester General Hospital

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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

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• 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)

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Female Reproductive Cycle

• Puberty
• Onset of menarche

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• The menstrual cycle and a womens 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

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Disorders of the Menstrual Cycle

• Amenorrhoea
• Menorrhagia
• Premenstrual tension
• Dysmenorrhoea

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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

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Premenstrual Syndrome

• General emotional problems co-exist with reports
  of PMS in women attending medical services

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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

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Psychological factors which may influence
reporting of menstrual symptoms

• Personal History
• E.g. Age of menarche
• Early experience of menstrual pain
• Preparation for menstruation
• Mothers attitude towards menstruation
• Mothers own behaviour when menstruating
• Attitudes
• Towards menstruation and the feminine role and
  self

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Psychological factors which may influence
reporting of menstrual symptoms

1. Stressful life events
2. Personal coping strategies for dealing with pain

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Psychological Approaches to the Management of
Pre-Menstrual Symptoms

• Promoting health behaviours, improved diet and
  exercise
• Relaxation
• Cognitive restructuring
• Psychotherapy/ Counselling
• Self-help groups

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Female Reproductive Cycle

• Puberty
• Onset of menarche
• ?
• Sexual Experience
• ? ?
• Wanted Enjoyable
• Or Unwanted or Problematic

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Female Psychosexual Problems

1. Vaginismus
2. Dyspareunia
3. Sexual arousal disorder
4. Orgasmic dysfunction
5. Loss/ lack of sex drive
6. Recurrent discharges/ infections

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Female Reproductive Cycle

• Puberty
• Onset of menarche
• ?
• Sexual Experience
• ? ?
• Wanted Enjoyable
• Or Unwanted or Problematic
• ?
• Conception
• ? ?
• Infertility TOP

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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

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Infertility

• The relationship between infertility and
  psychological functioning is complex
• It may be causal
• Neuroendochrine perspective
• Stress ? Reduced efficiency ? Irregular activity
• of pituitary gland of
  ovaries

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Infertility

• Supportive evidence from case histories
• Conception following adoption
• Conception ? on holiday

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Infertility

• Sexual problems
• Accounts for 5.5 of cases of infertility
  (Dubin and Amebarr, 1972)
• Vaginismus
• Erectile failure
• Retarded ejaculation

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• The relationship between infertility and
  psychological functioning
• Consequential
• The Emotional response to infertility has been
  likened to a grief reaction and includes stages
  of
• Surprise/ shock
• Denial
• Anger
• Isolation
• Guilt
• Acceptance/ resolution

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• 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

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Psychological intervention with Infertile couples

• Grief Work
• For loss of fertility and its effect on
  sexuality, loss of pregnancy experience, loss of
  control may be actual bereavement, eg
  miscarriage
• Explore links between past events and current
  reactions, eg previous bereavement or TOP

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Psychological intervention with Infertile couples

• Relationship/ Sexual Counselling
• Sexual/ marital difficulties may be pre-existing
  or reactive
• Strengthen support and communication
• Stress management
• Cognitive/ behavioural techniques

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Termination of Pregnancy

• In 1991, approximately one sixth of
  pregnancies in the UK were terminated. The main
  reason was psychosocial risk to the woman.

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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.

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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)

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• 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)

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• Puberty
• Onset of menarche
• ?
• Sexual Experience
• ? ?
• Wanted Enjoyable
• Or Unwanted or Problematic
• ?
• Conception
• ? ?
• Infertility TOP
• ?
• Pregnancy
• ? ?
• Miscarriage Hyperemesis
• Anxiety

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Miscarriage or Spontaneous Abortion

• Spontaneous loss of a pregnancy within the first
  24 weeks
• Occurs in approximately 20 of all known
  pregnancies

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Common Reactions

• Guilt and self blame
• Grief reaction
• Intense sadness and sense of loss
• Anger
• Anxiety
• Depression

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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

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• 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

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Stray-Pederson Stray-Pederson (1984)

• Control Group
• N 24
• Women who concurrently
• Miscarry (no identified
• Abnormality)
• Experimental Group
• N 37
• Optimal psychological
• Support TLC

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Stray-Pederson Stray-Pederson (1984)

• Control Group 33 had successful
  pregnancies
• Experimental Group 86 had successful
• pregnancies

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• Puberty
• Onset of menarche
• ?
• Sexual Experience
• ? ?
• Wanted Enjoyable
• Or Unwanted or Problematic
• ?
• Conception
• ? ?
• Infertility TOP
• ?
• Pregnancy
• ? ?
• Miscarriage Hyperemesis
• Anxiety
• ?
• Childbirth
• ? ?

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• Puberty
• Onset of menarche
• ?
• Sexual Experience
• ? ?
• Wanted Enjoyable
• Or Unwanted or Problematic
• ?
• Conception
• ? ?
• Infertility TOP
• ?
• Pregnancy
• ? ?
• Miscarriage Hyperemesis
• Anxiety
• ?
• Childbirth

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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

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Gynaecological Surgery

• E.g. Hysterectomy
• Cancer
• Chronic Pelvic Pain

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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)

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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

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Chronic Pelvic Pain

• Laparoscopic assessment of women with CPP reveal
  that approximately 60 have no apparent pelvic
  pathology

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Common diagnoses-

• Pelvic Inflammatory disease
• Endometriosis
• Adhesions
• Fibroids
• Irritable Bowel Syndrome

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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

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Detailed Psychological Assessment

• Pain history and pain analysis ABC and daily
  diaries rating symptoms and mood together
• Pain beliefs and attributions

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• 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

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• 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

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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