Age of uptake of early cancer detection facilities by low-risk and high-risk patients with familial breast and ovarian cancer.

INTRODUCTION: Some 5-10% of all cases of breast cancer and ovarian cancer have a hereditary genesis. In the setting of an interdisciplinary cancer genetics clinic, a study of the age at which patients first take advantage of early cancer detection (ECD) facilities was conducted in order to assess the influence of familial risk on health issues. METHODS: The study included 556 women who fulfilled the inclusion criteria (IC) for genetic analysis of the BRCA1 and BRCA2 genes, as well as 205 who did not meet these criteria but attended the primary consultation. RESULTS: Consulters who met the inclusion criteria took advantage of nearly all methods of ECD at an earlier time than women who did not. A comparison of consulters with or without breast cancer showed that those without breast cancer participated in all methods of ECD at an earlier time. CONCLUSION: Methods of improving and increasing participation in ECD facilities, and of encouraging women who are at risk to start on such programs at a younger age, need to be discussed. In this study, familial risk already resulted in a younger age of uptake of ECD facilities.

Use of intensified early cancer detection in high-risk patients with familial breast and ovarian cancer.

A prospective follow-up study was carried out to evaluate the influence of risk and genetic counselling on use of early cancer detection. Five hundred and fifty-six subjects who fulfilled inclusion criteria for a genetic analysis of the BRCA1/2 genes (the high-risk group A) and 205 who did not fulfil the inclusion criteria (the lower risk group B) attended primary consultation in the interdisciplinary cancer genetic clinic. Information about participation in the early cancer detection programme was documented. Information about changes in use after consultation could be evaluated from 349 women (94 group B and 255 group A). Methods such as monthly self-palpation, breast palpation by gynaecologist, ultrasound of the breast, transvaginal ultrasound and pelvic examination had all been commonly used. Consultees at higher risk used mammography less often than women at lower risk. Magnetic resonance imaging of the breast was used rarely. Most methods were used more often at the recommended interval by women at higher risk during the follow-up period. In conclusion, at present intensified early cancer detection programmes for women at risk provide a less invasive option than chemoprevention or prophylactic surgery. Although the methods are used at high frequency it seems feasible to motivate women at risk to participate. This can be done by providing information and counselling in the cancer genetic clinic.

[Psychosomatic aspects of urogynaecology: model considerations on the pathogenesis, diagnosis and therapy]. / Psychosomatische Aspekte der Urogynäkologie: Modellüberlegungen zur Pathogenese, Diagnostik und Therapie.

Disorders of micturition and other symptoms in the area of the lower urinary tract are frequent in gynaecological consultation. The uro-gynaecological clinical symptoms and diseases refer to the following syndromes: irritable bladder, recurrent cystitis, interstitial cystitis, urinary retention and forms of incontinence. In view of the great aetiological importance of depression and its psycho-neuroendocrine associations with urge symptoms correlating with oestrogen deficiency, the option of employing newer approaches, and also psychopharmacological approaches, must be considered. In the pathogenesis, the stress and conflict model offers approaches to explanation and treatment. The psychosomatically oriented diagnosis and treatment of symptoms and disorders of the lower urinary tract in women is primarily the task of the gynaecologist, who has to go beyond investigations for organic diseases and must also clarify and treat the psychological dimensions. If there is major psychiatric comorbidity, referral to a doctor specialising in psychotherapeutic medicine and psychotherapy is required, or to a specialist in psychiatry and psychotherapy in the case of clinical and neurophysiological implications and symptoms from the depressive spectrum.

[Chronic pelvic pain syndrome--a multifactorial syndrome]. / Chronische Unterbauchschmerzen. Chronic Pelvic Pain Syndrome--ein multifaktorielles Krankheitsbild.

OBJECTIVE: As a clinically significant syndrome in the field of gynaecology, chronic pelvic pain syndrome (CPPS) leads to illnesses which are prolonged over many years and, in some cases, to a high incidence of surgical intervention. Answers to questions about its aetiology, gynaecological associations, such as adhesions or endometriosis, and new approaches to diagnosis and treatment are urgently required. PATIENTS AND METHODS: Psychometric data were evaluated in 106 patients with CPPS and in 36 clinical controls with vulvodynia. Psychological testing was undertaken in 68 patients with CPPS and 24 with vulvodynia, in comparison with a control group of healthy women (n = 34). DSM IV and ICD 10 classifications were used and neurosis-orientated diagnoses were also assigned. In order to investigate musculoskeletal diseases in CPPS, these patients (106/36) underwent orthopaedic examination and were compared with a control group with no pain (n = 35). RESULTS: An interdisciplinary diagnostic work-up proved to be of clinical relevance, with a significantly higher frequency of cases of facet syndrome in CPPS. After an interdisciplinary diagnostic work-up and treatment directed towards psychosomatic symptoms, the gynaecological differential diagnosis may possibly include laparoscopy. The psychological aggression conflict associated with a significantly greater number of patients with so-called "early disturbance" and latent depression can find pronounced expression during treatment. Results of qualitative investigations in patients with endometriosis show typical psychological symptoms. CONCLUSIONS: Treatment that is both interdisciplinary and strictly orientated towards psychosomatic disorders seems appropriate to this complex syndrome. In particular, the psychological dynamics of an aggression conflict in the patient must be taken into consideration, so that this conflict does not transmit to the treatment.

What does a young girl experience in her first gynecological examination? Study on the relationship between anxiety and pain.

STUDY OBJECTIVE: The purpose of the two-part study was to determine how the initial gynecological examination was experienced, examining the relationship between anxiety and pain. DESIGN AND PARTICIPANTS: A total of 669 patients who had attended the special gynecological outpatient clinic for female children and adolescents, and 800 female pupils of either high schools (H) or vocational schools (V), were retrospectively asked to complete a standardized questionnaire (30 questions). The statistical instruments used were Chi-square test, loglinear models, and Spearman correlation coefficients. RESULTS: A total of 169 completed questionnaires could be evaluated in the case of children who attended the special outpatient clinic and 210 in the case of the pupils. (1) There was a significantly positive correlation between anxiety and pain; however, the sex of the examiner had no influence on how the examination was experienced. The accompanying persons underestimated the anxiety of the patients prior to the examination and overestimated the pain experienced. (2) Loglinear models showed that there is no relationship between the type of school attended and the pain score, a significant relationship between the type of school and the anxiety (P <.01), and a significant relationship between the anxiety and pain score irrespective of the type of school attended. CONCLUSIONS: The studies showed a surprisingly high frequency of pain, anxiety, and their correlation during the initial gynecological examination. Further studies of influencing factors and interventions are needed.

Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects.

The purpose of our study was to examine the chronic pelvic pain syndrome (CPPS) and the chronic vulvar pain syndrome (CVPS) as two psychosomatic gynecological syndromes. Sociodemographic data were collected from 106 CPPS and 36 CVPS in-patients (under internal and external supervision). Sixty-eight CPPS and 24 CVPS patients were examined using psychological tests (Freiburg Personality Inventory (FBI) and Giessen Test (GT)) and compared with a control group of 34 healthy women. Descriptive statistics, the chi-square test, multi-variant analyses, and regression analyses were used for statistical evaluation. There was a significantly higher incidence of sexual abuse and severe psychological disturbances in the CPPS group (p < 0.03). Sexual abuse was found to be a significant predictor of the CPP syndrome. The CPPS and CVPS patients were significantly more depressed than the control group (p < 0.03). CPPS and CVPS are two distinct psychosomatic gynecological syndromes accompanied by different psychological disturbances.

[Chronic pelvic pain and chronic vulvodynia as multifactorial psychosomatic disease syndromes: results of a psychometric and clinical study taking into account musculoskeletal diseases]. / Chronische Unterbauchschmerzen und chronische Vulvodynie als multifaktorielle psychosomatische Krankheitsbilder: Ergebnisse einer psychometrischen und klinischen Studie unter besonderer Berücksichtigung der muskuloskeletalen Erkrankungen.

OBJECTIVE: Chronic Pelvic Pain Syndrome (CPPS) and vulvodynia (CVPS) are two gynecological syndromes with psychosomatic implications. The purpose of the study was to examine multifactorial psychosomatic syndromes taking into account musculoskeletal diseases. PATIENTS AND METHODS: The psychosomatic data acquired in respect of 106 CPPS and 36 CVPS patients was evaluated. In addition, these patients were subject to orthopedic clinical examinations and the results compared with a control group without pain (n = 35). 68 CPPS and 24 CVPS patients took part in psychological tests, the results of which were compared with those of a control group of healthy women (n = 34). RESULTS: There was a significantly higher incidence of sexual abuse among the CPPS group. Sexual abuse and somatization were found to be significantly predictive factors. The CPPS and CVPS patients were significantly more depressive than the healthy group. The two clinical groups differ in that the CPP syndrome is significantly more frequently linked with a so-called early disturbance. The incidence of musculoskeletal diseases was higher in the case of the CPPS patients. CONCLUSIONS: Interdisciplinary psychosomatic treatment, which also includes nongynecological disorders, especially musculoskeletal diseases, is necessary in the case of both these syndromes.

Psychosomatic aspects of vulvodynia. Comparison with the chronic pelvic pain syndrome.

OBJECTIVE: To examine psychosomatic aspects of vulvodynia (VD) in comparison with the chronic pelvic pain syndrome (CPPS). STUDY DESIGN: Sixty-seven VD patients and 97 CPPS patients were examined with psychological tests (Freiburg Personality Inventory, Giessen Test) and compared with a control group of 34 healthy women. Sociodemographic data and psychoanalytic diagnoses were collected for 36 VD patients and 106 CPPS patients (inpatients). Descriptive statistics, chi 2 test and multivariant analyses were used. RESULTS: CPPS patients had significantly higher somatization than VD patients (P < .004). Both CPPS and VD patients, as inpatients, were significantly more depressive than the control group. In milder forms of VD, the patients (outpatients) exhibited no depression. The incidences of sexual abuse and severe psychological disturbances were significantly higher in the CPPS group (P < .01). CONCLUSION: VD and CPPS are two, distinct psychosomatic gynecologic syndromes and indicate psychosomatically oriented therapy.

Psychosomatic aspects of urinary incontinence.

Psychosomatic aspects of urogynecological disorders may play an important role in their clinical presentation. 72 patients presenting to the urogynecological clinics and a control group of 34 healthy women were included in this study. After informed consent had been obtained, all patients were subjected to (1) a detailed enquiry about personal- and medical history (2) psychological tests (Freiburg's personality inventory, a questionnaire focused on anxiety and anger, and Beck's depression inventory) and (3) routine urodynamic measurement. Patients with stress incontinence had a mean duration of symptoms of 59 months. In 67% there was a combination with clinical urge symptoms. 53% of the patients did not have regular sexual intercourse. Of those who had regular intercourse 23% had incontinence during intercourse and 25% were anorgasmic. 59% of the patients had dysmenorrhea and a negative attitude to their menarche. Urodynamic evaluation showed stress, urge or no incontinence in 39%, 12% and 39%, respectively. Analysis of the psychosomatic tests did not show a specific psychosomatic influence. Negative sexual life correlated with depressive mood, which was not based on the urogynecological problem. There was no causal relationship between personality traits and urogynecological problems. The individual perception of incontinence, however, may depend on or influence personality structure.

[Diagnostic and therapeutic concepts of HPV infection in HIV-positive women]. / Diagnostische und therapeutische Konzepte bei HPV-Infektion HIV-positiver Frauen.

Among HIV-seropositive women there is a high prevalence of anogenital human papillomavirus (HPV) infection. HPV-DNA is more frequent detected in cervicovaginal-lavage specimens from HIV-seropositive women as in those from HIV-seronegative women. We and others suggest that HIV-infection increases the risk to have HPV-associated lesions of the lower female genital tract, especially the risk for developing a squamous intraepithelial lesion of the cervix. In this report we describe the current diagnostic and therapeutic strategies in HIV-seropositive women with HPV-infection. The gynecological examination should be performed at six to twelve month intervals, including the colposcopy and the Pap smear test. We hope to improve the quality of our screening program by doing an additional HPV-test. At last we investigate the CD4+ T-lymphocyte counts because it is observed that women with low CD4+ cell counts (< 200/microliter) were more likely to have persistent HPV-infection as those with higher counts (> 500/microliter). The treatment method is dependent on the development of the HPV-associated lesion and the clinical status of the HIV infected women. In cases with external warts local application of Condylox should be the first line treatment. Probably in about few months we could use other drugs like Wartec or Aldara in Germany. But the effectiveness of these drugs in HIV-positive women has to be proven yet. In the cause of persistence of external warts or recurrence of the disease the systemical application of Intron A or Roferon A is possible. The CO2-lasertreatment is performed under colposcopic guidance, especially in cases with multicentric condylomatous lesions. The treatment of cervical intraepithelial neoplasia (CIN) by CO2-laservaporisation or Loop Electrosurgical Excision Procedure (LEEP) is based on the clear colposcopic visualisation of the upper limit of the lesion. If CIN reaches the endocervix, being out of colposcopic view, and the squamocolumnar junction is localised in the endocervical canal conisation by laser or cold knife has to be performed. Before performing the treatment of CIN one should exclude multicentric cervical, vaginal and vulval intraepithelial neoplasia by colposcopy, because multicentric intraepithelial neoplasia of the lower female genital tract is more frequently than in HIV-seronegative women. Multicentric disease seems to be one cause of the high recurrence of HIV-seropositive women. However, higher levels of immunosuppression (CD4+ T-lymphocyte counts < 200/microliter) are also important determinants of recurrence of the disease. Therefore, an accurate short-term follow-up with colposcopy, Pap test and HPV test should be carried out after the treatment of HIV-seropositive women with low CD4+ counts.

[Not Available]. / Qualitativ-inhaltsanalytische Studie zu pychosomatischen Aspekten der Endometriose/ Qualitative Research on Psychosomatic Aspects of Endometriosis.

Endometriosis is one of the most frequent gynecological disorders in the reproductive age. Discrepancies between clinical findings and subjective Symptoms cause the question of the determing factors for the subjective experience. In the present study an hermeneutic, sense-orientated approach was employed by using qualitative methods of research. Eleven interviews with endometriosis patients were recorded on tape and transcribed, followed by an individual-case and a comparative analysis in partly deductively and inductively defined categories. The psychosexual development has been found as negatively influenced. Endometriosis patients show conflicting concepts of their sex-specific role. A found aggression conflict manifests itself in the pain Sensation, at an intrapsychic land an interpersonnel level: it influences the relations with other persons, in particular, the doctor-patient relationship. Changes of sense in the doctor-patient-relationship and recent concepts of psychosomatic disorders are discussed.

[Measuring bone density with ultrasound osteodensitometry--results of a pilot study]. / Knochendichtemessung mittels Ultraschallosteodensitometrie--Ergebnisse einer Pilotstudie.

Osteoporosis is a systemic bone disease with a decrease in bone structure and increased risk of fractures. The primary diagnosis of osteoporosis and the surveillance of therapeutic interventions is based either on laboratory or on radiological diagnosis. In a pilot study encompassing 274 women the routine use of ultrasound osteodensitometry (QUS, Lunar Achilles) of the os calcaneus was validated and tested. Velocity of the ultrasound signal (SOS) and frequency attenuation (BUA) were measured and the proprietary index stiffness calculated. In 47 women ultrasound data were compared with the DXA measurements. Results from both methods correlated significantly. Postmenopausal patients with HRT had significant better QUS values than those without HRT. Results from both diagnostic methods (QUS versus DXA) correlated significantly. Women with HRT showed significantly increased bone measurements compared to those without HRT. This correlated with an increase in bone metabolism. QUS of the os calcaneus was easy to perform, without time spent or inconvenience for and with high acceptance by the volunteers/patients. The conformity of the results of the different methods (DXA, QUS) may--if the follow up study confirms these results--lead to a routine use of QUS for screening and therapy monitoring.

[Tumor risk consultation for predisposed women from high risk cancer families]. / Tumorrisikosprechstunde für prädisponierte Frauen aus Krebsrisikofamilien.

Germline mutations of the cancer susceptibility genes BRCA1 and BRCA2 seem to lead to a very high risk for breast and/or ovarian cancer. Therefore, genetic counselling and identification of high-risk families may be essential to offer the opportunity to participate in a specific early cancer detection program and to provide individualized psychological support. In a two year period (August 1994-August 1997) 304 consultees present for genetic counselling at the interdisciplinary cancer genetic clinic (Department of Obstetrics & Gynecology and Human Genetics, Heinrich-Heine-Universität, Düsseldorf). For genetic testing a BRCA1/2 mutation detection strategy including protein truncation test (PTT), single strand conformation polymorphism (SSCP), and direct DNA sequencing is used. 161 families fulfilled the inclusion criteria; at present, 72 families for whom complete analytical material is available are analyzed. Although genetic testing for BRCA1 and BRCA2 is technically challenging, women with a family history of multiple sporadic breast/ovarian cancers and those with a hereditary BRCA1 and BRCA2 gene defect may be distinguished. For the first group of consultees this may ease their concern, for the second group preventive measures including an early cancer detection or prevention program, psychological support or prophylactic surgery may be discussed.

The effect of antigamete antibodies on the success of assisted reproduction.

The aim of the study was to investigate the presence of antigamente antibodies in unexplained infertility patients and to prove the efficiency of IUI and IVF-ET treatments for these patients. The study includes 46 unexplained infertility patients and as controls, a group of 21 tubal infertility patients. Serum, follicular fluid and cervical mucus samples were collected from each patient and antibodies were measured with commercial ELISA kits. Twenty-two of the 46 unexplained infertility patients produced at least one of the antibodies against sperm or ovary. Fertilization rates were lower in immunological and unexplained infertility patients than in tubal infertility patients, being statistically significant. Pregnancy rates were lower in immunological and unexplained infertility patients than in tubal infertility patients after IVF-ET, but this was not statistically significant. Pregnancy rates after IUI treatment were equal in both immunological and unexplained infertility groups. AGA (antigamete antibodies) were found in 45% of unexplained infertility patients and therefore may be a possible cause of infertility. IUI and IVF-ET are successful choices for treatment of these patients.

Early cancer detection programmes for women at high risk for breast and ovarian cancer: a proposal of practical guidelines.

Women from families with multiple breast and/or ovarian cancers may be at increased risk to develop breast/ovarian cancer themselves. Due to personal experience with family members having these diseases they are anxious and ask for specific prophylactic measurements or treatment. The detection of two susceptibility genes, BRCA1 and BRCA2, has given insight into the genetic background of part of the familial breast/ovarian cancer syndromes. This has led to an increased demand in genetic counselling, testing, and early cancer detection programmes. Prospective data from early cancer detection programmes in this high risk population are yet not available. Based on data from epidemiological risk studies, breast and ovarian screening programmes and follow up data from breast cancer trials recommendations for an early cancer detection programme have been summarized. At the present these recommendations are tested in a prospective trial.