Premenstrual disorders in Polish adolescent girls: prevalence and risk factors.

AIM: The aim of the study was to evaluate the prevalence and risk factors of premenstrual disorders among Polish adolescent girls. MATERIAL AND METHODS: A total of 2500 females from the Upper Silesian region of Poland, aged 16 to 45 years, were eligible for a prospective population-based study. The subjects were recruited randomly by the regional public opinion research centre. The preliminary study population consisted of 1540 females. Seventy-two adolescent girls, aged 16 to 19 years, were included in the final analysis. The research was based on a self-prepared questionnaire containing socio-economic status, general health, medical and reproductive history, premenstrual symptoms based on American College of Obstetricians and Gynecologists criteria for diagnosing premenstrual syndrome as well as American Psychiatric Association criteria for premenstrual dysphoric disorder and patient prospective daily ratings of symptoms. RESULTS: The mean age of the studied population was 17.27±0.97 years. In the studied population the majority of the adolescent girls lived in large cities of over 50,000 citizens (54.29%), were physically active declaring daily physical exercise (55.22%) and sexually active (54.17%). Study results indicated that the prevalence of premenstrual syndrome and premenstrual dysphoric disorder was 76.39% and 4.17%, respectively. The final statistical analysis revealed that only place of residence (large cities) increased the risk of premenstrual syndrome (OR=3.58; P=0.01). CONCLUSION: Adolescent females living in urban areas are more vulnerable to premenstrual syndrome. Reproductive, sexual and socio-economic factors are not significant risk factors for premenstrual syndrome.

The complexity of premenstrual dysphoric disorder--risk factors in the population of Polish women.

BACKGROUND: Premenstrual dysphoric disorder has multiple determinants in the biological, psychological and socio-cultural domains. The aim of the study was to evaluate the risk factors for premenstrual dysphoric disorder in Polish women, considering their reproductive history, socio-economic factors, as well as lifestyle and health-related factors. METHODS: 2,500 females, aged 18 to 45, from the Upper Silesian region of Poland were eligible for the prospective population study. The final study sample was 1,540 individuals. The research was based on a questionnaire containing socio-economic status, general health, lifestyle, medical and reproductive history, premenstrual symptoms based on the American Psychiatric Association's criteria for diagnosing premenstrual dysphoric disorder, and patient prospective daily ratings of symptoms. The Statistica 8.0 computer software was used for statistical analysis. The value of p < 0.05 was adopted as the level of statistical significance. RESULTS: The mean age of the studied population was 31.9 +/- 7.3 years. The majority of the studied women were married (57.9%), lived in large cities (42.0%) and had tertiary education (43.2%). The results of the study indicated that the prevalence of premenstrual dysphoric disorder was 2.1%. The final statistical analysis revealed that only tertiary education decreased the risk of premenstrual dysphoric disorder (OR = 0.08; p < 0.05). CONCLUSIONS: Our research showed that women with tertiary education are less vulnerable to premenstrual dysphoric disorder than women with a lower level of education. Reproductive and lifestyle factors seem to be play a lesser role.

Sexual satisfaction in females with premenstrual symptoms.

INTRODUCTION: The impact of premenstrual symptoms, such as the premenstrual syndrome (PMS) and the premenstrual dysphoric disorder (PMDD), on sexual satisfaction, sexual distress, and sexual behaviors has not yet been established. AIMS: To assess the correlates and risk factors of sexual satisfaction and to evaluate sexual behaviors among Polish women with premenstrual symptoms. METHODS: 2,500 females, aged 18 to 45 years, from the Upper Silesian region of Poland were eligible for the questionnaire-based, prospective population study. All the inclusion criteria were met by 1,540 women who constituted the final study group. The participants were further divided into two subgroups: PMS+ (749 females) and PMS- (791 healthy subjects). Two additional subgroups were created: PMDD+ encompassing 32 subjects diagnosed with PMDD, and PMDD- comprising 32 healthy women, matched to the PMDD+ females for age, marital status, education level, employment status, place of living, and body mass index. A multiple logistic regression analysis was performed to evaluate the influence of PMS on sexual satisfaction and adjust for potential confounders. MAIN OUTCOME MEASURE: To evaluate risk factors for sexual dissatisfaction in a population of Polish females of reproductive age, diagnosed with PMS and PMDD. RESULTS: Women from the PMS+ group were less sexually satisfied than PMS- (77.73% vs. 88.66%, P=0.001) and reported more sexual distress (28.65% vs. 15.24%, P=0.001). There were no significant differences in sexual satisfaction between PMDD- and PMDD+. Sexual satisfaction correlated positively with a higher frequency of sexual intercourses and a higher level of education. The presence of PMS correlated negatively with sexual satisfaction, even after adjusting for potential confounders in the multivariate logistic regression model (odds ratio=0.48; confidence interval: 0.26-0.89; P=0.02). CONCLUSIONS: The presence of PMS is a risk factor for sexual dissatisfaction in Polish women of reproductive age.

Diabetes mellitus and sexuality--does it really matter?

INTRODUCTION: The extent to which diabetes may influence sexuality has not yet been established. Identifying the risk factors of female sexual dysfunctions will facilitate the introduction of effective therapeutic models that aim to normalize the glycemic control and will enhance sexual functioning. AIMS: To evaluate the influence of diabetes mellitus on female sexual functions, behaviors and depressive symptoms as well as to establish the predictors for female sexual dysfunctions in diabetic subjects. MAIN OUTCOME MEASURES: To asses reported female sexual dysfunctions by using Female Sexual Function Index in diabetic females. METHODS: A total of 544 females living in the upper Silesia region aged 18-55 years old were eligible for this questionnaire-based, retrospective, cross-section study. The study group included females with diabetes mellitus (N = 264), regardless its type and duration; healthy non-diabetic subjects were controls. The Blatt-Kuppermann Index was used to evaluate climacteric symptoms, the Back Depression Inventory-to screen for depressive symptoms and the Female Sexual Function Index-for sexual dysfunction in female (FSD). RESULTS: Multiple logistic regression revealed that the risk of desire and arousal dysfunction was lower in respondents for whom having a satisfactory sexual life was extremely important compared to those for whom it was slightly important or not important at all (referent) (OR: 0.05 and 0.01, respectively). Respondents highly satisfied with sexual contacts with their partner were at lover risk of desire, arousal, and orgasmic disorders and FSD compared to referent subjects (OR: 0.12; 0.03; 0.01 and 0.03 respectively). Depressive symptoms were associated with higher prevalence of arousal disorders and FSD (OR: 13.6 and 3.57, respectively), diabetes-orgasmic dysfunctions (OR = 10.1). CONCLUSIONS: In women, the presence of diabetes is an independent predictor of orgasmic dysfunctions. However, the presence of depressive symptoms, individual perception of sexual needs and partner-related factors are stronger predictors of female sexual dysfunctions.

Physical activity and sexuality in perimenopausal women.

OBJECTIVES: To determine if there is a link between physical activity and sexual functioning in perimenopausal women, by comparing groups of women with low, moderate and high physical activity levels with regard to selected domains of their sexual functioning. METHODS: The research involved 400 healthy Polish women, aged 45-55 years. The final analysis encompassed 336 women who fulfilled all the inclusion criteria. The research tool was a two-part questionnaire. The first part covered the socio-economic status, patient history, and gynaecological-obstetric history. Part two consisted of an extended version of the International Physical Activity Questionnaire long form, evaluating the level of physical activity over the last seven days, and the Female Sexual Function Index. RESULTS: The mean age of the respondents was 50.56 ±â€Š2.33 years. The analysis showed statistically significant differences between all the domains of physical activity and the FSFI of the studied women. In the group of women without sexual disorders, respondents with a low physical activity level in all questionnaire domains were the least numerous. CONCLUSIONS: In perimenopausal women an association is seen between high levels of general physical activity and better sexual functioning.

Recommendations of the Polish Gynecological Society concerning child sexual abuse.

The World Health Organisation defines child sexual abuse as the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. It is estimated that in the world on average one in 3-4 women and one in 6-10 men were victims of sexual abuse in childhood. In Poland, according to the estimates of the Child's Rights Protection Committee, approximately 20% of girls and 5-6% of boys under the age of 15 years has suffered sexual abuse. In 2007 there was an increase in violence victims in all age categories, but the most alarming data concerned minors under 13 years. Girls fall victim to sexual abuse three times more frequently than boys. Sexual abuse of boys frequently involves violence. Data show that there are fewer women than men who execute such actions against a minor. Most victims (49-84%) know the perpetrator, and approximately 14-20% of acts of violence take place within the family. This article presents recommendations of the Polish Gynecological Society concerning procedures in cases of suspected sexual abuse of children.

Evaluation of marital and sexual interactions of Polish infertile couples.

INTRODUCTION: The World Health Organization defines infertility as inability to conceive despite regular sexual intercourse sustained for a period exceeding 12 months with no contraceptive methods. AIM: The aim of this study was to evaluate the effect of infertility on marital and sexual interactions among infertile couples. METHODS: Two hundred six infertile couples were qualified to the study as the research group. The control group consisted of 190 fertile couples. MAIN OUTCOME MEASURES: A specific questionnaire was used as a research tool in this study. It included the sociodemographic part, infertility status, and validated scales: Polish version of Index of Marital Satisfaction and Index of Sexual Satisfaction. Statistica 6.0 (Medical University of Silesia; Katowice, Poland) was used in the statistical analysis. The statistical analysis made use of: Mann-Whitney U-test, chi-square with Yates' continuity correction, ancova log-linear analysis of covariance, and logistic regression analysis. RESULTS: The study showed a significantly better partner relationship in female infertile as compared with female fertile. Clinically significant disorders of partnership stability were observed in 11.65% of studied women and in 20% of controls. Marital adjustment and sexual satisfaction were comparable among male groups. The probability of marital disorders increased with: age above 30 (odds ratio [OR] = 1.6), female sex (OR = 1.5), and lower education (OR = 1.7) among the study population. Diagnosed male factor and infertility duration of 3-6 years were connected with the highest relationship instability and the lowest sexual satisfaction both in female and male infertile. CONCLUSIONS: The risk factors of marital dissatisfaction in infertility include: female sex, age over 30, lower education level, diagnosis of male infertility, and infertility duration of 3-6 years.

Sexual functions and depressive symptoms after photodynamic therapy for vulvar lichen sclerosus in postmenopausal women from the Upper Silesian Region of Poland.

INTRODUCTION: Although lichen sclerosus (LS) may affect women's physical functioning, mood, and quality of life, restricting their physical activities, sexual, and non-sexual contacts, there are limited data on the sexual functioning of women diagnosed with LS. AIMS: The aim of the study was to evaluate the influence of photodynamic therapy for vulvar LS on sexual functions and depressive symptoms in postmenopausal women from the Upper Silesian Region of Poland. METHODS: A total of 65 women aged 50-70 visiting an outpatient clinic for assessment of vulvar dermatoses were screened for the clinical trial. Finally, 37 women who met all the inclusion/exclusion criteria were included in the study. All the subjects were treated by topical laser therapy (photodynamic therapy). Sexual functions and depressive symptoms were assessed before and after the therapy using Female Sexual Function Index and Beck Depression Inventory, respectively. MAIN OUTCOME MEASURES: Sexual behaviors, sexual functions, and depressive symptoms in females after photodynamic therapy for vulvar LS. RESULTS: The total FSFI score was significantly lower after the treatment of vulvar LS as compared with the baseline (median 24.6 vs. 15.9). However, the prevalence of clinically significant FSD was stable throughout the medical intervention except lubrication disorders (higher prevalence after the treatment: 40% vs. 68.57%). Although the scores of BDI at the baseline dropped significantly after the photodynamic therapy (median 12.0 and 9.0, respectively), there were no significant differences in the prevalence of depressive symptoms (48.65% vs. 45.94%). CONCLUSIONS: Topical laser therapy for vulvar LS has a good clinical outcome, especially in the context of no major negative effects on sexual functioning and the positive impact on the severity of depressive symptoms in postmenopausal women. However, patients should be informed about the possible lubrication disorders following the treatment.

Biopsychosocial functioning of women after mastectomy.

AIMS: The aim of this work was to identify the problems of women after total mastectomy and partial mastectomy with regard to various factors and intensity of discomfort which affect the quality of life. BACKGROUND: The loss of the attribute of femininity, maternity and sexuality, as the mammary gland is perceived by patients, is a highly traumatic experience, frequently resulting in re-evaluation of life and functioning to date. DESIGN AND METHODS: The survey encompassed 494 women after operational treatment of breast cancer with varying time since the procedure. The research group consisted of women after radical mastectomy, and the control group consisted of patients after partial mastectomy. RESULTS: The intensity of post-traumatic stress was an important factor affecting the level of depression and anxiety. This correlation appeared to be statistically highly significant in the group of women after total mastectomy. Life satisfaction, the level of depression and anxiety in women after such an operation were dependent on the intensity of post-traumatic stress and they caused inferior biopsychosocial functioning. CONCLUSIONS: Women after mastectomy require professional long-term support; this need should result in the enhancement of services provided in relevant women's support groups. RELEVANCE TO CLINICAL PRACTICE: When evaluating holistically the life of women after mastectomy, all spheres of everyday functioning should be taken into account: physical, cognitive, emotional and social.

[Emergency contraception--awareness among young women from Upper Silesia region]. / Antykoncepcja awaryjna--swiadomosc mlodych kobiet z terenu Górnego Slaska.

OBJECTIVES: Evaluation of prevalence, acceptation and awareness about emergency contraception among young woman from Upper Silesia region. MATERIAL AND METHODS: A questionnaire study was performed in a group of 396 female students of Silesia colleges and universities, aged from 19 to 29. Self-prepared questionnaire was used to evaluate the research group. We asked questions about sexual life, birth control and emergency contraception. Statistica 6.0 software was used for statistical analysis. RESULTS: Mean age of the respondents was 22.1 (+/-1.54) years. Most of the respondents were sexually active (66%), mean age of the first sexual intercourse was 19.1 years. Almost all of the respondents heard about emergency contraception, but the majority claimed that it was not a safe method of birth control and should not be administered without prescription. Half of the women perceived emergency contraception as an abortive method. Thus, most of them would not use any kind of emergency contraception, the reason being either that they were against abortion or that the very concept of emergency contraception was against their personal beliefs. 12.7% of the sexually active woman applied emergency contraception and 10 women (3.7%) used it more than once. CONCLUSIONS: The use of emergency contraception among young woman from Upper Silesia is connected with sexual intercourse without protection. Those young women identify emergency contraception as an abortive method. Knowledge about emergency contraception in this group is not only limited but also incorrect.

[Obesity and its consequences for pregnant women]. / Otylosc i jej konsekwencje dla kobiet w ciazy.

Obesity is an increasingly common disease complicating the course of pregnancy, labour and post-birth recovery. Therefore, conscious decision about conception seems to be vital as maternal obesity can also influence the baby's birth weight and health. The cascade of complications that may occur in the perinatal period in women with excessive BMI has a negative impact on the mother and the child, what translates directly into significant problems--of obstetric and gynaecological, pediatric and often also physiotherapeutic nature.

[Health-related quality of life in women with endometriosis]. / Jakosc zycia u kobiet z endometrioza.

According to definition, endometriosis is a chronic gynaecological disease which results from ectopic location of the endometrium outside the uterine cavity. On the basis of various researches it is estimated that prevalence of endometriosis in the general population is 10% and the disease concerns women mainly in reproductive age. As an effect of the disease, following common gynaecological and psychiatric symptoms appear: chronic pelvic pain which occurs in different circumstances, depressive and anxiety disturbances. In relation to pathological changes, decrease of health-related quality of life (QOL) is observed. The topic of medical researches concerns frequently an influence of pharmacological and surgical treatment on QOL improvement in women with endometriosis. To achieve objective results in evaluation of quality of life, it is recommended to use standardized and validated questionnaires, such as EHP-30, EHP-5, SF-36, WHOQOF-100 or WHOQOL-BREF.

Evaluation of quality of life and sexual functioning of women using levonorgestrel-releasing intrauterine contraceptive system--Mirena.

The advantages ensuing from the high contraceptive efficacy, positive effect on the parameters of the menstrual cycle as well as other values of the levonorgestrel-releasing intrauterine system may play an important role in women's sexual life. The aim of the study was to evaluate the effect of the levonorgestrel-releasing intrauterine system on the quality of life and sexual functioning of women. The research encompassed 200 women aged between 30 and 45. 52 women using the levonorgestrel-releasing intrauterine system were qualified to the study as the research group (Mirena Group). The control groups consisted of 48 women using a different type of intrauterine device (Control Group I--Other IUD) and 50 women using no contraception (Control Group II). A specific questionnaire with a general part concerning socio-demographic conditions, a part dealing with contraception and Polish version of self-evaluation inventories: Short Form-36 Health Survey, Female Sexual Function Index and Mell-Krat Scale was used as a research tool. Quality of life parameters for women using the Mirena system were higher than for the control groups, especially in the aspect of general health, energy/fatigue and emotional well-being. A significant beneficial effect of the levonorgestrel-releasing intrauterine system on sexual functioning (sexual desire and arousal) was also revealed in the study. Sexual dysfunctions were diagnosed in 20.8% of Other IUD, 34.7% of Control Group II and 9.6% of Mirena Group. Levonorgestrel-releasing intrauterine system increases female quality of life and sexual functioning parameters.

[Endometriosis in pediatric and adolescent gynecology]. / Endometrioza w ginekologii dzieciecej i dziewczecej.

Endometriosis is the most common cause of chronic pelvic pain in adolescent girls (50-70%), unresponsive to treatment of oral contraceptives and non-steroidal anti-inflammatory drugs. The most common symptoms of the disease are: acquired or progressive dysmenorrhea, acyclic and cyclic pain, dyspareunia (in sexually active girls), urological symptoms and gastrointestinal complaints. When evaluating an adolescent with suspected endometriosis, a gynecological examination (rectal or vaginal examination) and imaging studies (ultrasonography, magnetic resonance) should be performed. Moreover, in diagnostic process laparoscopy should be carried out in all girls and teenagers with chronic pelvic pain unresponsive to medical treatment. Initial therapy of endometriosis in adolescent girls involves: surgical methods (laparoscopy/laparotomy), hormonal pharmacotherapy (combined contraceptives, progestin-only protocols), GnRH agonists (adolescents over 16 years of age), non-steroidal anti-inflammatory drugs, alternative pain therapies and psychotherapy. Early diagnosis and treatment during adolescence may decrease disease progression and prevent subsequent infertility.

[Dysmenorrhea in pediatric and adolescent gynaecology]. / Bolesne miesiaczkowanie w ginekologii dzieciecej i dziewczecej.

Dysmenorrhea is the most common problem in pediatric and adolescent gynaecology and it reaches approximately 20-90% of adolescents and young adult females. Dysmenorrhea in adolescent girls is usually primary and is associated with normal ovulatory cycles and with no pelvic pathology. Secondary dysmenorrhea, associated with some pelvic pathology, constitutes approximately 10% of the cases and its most frequent reasons are: endometriosis, pelvic inflammatory disease, congenital mullerian anomalies and ovarian cysts. Prostaglandins and leukotriens play a significant role in etiopathogenesis of the primary dysmenorrhea. The therapy of the primary dysmenorrheal in adolescent girls involves: nonsteroidal anti-inflammatory drugs for at least 3 months, combined with oral contraceptives for at least 3-6 menstrual cycles, as well as dietary supplementation, other alternative therapies (vitamins, herbal remedies, acupuncture, TENS) and surgical treatment Secondary causes of dysmenorrhea should be considered in adolescents with dysmenorrhea who do not respond to the treatment. The role of the pediatric and adolescent gynaecologist is to diagnose the reason of symptoms, educate the patient, review effective treatment options as well as to restore normal daily functioning.

[Budd-Chiari syndrome induced by hormonal oral contraception in the patient with congenital thrombophilia-factor V Leiden mutation--a case report]. / Zespól Budd-Chiari indukowany doustna antykoncepcja hormonalna u pacjentki z wrodzona trombofilia-mutacja czynnika V Leiden--opis przypadku.

The Budd-Chiari syndrome is a rare pathology resulting from various etiological factors which often contribute to its late diagnosis. Liver cirrhosis, malignant tumors and haematological disorders resulting in hypercoagulability, are the most common reasons of Budd-Chiari syndrome. The syndrome is characterized by portal hypertension and splanchnic congestion due to obstruction of hepatic venous outflow. The first symptoms include pain, ascites and hepatosplenomegaly. The diagnosis of Budd-Chiari syndrome can be achieved by Doppler ultrasonography, Computed Tomography scan, Magnetic Resonance or Single Photon Emission Computed Tomography. In the following article, a case report of a patient with diagnosed Budd-Chiari syndrome as a result of congenital thrombophilia-factor V Leiden gene mutation is presented. Clinical symptoms, diagnostic process, as well as treatment options, were shown in the article.

[Sexual dysfunctions in selected endocrinopathies]. / Zaburzenia seksualne w wybranych endokrynopatiach.

According to the socio-sexological reports approximately 40-45% of women and up to 30% of males may suffer from different sexual dysfunctions. The prevalence of those disorders is gradually increasing with age. Multiply numbers of endocrinopathies may influence the human sexual life. In diabetic patients all phases of the sexual responses cycle, especially orgasm, might be affected. Women diagnosed with PCOS have decreased adaptation to the sexual life, low self-esteem and perception of self sexual attractiveness. The intimacy of infertile couples has not been well described and the characteristic of particular dysfunction in sex life has not been established yet. Interdisciplinary approach, understood as treatment of the endocrinopathy accompanied with psychological and sexological counseling, seems to be the fundamental issue in the therapy of sexual dysfunctions in patients with endocrinological disorders.

[Evaluation of the quality of life of women in the climacteric period]. / Ocena jakosci zycia kobiet w okresie klimakterium.

OBJECTIVES AND STUDY DESIGN: Evaluation of quality of life of women in the climacteric period with the use of an individually developed questionnaire of a transitory period. Evaluation of the effect of Hormonal Replacement Therapy (HRT) on health related quality of life. MATERIALS AND METHODS: A group of 190 women in the perimenopause period was subject to an analysis. The criterion of qualification for the investigated group was medical history of a patient, which revealed climacteric symptoms and age of women (from 45 to 60 years old). The patients were divided into two main groups depending on the use of HRT The first group--investigated group - adhibiting HRT consists of 76 patients, the second one--control group--114 patients. Within each of the groups, 5 subgroups were isolated basing on the moment of the menopause occurrence. The research tool was an individually developed questionnaire consisting of SF-36, Green Scale and Beck Depression Scale. RESULTS: Between the group subject to HRT and the control group, a statistically significant difference (p < 0.05) was observed concerning the quality of life parameters, intensification of depression connected with climacteric and symptoms of the climacteric syndrome. CONCLUSIONS: 1. The application of HRT in women after menopause contributes to an improvement of the general quality of life, of mood and vitality. 2. Women subject to the therapy constitute a minority. Thus, HRT should be promoted in order to improve the life quality of women in that period so difficult for them. 3. The transitory period questionnaire is a good work tool, which allows to determine the necessity of the therapy application and to monitor its course.

[Selected aspects of diagnosis and treatment of transsexualism in Poland]. / Wybrane aspekty diagnozy i leczenia transseksualizmu w warunkach polskich.

Transsexualism is a form of sexual identity disorder. In this disorder sexual identification psychological level is inadequate to biological level. One man out of 30000 and one woman out of 100000 ones is transsexual. The etiology of transsexualism has not been known yet. The treatment is complex and a cooperation of the specialist team is necessary. An operation is a second step after the diagnosis of transsexualism (psychological, psychiatric and sexological), hormonal therapy end Real Life Test. Follow-up therapy with the psychologist and supportive therapeutic group is extremely important after the operation.

[Phytoestrogens--an alternative to hormonal replacement therapy]. / Fitoestrogeny--alternatywa hormonalnej terapii zastepczej.

Perimenopausal period is associated with the reduction of endogenous estrogens which might lead to many disorders of general health in women. Traditional hormone replacement therapy (HRT) is effective for controlling vasomotor symptoms and reducing the risk of cardiovascular disease and osteoporosis in postmenopausal women. However, according to the latest studies, many women are reluctant to initiate this therapy because of concerns regarding the benefits and risks considering contraindications and side effects of it. Therefore, a lot of studies were carried out to find the influence of phytoestrogens on menopausal symptoms. Phytoestrogens are defined as naturally occurring compounds, found in plants; they have a variety of activities: estrogenic and antiestrogenic. Could phytoestrogens be used as an alternative to hormonal therapies for the management of menopausal symptoms?