Patients Presenting to the Emergency Unit with Gynaecological Lower Abdominal Pain, with and without Pathological Clinical Findings - Service Utilisation, Pain History, Implications.

Introduction: Few studies have evaluated the utilisation of emergency gynaecological services, although lower abdominal pain (LAP) is one of the most common symptoms prompting emergency presentation. Although such pain may be caused by potentially life-threatening gynaecological diseases, very often no clinical cause is found. The aim of this study was to describe the characteristics of emergency presentations in order to enable quicker identification of real emergencies in routine clinical practice. Materials and Methods: Standardised, so-called first aid cards of 1066 consecutive patients with LAP presenting acutely to one emergency unit were analysed in this retrospective, cross-sectional study. Results: Over one third of cases did not constitute actual medical emergencies on objective criteria, with investigations yielding "no pathological findings". Parameters were identified that more often lead to hospital admission, e.g. palpation of a mass/resistance or at least one pathological ultrasound finding. In addition, it was found that symptoms of longer duration (average 8 days), and not only acute LAP, were also often experienced by patients as emergencies. Conclusion: A diagnosis of "no pathological findings", which was common in our study, suggests a subjective experience of an emergency from the patient's point of view, although the possibility of unrecognised pathology has to be borne in mind. Apart from functional disorders, the origins of symptoms may include psychosomatic causes and psychosocial problems, which cannot be further defined in the emergency care setting. Also, the phenomenon of increased utilisation of emergency services parallel to the assumed opening hours of routine outpatient care facilities must be seen in a critical light.

Osteopathy for Endometriosis and Chronic Pelvic Pain - a Pilot Study.

Introduction: Pelvic pain is a common problem in gynaecological practice. It is often unclear whether definite causality exists between reported symptoms and objective clinical findings of the female genital tract, and medical or operative treatments do not always achieve long-term resolution of symptoms. Methods: This pilot study investigated 28 patients (age 20-65, median 36.5 years) from a gynaecology practice whose only clinical finding was painful pelvic floor muscle tightness. Following standardised gynaecological and physiotherapist examination, all patients received osteopathic treatment. Pain had been present for a median of 3 years (range 1 month to 20 years). 14 patients had previously confirmed endometriosis. Treatment success was evaluated on consultation with patients in person or in writing. Results: 22 of the 28 participants completed the treatment according to plan. Overall, 17 reported symptom improvement, while 10 of the 14 patients with endometriosis did. Conclusion: Osteopathy is well received by women with painful pelvic floor muscle tightness and appears to be an effective treatment option.

[Chronic pelvic pain in women]. / Chronischer Unterbauchschmerz der Frau.

BACKGROUND: Chronic pelvic pain in women represents a difficult diagnostic and therapeutic problem in the gynecological practice which is always a challenge when dealing with affected women. GYNECOLOGICAL CAUSES: Possible gynecological causes are endometriosis, adhesions and/or pelvic inflammatory disease (PID), pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome, interstitial cystitis and fibromyalgia. PSYCHOSOCIAL FACTORS: Psychosocial causes contributing to chronic pelvic pain are a high comorbidity with psychological factors, such as anxiety disorders and substance abuse or depression but the influence of social factors is less certain. The association with physical and sexual abuse also remains unclear. DIAGNOSTICS AND THERAPY: Important diagnostic steps are recording the patient history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are considered to be very promising. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage.

S3 Guideline "Management of Patients with Non-Specific, Functional and Somatoform Physical Complaints" - What is Important for Gynaecological Practice?

When the guideline was compiled, the available evidence was heterogeneous; the evidence varied depending on the subject addressed and was often of only moderate quality. Nevertheless, a strong consensus was reached on almost all subjects. It is recommended that physicians develop a collaborative working relationship with the patient, focus on symptoms and coping strategies and avoid making stigmatising comments. A biopsychosocial diagnostic evaluation with a sensitive discussion of the signs of psychosocial stress allows problems of this type and co-morbid conditions to be recognised early on and reduces the risk of iatrogenic somatisation. In uncomplicated cases, establishing a biopsychosocial explanatory model and physical/social activation are recommended. More serious cases call for collaborative, coordinated management with regular appointments (as opposed to ad-hoc appointments when the patient feels worse), gradual activation and psychotherapy. The comprehensive treatment plan can be multimodal and can potentially include physical management strategies, relaxation techniques and antidepressants.

Yoga for Patients with Early Breast Cancer and its Impact on Quality of Life - a Randomized Controlled Trial.

The aim of this prospective, randomized, controlled trial was to investigate the impact of yoga on newly diagnosed patients with early breast cancer in the immediate postoperative phase. 93 women newly diagnosed with early breast cancer were randomized into an intervention group (IG) and a control group (waiting group, WG). The IG started yoga immediately after the operation. The WG started yoga 5 weeks after surgery. Both groups attended yoga classes twice weekly for 5 weeks. Quality of life (QoL) was evaluated using the EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires before the intervention, immediately after the operation and after 3 months. After 3 months the patients were asked whether yoga improved their physical activity and whether they wished to continue with yoga. The overall QoL (p = 0.002) and the functional status (p = 0.005) increased significantly in the IG, while physical symptoms decreased over time in both groups. 86 % of patients in the IG and only 59 % of patients in the WG (p = 0.04) confirmed a positive change in their physical activity through yoga. More women in the IG intended to continue with yoga (p = 0.03). Early initiation of yoga as a supportive treatment in cancer had a positive impact on QoL. Teaching yoga allowed patients to practice yoga by themselves, enhanced the patients' QoL and was found to improve physical activity.

Chronic Pain Syndromes in Gynaecological Practice: Endometriosis and Fibromyalgia.

As gynaecologists frequently function as "general practitioners" for women, gynaecologists are frequently confronted with questions which initially appear to have only a tenuous connection to their field. Chronic pain syndromes represent a particular challenge, especially as pain syndromes are often associated with severe psychosocial stress for the affected woman. This article discusses some of the psychometric aspects of chronic pain in endometriosis and fibromyalgia together with practical therapeutic approaches.

[Chronic pelvic pain in women from a gynecologic viewpoint]. / Chronischer Beckenschmerz der Frau aus gynäkologischer Sicht.

Chronic pelvic pain in women is a difficult subject that challenges the gynecologist in practice. Possible gynecological causes are endometriosis, adhesions/PID, pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome and fibromyalgia.Confirmed psychosocial factors contributing to chronic pelvic pain are comorbidity with anxiety disorders, substance abuse or depression, but the influence of social factors is less certain. The connection to physical and sexual abuse also remains unclear. Important diagnostic steps are studying the patient's history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are helpful. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage of the disease.

Intraperitoneal immune cell status in infertile women with and without endometriosis.

Endometriosis is a widespread chronic disease characterized by endometrial tissue located outside the uterine cavity. Clinical signs are chronic pelvic pain and infertility. Emerging evidence indicates that the immune system is profoundly involved in the onset and/or progression of endometriosis. However, mechanistic pathways have not yet been conclusively specified. In this study, women undergoing diagnostic laparoscopy due to infertility were recruited, and classified as early-stage endometriosis (n=30), advanced-stage endometriosis (n=8) or no endometriosis (n=31). The frequency and phenotype of leukocytes were evaluated in peritoneal fluid. While the frequency of lymphocytes was not significantly different, neutrophils were increased in endometriosis. Flow cytometry analysis revealed an increased frequency of CD4(+) and CD8(+) cells in peritoneal fluid of endometriosis patients. In addition, the frequency of CD4(+)CD25(+)CD103(+) cells and lineage(-)HLA-DR(+)CD11c(+)CD123(+) dendritic cells was decreased in peritoneal fluid in endometriosis, whereas CD57(+) NK cells and CD8(+)CD28(-) T suppressor cells remained largely unaltered. We conclude that therapeutic approaches in endometriosis might focus on peritoneal leukocytes as a target or surveillance marker; however, immune alterations in peritoneal fluid are subtle and their analysis will require highly standardized and harmonized protocols.

Which gynecological and obstetric patients want to attend psychosomatic services?

OBJECTIVE: The aim of this study is to explore the wish of gynecological and obstetric inpatients to attend psychosomatic services. Predictors influencing this wish are evaluated. METHOD: Three groups of patients participated in the study. The groups consisted of patients diagnosed with malignant gynecological diseases (n = 175), benign gynecological diseases (n = 302), and obstetric diseases (n = 238). The following domains were assessed in a cross-sectional design: symptoms of anxiety and depression (HADS), physical complaints (GBB-24), health-related quality of life (SF-12), and the wish to attend psychosomatic services. RESULTS: 34% of the participants indicated that they wanted to attend psychosomatic services during their stay in the hospital. The group of patients diagnosed with malignant gynecological diseases had the highest proportion of women who stated that wish (43%). Multiple logistic regression models showed that former psychotherapeutic experiences as well as low psychological quality of life predicted the wish to attend psychosomatic services in patients diagnosed with malignant gynecological or obstetric diseases. CONCLUSION: It was shown that a considerable proportion of patients wanted to attend psychosomatic care during their hospitalization. Contrary to physical and sociodemographic variables, psychological factors were significant predictors of the inpatient's wish to attend psychosomatic services. This suggests that the subjective estimation of impairments is a major predictor of the wish to attend psychosomatic care.

Psychological and physical factors influencing the health-related quality of life of patients of a department of gynecology in a university hospital.

The aim of our study was to assess the physical and mental quality of life of in-patients of a Gynecological University Hospital and the factors influencing the quality of life. 715 women, who were treated in hospital with non-malignant or malignant gynecological or obstetrical diseases, took part in the study. Besides demographical data and relevant medical parameters the quality of life (SF-12), anxiety and depression (HADS) as well as physical discomforts (GBB) were assessed. The physical quality of life of the study population was significantly lower than that of the normal population (p < 0.001). Patients with obstetric diseases in comparison with patients with malignant gynecological and other gynecological diseases had the lowest physical quality of life. Regarding the mental factor, patients with malignant gynecological diseases feel most impaired, followed by those with other gynecological and obstetrical conditions. The multivariate analysis of the quality of life showed that up to 60% of the variance could be explained. The lowest variance elucidation was found in obstetrical patients in whom the physical complaints elucidated only a small part of the variance. Our results show on the one hand the high impairment of mental and especially of physical quality of life in women who are in hospital with gynecological or obstetrical diseases. On the other hand they show the great significance of the quality of life as an outcome parameter. These findings should be considered in gynecological in-patient treatments by using integrated psychosomatic care.

[Chronic pelvic pain in women]. / Zum chronischen Unterbauchschmerz der Frau.

In this review we discuss the pathophysiological mechanisms and diagnostic criteria of chronic pelvic pain in women. The psychosomatic correlations and important somatic reasons of this complicated disease picture is discussed. For a large number of the patients the diagnostic criteria of somatoform pain disorder are fitting. The therapeutic approaches, which to a large extend are based on experience, are described. Psychosomatic knowledge is very helpful in the management of chronic pelvic pain in women and contributes to a satisfying doctor-patient-relationship.

[Cesarean section on request--a medical and psychosomatic problem]. / Die Wunschsektio--medizinische und psychosomatische Problematik.

Caesarean section on request of the mother turned out lately to be very actual in obstetrical discussions. To come to rational decisions the scientific results of several medical disciplines should be taken into consideration. There is no scientific evidence for benefits of such elective c-section in paediatrics and psychosocial medicine. The obstetricians view shows both benefits and disadvantages, the later overweighing the first. In the light of these data, elective caesarean without other indication but the mothers request does not show to be an acceptable routine procedure.

[Is there an effect of psychosocial factors on pregnancy rates in sterility therapy?]. / Gibt es einen Einfluss psychosozialer Faktoren auf die Schwangerschaftsrate während Sterilitätstherapie?

OBJECTIVE: We examined the possible connection between mood state of patients during IVF/ICSI-treatment and pregnancy rate. Which influence does the patient's age and the social support have on the mood state? MATERIAL AND METHODS: Questionnaires were handed out to 100 patients of our fertility center during an IVF/ICSI-treatment-cycle. We used the standardized Leipziger Stimmungsfragebogen (LSB), a visual analogue-scale for free indication of mood state and the questionnaire for social support (SOZU). RESULTS: Per oocyte pick up 32 women became pregnant (32.7%), 58 women did not become pregnant (59.2%). Lower rating on the aggressivity-scale showed a tendency (p = 0.085) and higher rating on the balance-scale showed a trend toward higher pregnancy rates. There was no significant relation shown on the visual analogue-scale as well as on the LSB-scales grief, activity and fatigue. There was no correlation between age and mood state or between social support and pregnancy rate. CONCLUSIONS: We could not show a significant relation between general mood state and pregnancy rate. Yet there was a tendency concerning certain components of mood. Increasing age of the patient does not have a negative influence on the mood state either. The individual situation and adjustment seem to be decisive.

Clomiphene citrate as a possible cause of a psychotic reaction during infertility treatment.

Secondary side-effects often occur in women undergoing hormonal stimulation treatment with clomiphene citrate. In general 10.4% of women experience hot flushing, 5.5% have complaints caused by enlargement of the ovaries and 3.5% experience central nervous symptoms (nervousness, sleeplessness, headaches, visual disturbances, vertigo). During ovarian stimulation with clomiphene citrate for in-vitro fertilization, a 32 year old patient developed psychotic symptoms, commencing 3 days after initiation of treatment. Hospitalization in the psychiatric ward became necessary when severe formal and rational thought disturbances arose together with perceptory and sensory delusions. Under neuroleptic treatment the symptoms improved. Nevertheless, follow-up psychiatric care on an outpatient basis was deemed necessary. The infertility treatment was continued with human menopausal gonadotrophin stimulation. Psychiatric instability occurred neither at this point nor during the 2 year follow-up observation period. Both an exogenous psychosis (ICD F23.9) as well as the exacerbation of an endogenous psychosis (ICD F29) may be considered for the differential diagnosis. The stimulation with clomiphene citrate in connection with the physical and psychic stress of the infertility therapy can be regarded as the trigger factor. For patients with evidence of psychiatric illness in their case history, ovulation-inducing substances such as clomiphene citrate should be implemented with particular care.